HIV- Positive Patients; How to Follow?

The clinical spectrum of HIV infection includes primary infection, asymptomatic infection, early symptomatic infection, and advanced immunodeficiency with opportunistic complications. A careful history is needed in HIV-infected patients for the first time, focusing specifically on common HIV related symptoms. A complete physical examination should be performed on all patients at the time of the initial encounter. Laboratory studies that should be obtained on new patients should include CBC with differential, chemistry panel, CD4+ cell count, quantitative HIV RNA or bDNA assay, VDRL or RPR, anti-toxoplasma IgG, anti-CMV, PPD skin test, and a pap smear in women. HIV serology - HBs Ag, anti-HAV IgG, HBsAb or anti HBc Ab, anti HCV Ab, G6PD level, chest radiography and anti varicella IgG should be ordered in selected patients. Prophylaxis against PCP, toxoplasosis, TB, MAC and CMV should be considered in selected patients. CD4+ cell counts and viral load measurement every 3-6 months is the main follow up program in asymptomatic cases (in addition to above lab tests). CD4+ cell counts and viral load measurement is also used for anti-viral therapy response monitoring and for necessity of opportunistic infection prophylaxis or treatment. There are now 15 available agents that suppress HIV viral replication, representing three distinct classes. An initial regimen of three antiretroviral medications that includes a protease inhibitor or nonnucleoside reverse transcriptase inhibitor which is considered the standard of care to maximally suppress viral replication. Live virus or live bacterial vaccines (including BCG, OPV, oral typhoid vaccine (type 21) VZV vaccine, and yellow fever vaccine) should not be given to HIV-infected individuals. Pneumococcal vaccine, influenza vaccine, hepatitis vaccine (both HBV and HAV), hemophilus influenza type -B vaccine and tetanus-diphtheria vaccine (Td) is recommended for HIV-infected individuals. Response to vaccination is greater with higher CD4+ cell counts.