Diagnosis and Assessment
2
Table 1. Initial Assessment—History—Present and Past
Past History
• HIV diagnosis: how, where, when and why was diagnosis was made
• Duration of infection: dates of prior negative tests and/or diagnosis and/or
symptoms of acute retroviral syndrome
• HIV-related conditions: Infections, malignancies, or other conditions
potentially related to HIV (e.g., thrush, oral hairy cell leukoplakia, herpes
zoster, cervical or anal cancer or dysplasia, PCP or other opportunistic
infections [OIs], Kaposi sarcoma, lymphoma, neuropathy, anemia, neutropenia,
thrombocytopenia [115] and neurocognitive impairment)
• HIV Medications: Prior use of antiretroviral therapy including prevention for
mother to child transmission or pre-/post-exposure prophylaxis, including
specific drugs, duration of therapy, complications or side effects, drug resistance,
virologic response and adherence
• Comorbidities: History of and risk factors for coronary heart disease,
dyslipidemia, diabetes mellitus, kidney disease and osteoporosis
• Psychiatric history: treatment for or symptoms of depression, anxiety, suicidal
ideation or PTSD: psychiatric hospitalizations
• Sexually transmitted diseases (STDs):gonorrhea, chlamydia, pelvic
inflammatory disease, chancroid, syphilis, herpes simplex virus, viral hepatitis,
human papilloma virus (HPV), and trichomoniasis, including treatment history
and outcome
• Women: gynecologic and obstetric history, plans for future pregnancy, birth control
practices, last Pap test, abnormal PAP test ever menstrual history, mammogram
(if applicable)
• Pediatric: maternal obstetric and birth history, exposure to perinatal
antiretroviral, exposure to infectious diseases, growth and development
• Health care maintenance:
▶ Latent tuberculosis: history of TB or TB exposure and last screening test for
latent TB, with treatment if applicable
▶ Immunization history: childhood vaccination, dT or Tdap, hepatitis A and
B, HPV, influenza meningococcal, pneumococcal, varicella/zoster, and travel
vaccinations
▶ Last eye exam, including dilated funduscopic exam
▶ Last dental visit
• Past Medical History: Include any hospitalizations, surgeries, blood product
receipt not mentioned above
• Family Medical History: diabetes, early heart disease, hypertension, cancer
