Initial assessment for patients with HIV

History

• Date and context of diagnosis
• History of Opportunistic infections in HIV
• Sexual history

Investigations

• HIV-specific
  • CD4/CD8 count
  • HIV-RNA viral load
  • HIV genotype
  • HLA *B5701 genotyping (for abacavir)
  • Genetic resistance assays (± tropism testing for CCR5 inhibitors)
  • G6PD deficiency
• Routine
  • CBC, lytes, creatinine
  • Fasting lipids, Hb A1c
  • Urinalysis (glucose and protein)
  • Consider bone mineral density testing and vitamin D levels
• STIs and coinfections
  • TB skin test
  • Consider chest x-ray
  • HAV-IgG, HBV-sAg/sAb/cAb, and HCV-Ab
  • Syphilis
  • Three-site mucosal (genital/rectal/throat) NAAT for chlamydia and gonorrhea
  • Toxoplasma, varicella, CMV, and measles serologies
• For cis women and trans men
  • Pap smear
  • Rubella serology
  • Trichomonas testing
• Low threshold for CT chest/abdo/pelvis for lymphadenopathy and non-tuberculous mycobacteria in patients with low CD4 counts

Physical Examination

• Assess for cutaneous Kaposi sarcoma

Initial Regimens

• All are integrase inhibitor with two nucleoside analogues
• Consider one of the single-tablet regimens for HIV
  • Biktarvy 1 tablet PO once daily
  • Triumeq (if HLA B5701 negative): dolutegravir, abacavir, and lamivudine
  • Truvada (tenofovir/TDF and emtricitabine) with either dolutegravir or raltegravir
  • Stribild: elvitegravir/cobicistat/tenofovir disoproxil/emtricitabine
  • Complera: emtricitabine/rilpivirine/tenofovir disoproxil
• Don't forget to add TMP-SMX DS 1 tablet PO daily if presumed low CD4 count

Further Reading

• Clinical Care Guidelines for Adults and Adolescents Living with HIV in Ontario, Canada
• Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update. Clin Infect Dis. 2014:58(1):e1–e34. doi: 10.1093/cid/cit665