BC Centre in HIV/AIDS Primary Care Guidelines

Home Search

1.1 History

All HIV+ individuals should be evaluated by a primary care clinician. If the clinician is not experienced in the management of HIV, it is recommended that the patient should be referred to a physician with this expertise, or the clinician should consult a physician at the BC-CfE by calling the REACH line at 604-681-5748 (Vancouver) or 1-800-665-7677 (outside Vancouver).

Schedule routine monitoring visits at least every 3 – 6 months for patients who are clinically stable and on ARV therapy. More frequent visits should be scheduled for those who are clinically unstable or not on antiretroviral therapy. See also: 2.3 Monitoring

Assessment of symptoms may require direct questioning because patients may not consider their symptoms important until after the symptoms have already caused significant morbidity.

General History
  • Review sources of past medical care; obtain medical records whenever possible
  • Past hospitalizations, past and current illnesses
  • Tuberculosis history
    • Possible recent exposure to tuberculosis
    • History of positive PPD and/or IGRA, Mycobacterium tuberculosis (TB) disease, or treatment of latent TB infection
  • History of hepatitis A, B and C
  • Assess risk for cardiovascular disease, chronic kidney disease, diabetes, and osteoporosis
  • Current prescription and non-prescription medicines, including complementary and alternative medicines and hormones
  • Vaccination history including hepatitis A and B series, pneumococcal vaccine, flu shots, tetanus
  • Reproductive history, including pregnancies, births, termination of pregnancy; current contraceptive use and needs
  • Partner information for disclosure of HIV status
  • Allergies
  • Travel history/place of birth
  • Occupational history and hobbies
  • Pets/animal exposures
HIV-Related History
  • HIV exposure history
    • Date and place of the diagnosis
    • Route of exposure, if known
  • Most recent viral load and CD4 cell count
  • Seroconversion illness
  • Nadir CD4 cell count and peak viral load
  • Drug-resistance testing (Genotype)
  • Current and previous antiretroviral regimens and date of initiation of ARV therapy
  • Previous adverse ARV drug reactions
  • Opportunistic infections
  • Previous adverse reactions to drugs used for opportunistic infection prophylaxis
  • Providers who have been involved in the patient’s HIV treatment
  • Patient’s understanding of HIV disease, including risk of transmission
  • Patient's understanding of HIV treatment and potential barriers to adherence
Mental Health History
Substance Use History
  • Types of drugs; past and current use
    • Street drugs—marijuana, cocaine, heroin, methamphetamine, ecstasy, etc.
    • Illicit use of prescription drugs (e.g. opiates, benzodiazepines)
    • Alcohol
    • Tobacco
  • Frequency of use and usual route of administration
  • Risk behaviours—drug/needle sharing, exchanging sex for drugs, sexual risk-taking while under the influence of drugs or alcohol
  • History of treatment and barriers to treatment
  • See: BC Guidelines Problem Drinking: Screening and assessment for alcohol use
  • See: NIDA Quick Screen: Screening tool for drug use
Sexual History
  • Current sexual activity
  • History of sexually transmitted infections—syphilis, herpes simplex, genital warts, chlamydia, gonorrhea, chancroid
  • Sexual practices—vaginal, anal, oral
  • Gender identity
  • Past and current partners
  • Risk behaviour assessment, including use of latex or polyurethane barriers, number of partners
Psychosocial Assessment
  • Housing status
  • Employment and insurance status
  • Educational level
  • Family and partner contacts
  • Stability of personal relationships
    • Domestic violence screening
  • Immigration status
Review of Systems
  • Constitutional—weight loss, malaise, fevers, night sweats, changes in appetite, changes in sleep, adenopathy
  • Eyes—change in vision, including blurry vision, double vision, flashes of light, or loss of vision
  • Ears, nose, throat—dysphagia, odynophagia, hearing loss, sinus infection, discharge, dental pain, periodontal disease, oral herpes simplex, oral thrush, oral hairy leukoplakia
  • Pulmonary—cough, dyspnea at rest or on exertion, hemoptysis, sputum
  • Cardiac—chest pain, palpitations, heart murmur
  • Abdominal—nausea, vomiting, diarrhea, constipation, blood per rectum, hemorrhoids
  • Genitourinary:
    • Vaginal or penile discharge, vaginal pain, dysuria, genital/rectal warts (Human Papilloma Virus), classic and atypical herpes simplex virus
    • Obstetrics/gynaecology—menstrual status, bleeding, infections, last Pap test and result
    • Anal Pap status
  • Extremities—muscle wasting, muscle weakness, muscle pain, joint swelling
  • Neurologic—cognitive changes; tingling, burning, pain, or numbness in the extremities; weakness
Adapted from: Primary Care Approach to the HIV-Infected Patient. Office of the Medical Director, New York State Department of Health AIDS Institute. March 2007.

§ 1.2 Physical Examination →