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Table 1. Initial Assessment: History of the Present Illness
and HIV-specific History
History of the Present Illness
• Initial questions should focus on establishing rapport, putting the patient at ease, and
ascertaining the patient's primary reason for the visit, if not simply to establish the
patient in HIV care.
• Assess the patient's level of knowledge about HIV treatment and prevention, evaluate
educational needs, and determine what ancillary and social support might be
necessary (ideally in collaboration with effective case management).
• If not previously treated with ART, assess the patient's readiness to begin ART
immediately, including on the day of the first visit if feasible.
• If previously but not currently on ART, assess the patient's readiness to reinitiate
ART immediately, including on the day of the first visit if feasible and if adequate
information is available to choose an appropriate regimen.
• Assess the need for assistance with social services such as housing, transportation,
food access, and involve support staff early if appropriate.
HIV-specific History
• Approximate date of HIV diagnosis
• Approximate date of HIV acquisition, which can sometimes be determined on
the basis of prior negative test results, occurrence of symptoms suggestive of acute
retroviral infection, or timing of activities that may have resulted in exposure
• Prior HIV care
• Nadir CD4 cell count and highest viral load
• Current and past exposure to antiretroviral drugs
▶ Use of pre- or post-exposure prophylaxis (including medications and date of last
use)
▶ ART for prevention of perinatal transmission
▶ Prior antiretroviral treatment
0
Drug regimens taken and HIV RNA level while on those regimens
0 Duration of therapy
0 Reasons for changing regimens (e.g., virologic failure, tolerability,
simplification) and adherence challenges
0
Past medical record review (request records if not available)
▶ Results of all prior resistance testing
• Prior HIV-associated conditions
▶ Opportunistic infections and/or malignancies according to CDC Stage 3
definition
▶ Other HIV-related conditions (i.e., thrush)
People Who Currently Inject Drugs
• Current drug-use practices
• Source of needles and needle-sharing practices
Diagnosis
