AIDS Guide for Health Care Workers

Guidelines to help you better detect HIV-positive patients

Too many lost opportunities

Researchers at the Centers for Disease Control and Prevention’s 2nd National HIV Prevention Conference, held in Atlanta on Aug. 12-15, presented various studies showing how clinicians often miss opportunities to identify patients who are HIV-infected.

Large nonprofit health insurer Kaiser Permanente of Oakland, CA, has also investigated these types of missed opportunities and found that there are seven clinical events that indicate the patient should be tested for HIV infection: oral infection, pneumonia, unexplained fever, herpes zoster, seborrheic dermatitis, night sweats, and unexplained weight loss. Based on these clinical events, national screening guidelines, and the company’s research, Kaiser Permanente has developed clinical practice guidelines for HIV care. With Kaiser Permanente’s permission, AIDS Alert presents these excerpts from the guidelines, which address HIV and STD screening and initial evaluation of HIV-positive adults:

Diagnosing HIV Infection

Screening for Human Immunodeficiency Virus Infection

HIV infection continues to have significant impact on morbidity and mortality. Early detection and treatment are extremely important for the population infected. Early detection of HIV may also prevent further transmission. Perinatal transmission can be dramatically reduced with early detection and intervention. Screening for HIV is recommended for all pregnant women and those contemplating pregnancy. Individuals focused on risk-reduction strategies are most effective in reducing subsequent risk behaviors. All HIV test pre- and post-counseling and results for purposes of risk reduction should be provided by appropriately trained medical professionals.

Screening tests that have high sensitivity, specificity, and reliability are available. The initial screening test to detect antibodies to HIV is the enzyme immunoassay (EIA or ELISA). If HIV exposure of less than three months or acute retroviral syndrome is suspected, HIV viral load testing is recommended. Although the sensitivity of currently available tests for detecting HIV infection has improved, a true negative test is best assured by re-testing four to six months after the last possible exposure.

Patient history is an imperfect way to assess risk for HIV. Patients may conceal high-risk behaviors (e.g. injection drug use, men in heterosexual relationships who also have sex with men). Others, especially women, may be unknowingly at risk from an infected sexual partner. Using the following practice steps can assist clinicians in screening their patients for HIV infection.

Practice Steps for Infection Screening and STD and HIV Prevention and Counseling

• Take a sexual history as part of routine and periodic health examinations, using questions such as these:

— "Are you currently or were you recently in a sexual relationship?"

— "Have you had sex with men, women, or both?"

— "With how many men or women have you had sex in the last six months? Last year?"

— "What proportion of the time have you used a condom during sexual activity over the past six months? Last year?"

• Determine last possible exposure.

• Identify and screen patients at risk for HIV infection, including but not limited to:

— Anyone who acknowledges having unprotected sexual activity.

— Patients with current or previous STD.

— Patients with history of recreational or intravenous drug use.

— Men who have sex with men.

— Patients who receive transfusions of blood products in the United States (except immune globulin) between 1975 and 1985. Currently, transfusion continues to be a risk in many other parts of the world.

• In addition, consider screening for HIV infection in adults less than 60 years old with pneumococcal pneumonia, shingles, thrush, hairy leukoplakia, generalized adenopathy, unexplained fever or weight loss, seronegative mono-like illness, seborrheic dermatitis, hepatitis B, hepatitis C, and/or tuberculosis.

• Take a drug use history as part of routine and periodic health examinations.

• Women who are pregnant or considering pregnancy should be offered testing with informed consent. Voluntary testing is recommended for all pregnant women.

• Counsel all sexually active adults and teens on the potential risk of STD and HIV infection and means of reducing risk.

• Create a personalized plan for STD risk reduction:

— Create a realistic plan that maximizes safety.

— Motivate patients for behavioral change.

— Avoid language that may be insensitive to patient differences and which may impair disclosure.

• Screen for STDs and HIV as indicated.

• If patient is HIV-positive, provide immediate counseling and refer to an HIV specialist for further evaluation.

• Be alert for signs of depression and for a history of use of drugs and alcohol during sex — all of which may impair safer sex practices.

• Offer latex condoms and information on appropriate handling and lubricants to all sexually active persons.

• Assist the patient in creating a personalized plan for HIV risk reduction:

— Avoid false reassurance.

— Motivate patients for behavioral change.

— Avoid language that may be insensitive to patient’s background and which may impair further disclosure.

— Counsel regarding drug use, especially injection drug use.

— Offer latex condoms and information on appropriate handling and lubricants to all sexually active persons.

• Reassess sexual practices at future visits and plan for repeat testing (if person is HIV-negative), as appropriate.

Initial Evaluation of Adults with HIV Infection

This information is provided for the primary care provider faced with the initial evaluation of a patient with newly diagnosed HIV infection. It can also be used by the provider at the initial visit of a patient with known HIV disease entering the provider’s practice. Refer the patient to an HIV specialist for consultation and treatment. Below is the full evaluation that should be completed on all patients with HIV infection.

The Initial History

• Establish how and where the HIV diagnosis was made.

• Ask if the patient had a history compatible with an acute retroviral illness (or prior negative test) and thereby make an estimate as to the length of HIV infection.

• Ask about infections that may be related to HIV, e.g., thrush, oral hairy leukoplakia, recurrent HSV, VZV, recurrent vaginitis, cervical cancer or CIN, molluscum contagiosum, PCP, or other OIs.

• Ask about history of malignancy such as Kaposi’s sarcoma or non-Hodgkin’s lymphoma.

• Ask about any hematological complications such as ITP, neutropenia, or anemia.

• Review sexually transmitted diseases:

— Syphilis: how diagnosed and when; where and how treated; establish last titer of RPR. Has patient ever had a spinal tap to rule out neurological syphilis, gonorrhea, chlamydia, HSV, chancroid, hepatitis A, B, C, or condylomata.

• Inquire about:

— Last Pap smear.

— Exposure to TB: last PPD. If positive, was patient treated with medication? Establish type and duration of therapy. Document date of last negative PPD.

— Immunization history: Pneumovax, hepatitis A vaccine, hepatitis B vaccine, influenza vaccine, DPT, MMR, polio.

— Last eye (dilated retinal) exam: important if patient has fewer than 100 CD4 cells and is therefore at risk for CMV disease.

— Last dental visit.

— Psychiatric history: especially regarding depression, anxiety, suicidal ideation, or psychiatric hospitalization.

— Any prior experience with HIV therapy-specific drugs, duration of therapy, complications, or side effects from therapy.

Medications

• History of previous medications.

• Any use of alternative agents (nutritional, psychological, herbal, acupuncture).

Allergies

• Dates and types of reactions.

Social History

(Some or all of this information may be gathered by clinical support personnel):

• Ethnicity.

• Health-related behaviors: tobacco, alcohol, and drugs.

• Patient birthplace and residence history.

• Travel history: Establish risk for reactivation of geographically endemic infections such as histoplasmosis and coccidioidomycosis.

• Any history of donated blood, organs, or semen.

• Pet/animal exposure.

• Employment history.

• Establish how the patient was infected by asking the following nonjudgmental questions:

— Have your sexual partners been women, men, or both?

— Do you have a history of injection drug use?

— Have you shared needles for injection drug use?

— Have you had a transfusion or received blood products, especially between 1975 and 1985?

— Have you been the recipient of artificial insemination by an unidentified donor?

• Review specific sexual practices and discuss safer sex techniques.

• Determine marital/relationship status and partner’s health status and their access to health care, including HIV testing and whether the spouse/ partner is aware of patient’s seropositive status.

• Determine who knows about the partner’s HIV status/ diagnosis.

• Determine participation in any HIV support groups.

• Review diet and unusual dietary habits; review good nutrition and high-risk foods.

• Inquire about exercise.

• Inquire about insurance.

Review of Signs and Symptoms

A complete review of systems should be performed, with special attention paid to the areas listed below:

• Skin: skin discoloration, seborrheic dermatitis, psoriasis, new pigmented lesions, folliculitis, pruritus, vesicular lesions, nodules, straightening of hair in African-Americans, onychomycosis.

• Lymph nodes: localized or generalized enlargement of lymph nodes, a recent decrease in size of previously enlarged nodes.

• Eyes: vision change or loss.

• Mouth: oral sores, gum disease, aphthous ulcers, white areas on tongue (Candida, OHL), generalized oral pain.

• Neurologic and psychiatric: persistent and severe headaches, memory loss, loss of concentration, depression, apathy, paresthesias, paralysis or weakness, cognitive difficulties, seizures and sleep disorders, mood swings.

Physical Examination

A complete physical examination should be performed on all patients. It is common in the asymptomatic patient to have a normal physical examination. Special attention should be paid to the following areas: skin, lymph nodes, eyes, oropharynx, abdomen, genitourinary, anorectal, and neurologic.

Baseline Laboratory Tests

• HIV serology (strongly recommended if no prior confirmation is available and patient is asymptomatic with a normal CD4 cell count).

• CBC with differential and platelets.

• T-lymphocyte panel (CD4 count and %, CD8 count and %, and CD4:CD8 ratio).

• HIV viral load.

• Liver enzymes: ALT (=SGOT).

• Serum creatinine.

• RPR.

• Hepatitis A IgC and hepatitis B core antibody (Hepatitis B surface antigen and hepatitis B surface antibody if core antibody is positive) and hepatitis C antibody.

• Toxoplasma IgG (to identify patients at risk for reactivation).

• PPD (positive > 5mm).

• Pap smear.

• Lipid panel.

• Blood sugar.

[Editor’s note: For more information about Kaiser’s guidelines, contact the company’s Department of Quality and Utilization at (510) 987-2475 or at 1800 Harrison, Suite 410, Oakland, CA 94612.]