First Visit Basics MPAETC 2009 1. A Guide for Primary Care Providers

First Visit Basics 1 A Guide for Primary Care Providers

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First Visit Basics: Initiating Care for the HIV-Infected Patient Editor: Jeffrey Kwong, MS, MPH, ANP, ACRN Clinical Education Coordinator, Mountain Plains AETC Instructor, Division of Infectious Diseases, School of Medicine, University of Colorado Denver Contributors & Reviewers: Steven Johnson, MD Medical Director, Mountain Plains AETC Professor of Medicine, Division of Infectious Diseases, School of Medicine, University of Colorado Denver Lucy Bradley-Springer, PhD, ACRN, FAAN Principal Investigator and Director, Mountain Plains AETC Associate Professor, Division of Infectious Diseases, School of Medicine, University of Colorado Denver Elaine Thomas, MD Medical Director, New Mexico AIDS Education and Training Center Professor, Division of Infectious Diseases, Department of Internal Medicine University of New Mexico Health Sciences Center Publication Date: June 2009

First Visit Basics: Initiating Care for the HIV-Infected Patient This guide is intended to assist clinicians in initiating care for the HIV-infected patient. The first visit is critical in establishing an ongoing relationship for patients with this chronic disease. The following guide provides a succinct description of the initial history and physical, lays the groundwork for continuing care, and lists easily accessible resources. In addition, we have provided two sample flow sheets that can be used to document care for your HIV-infected patients. The recommendations provided in the health maintenance flow sheets are based on information from currently available guidelines. Please consult the resources at the end of this publication for the most up to date information. The sample flow sheets may be copied or modified for your personal or clinic use. 1

CHIEF COMPLAINT Patients may present to your clinic with an acute complaint, such as fever or sore throat. However, initial visits often occur as a result of having received a positive HIV antibody test. Some patients may have been treated at another facility and are transferring their care to your practice. ASSESS HISTORY History of Present Illness inquire about date of first diagnosis if this is a new diagnosis, ask about: previous HIV testing signs or symptoms of a flu-like illness that may have occurred between the last negative HIV test and the first positive HIV test. A recent flu-like illness may be suggestive of acute seroconversion and consultation with an HIV expert is recommended, as some patients and providers may consider treatment with antiretroviral therapy (ART) during acute seroconversion risk factors for acquiring HIV (e.g., sexual contact, intravenous drug use, blood transfusion, etc.) if patient has known history of HIV, ask about: date of first diagnosis HIV treatment history: o for all antiretroviral medications, include dates of use, reasons for discontinuation (such as side effects, drug resistance, poor adherence, etc.) o some patients recognize medications only by size and color. It is helpful to show a picture chart of medications to ensure accurate identification history of lowest CD4+ T cell count, most recent CD4+ T cell count, and HIV viral load, if known risk factors for acquiring HIV (e.g., sexual contact, intravenous drug use, blood transfusion, etc.) prior opportunistic infections and other HIV-associated conditions where previous care was provided, and whether records can be obtained for all patients, find out who knows about the patient s HIV diagnosis and assess support systems and coping mechanisms 2

Past Medical History Ask about: other chronic medical conditions (diabetes, heart disease, high cholesterol, etc.) other sexually transmitted infections (herpes, genital warts, syphilis, gonorrhea, etc.) history of tuberculosis, tuberculosis testing, or exposure hepatitis history (known infection with hepatitis A, B, or C, or prior immunization against hepatitis A and B) hospitalizations surgeries mental health or substance use treatment history for women, gynecological history including: date of last pap smear history of abnormal pap smear pregnancy history last menstrual period and menstrual pattern current method(s) of contraception, if applicable Immunization History Document prior vaccinations, including tetanus and hepatitis immunizations Medications Review all current medications, including: antiretroviral medications medications to prevent or treat opportunistic infections medications for conditions other than HIV infection (e.g., diabetes, cardiovascular disease, hyperlipidemia, etc.) over the counter medications herbs, alternative medications, nutritional supplements as needed and occasional prescriptions Allergies document allergic reactions to any medications document allergies to food and other environmental triggers 3

Health Maintenance Ask about: previous primary care, dental care, and eye care cholesterol screening anal cancer screening colon cancer screening breast cancer screening, including mammography cervical cancer screening prostate cancer screening Personal Social History Start with less threatening areas to establish communication and build rapport: employment (financial resources) housing (stability, safety of neighborhood) living arrangements (who lives with the patient) and social support pets (establish risk for infections such as toxoplasmosis) responsibilities (children, other relatives, partners, etc.) travel (especially to areas outside the United States) alcohol and tobacco use other substance use Do you now or have you ever used drugs that weren t prescribed by a physician? How do/did you use them (i.e., inject, smoke, snort, etc.)? Do/did you share your equipment with others? sexual activity Are you sexually active? In your life, have you had sex with men, women, or both? How do you protect yourself and your partner(s) from sexually transmitted infections? inquire about history of violence, including forced sex and domestic abuse Review of Systems Constitutional: fevers, chills, night sweats, weight change, anorexia, fatigue HEENT: visual symptoms, hearing changes, sinus pain, oral lesions, sore throat, or difficulty with swallowing Lymphatics: swollen or painful lymph nodes Respiratory: shortness of breath, cough, sputum production Cardiovascular: chest pain, palpitations Gastrointestinal: nausea, vomiting, diarrhea, abdominal pain Urinary: dysuria, frequency, urgency Genital-rectal: sores, warts, or other lesions, discharge, tenderness, rectal bleeding Neurologic: headaches, numbness or tingling in extremities Skin: rashes, sores Psychological: anxiety, depression, cognitive changes 4

PHYSICAL ASSESSESMENT Physical Exam Focus on the following during a comprehensive physical exam: HEENT: perform thorough oral, eye, and ear exams Lymph: evaluate for lymph node enlargement Heart: assess rhythm and rate, note presence of murmurs or rubs Lungs: assess breath sounds Abdomen: measure liver span, note any mass or organ enlargement Neurologic: test reflexes and sensations in lower extremities, assess mental status, cranial nerves Skin: note any rashes or lesions Extremities: evaluate for edema Note: depending on time, prioritization of needs, and patient comfort, GU and rectal exams may be deferred, but should be done soon to complete the physical assessment. Women: pelvic exam, anorectal exam, breast exam Men: genitourinary exam, anorectal exam, prostate exam Laboratory Studies HIV antibody (ELISA & Western Blot) should be done to confirm infection unless patient produces reliable documentation HIV plasma RNA level (HIV viral load) CD4+ T cell count (absolute and percentage) Complete blood count (CBC) with differential Comprehensive metabolic panel (including liver enzymes, creatinine, and glucose) HIV resistance assay (Genotype testing should be performed for newly infected and treatment naïve patients. Consider phenotype testing in addition to genotype testing for patients with known drug resistance.) Hepatitis serologies (HAV Ab, HBsAb, HBcAb, HBsAg, HCV Ab) STD testing (including gonorrhea, chlamydia, and syphilis) Baseline lipid profile and glucose (fasting) Toxoplasma serology Urinalysis PPD or interferon gamma release assay for tuberculosis 5

Additional Laboratory Testing Depending on the clinical situation, some clinicians recommend additional testing: HLAB*5701 (presence of HLAB*5701 is associated with abacavir hypersensitivity reaction. If present, abacavir should be listed as an ALLERGY and the patient should NOT be prescribed abacavir) Chest X-Ray (for symptoms and for epidemiologic exposure) Pregnancy testing ASSESSMENT & PLAN Should address: stage of HIV disease medical indication and readiness for ART, or appropriateness of current regimen if on ART prior ART exposure, history of intolerance, possible resistance medication interactions and adverse effects other medical conditions possible opportunistic infections need for prophylaxis against opportunistic infections need for partner tracing and prevention of transmission to others reporting of case to department of public health, if appropriate need for psychological or social support services Health Maintenance Considerations include: immunizations tuberculosis testing pelvic exam with cervical pap smear anorectal exam breast exam age appropriate health and wellness exams 6

Education Discuss: HIV pathophysiology including significance of HIV viral load and CD4+ T cell count routine lab tests with expected monitoring intervals plan of care including need for immunizations and routine health maintenance the importance of adherence to ART the importance of staying in care and keeping appointments HIV transmission and methods to decrease risks to partners community programs and social service needs FOLLOW UP schedule appointment to return to clinic explain how to contact providers between appointments, if needed review signs and symptoms to report refer to case manager for other services, including insurance and medication assistance, or other social service needs 7

Sample Flow Sheet For Laboratory Results and Medication Lists 8

Name: Date of Birth: Medical Record #: Telephone: Pharmacy: Pharmacy #: Date Date Date Date Date CD4+ T Cell Count (cells/mm 3 ) CD4+ T Cell Percentage (%) HIV viral load (copies/ml) Medications Name Dose Route Frequency Indication Start Date Stop Date Allergies: Prophylaxis Pneumocystis jiroveci pneumonia (PCP) Absolute CD4 < 200 cells/mm 3 or CD4 %< 14% Mycobacterium avium Complex (MAC) Absolute CD4 < 50 cells/mm 3 Medication Name(s) Toxoplasmosis + IgG, Absolute CD4 < 100 cells/mm 3 10 9

Sample Adult Health Maintenance Tracking Form Note: Clinicians are encouraged to consult the references in the bibliography for the most up to date and appropriate health maintenance recommendations for their clinic population. Some of the measures listed in the sample health maintenance tracking form are not covered in the national guidelines but are included here for the clinical settings that want to consider their use. 10

SAMPLE Adult Health Maintenance Tracking Form COMPONENT TIMING DATE DATE DATE Periodic Evaluations Complete physical exam HIV clinical laboratory studies (complete blood count, comprehensive metabolic panel, CD4+ T cell count, HIV viral load) Lipid screen STD screen Diabetes Hepatitis screen Tuberculosis screen Health history update Interval physical exam Hearing/vision exam Dental exam Diet and exercise Advanced directives Retinal exam Anal rectal exam Colon cancer screening Clinical breast exam Mammogram Cervical pap/pelvic exam Genital and digital rectal exam Prostate cancer screening GENERAL HEALTH baseline and annually baseline and every 3 months baseline and annually or every 6 months if at risk baseline, annually, and PRN baseline, before initiation of ART, and then annually; consider more frequent screening if high risk baseline and PRN for high risk patients baseline and annually if high risk for exposure every 3 months every 3 months annually every 6 months annually annually annually, every 6 months if CD4+ T Cell < 100 cells/mm 3 annually > age 50 colonoscopy every 10 years. If high risk, consider earlier WOMEN S HEALTH per guidelines for non-hivinfected women per guidelines for non-hivinfected women every 6 months, annually after 2 consecutive negative pap smears MEN S HEALTH annually annually after age 50; begin at age 45 with risks 12 11

Immunizations SAMPLE Adult Health Maintenance Tracking Form COMPONENT TIMING DATE DATE DATE Pneumococcal (polysaccharide) Tetanus/diphtheria (TDAP < 65 years old; TD every 10 years after) Hepatitis A Hepatitis B Hepatitis A and Hepatitis B combination vaccine Influenza Measles, mumps, rubella (MMR) Varicella Meningococcal see guidelines every 10 years for non-immune patient, series of two immunizations at 0 and 6-18 months for non-immune patient, series of three immunizations at 0, 1, and 6 months for patients in need of both hepatitis A & B vaccines, series of three immunizations at 0,1, and 6 months annually if not immune and CD4+ T cells > 200 cells/mm 3 if not immune and CD4+ T cells > 200 cells/mm 3 if at risk Risk Assessment Human Papillomavirus Herpes Zoster Tobacco Alcohol Illicit drug use Mental health: stress, anxiety, depression, suicide STD prevention Hepatitis A, B, C Seat belt use/helmet use Pregnancy and/or contraception Emotional support Domestic violence Geriatric functional status consider in women < age 26; use of vaccine in HIV-infected persons is currently under investigation. There are no data on the use of this vaccine in persons with HIV. The zoster vaccine is currently NOT recommended for persons with HIV. annually and prn annually and prn annually and prn annually and prn annually and prn annually and prn annually annually and prn annually and prn annually and prn > age 60, annually and prn 13 12

REFERENCES AIDS Education and Training Center National Resource Center. (2006). Clinical management of the HIV-infected adult. Retrieved January 8, 2009, from http://www.aidsetc.org/aidsetc?page=cm-200-00 American Cancer Society. (2008). American cancer society guidelines for the early detection of cancer. Retrieved January 9, 2009, from http://www.cancer.org/docroot/ped/content/ped_2_3x_acs_cancer_detection_ guidelines_36.asp Centers for Disease Control and Prevention & the HIV Medicine Association of the Infectious Diseases Society of America. (2009). Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the CDC, the National Institutes of Health, and the Infectious Diseases Society of America. Retrieved May 10, 2009, from http://www.cdc.gov/mmwr/pdf/rr/rr5804.pdf Department of Health and Human Services. (2008). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Retrieved January 8, 2009, from http://www.aidsinfo.nih.gov/contentfiles/ AdultandAdolescentGL.pdf U.S. Preventive Task Force. (2008). Guide to clinical preventive services, 2008. Recommendations of the U.S. Preventive Services Task Force. Retrieved January 8, 2009, from http://www.ahrq.gov/clinic/pocketgd.htm RESOURCES AIDSinfo www.aidsinfo.nih.gov 1-800-HIV-0440 (1-800-448-0440) A service of the U.S. Department of Health and Human Services providing information on HIV/AIDS clinical trials and treatment. AIDS InfoNet www.aidsinfonet.org Provides fact sheets on treatments, prevention, social services, and web resources. Easy to print, appropriate for patients and clinician education; updated on a regular basis. Most fact sheets available in Spanish; many are also available in other languages. National Clinical Consultation Center www.nccc.ucsf.edu 1-800-933-3413 A national HIV telephone consultation service for health care providers offering up-to-date clinical information and individualized consultations from clinicians experienced in HIV care. 13

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Mountain Plains AIDS Education and Training Center University of Colorado Denver (303)724-0867 www.mpaetc.org 16