All patients diagnosed with HIV should undergo a detailed history, clinical examination, and assessment of their social and economic circumstances. Patients in resource-poor settings often experience poor nutritional status, inadequate housing, and limited access to clean water, all of which increase the HIV-positive person’s susceptibility to opportunistic infections, especially TB, and waterborne organisms such as salmonella and cryptosporidium. As part of PIH’s programs in Haiti and Rwanda, a social worker, nurse, doctor, or community health worker visits the home of all newly diagnosed persons to assess the overall situation of the patient and her family.
During the new patient’s initial physical examination, the presence of AIDS-related complications should be carefully evaluated. In particular, per Section 2.4, the presence or absence of TB must be determined prior to assessing the patient’s immunologic status and deciding whether or not, and when, to start ART. All newly diagnosed HIV patients routinely undergo a tuberculin test, a chest radiograph, and, if a cough is present, three consecutive microscopic examinations of sputum for acid-fast bacilli. Lastly, an erythrocyte sedimentation rate is often performed in the workup, as a low rate may be helpful in excluding TB; an elevated erythrocyte sedimentation rate can be associated with TB, cancer, and even advanced AIDS.
Additional laboratory exams include a pregnancy test for all women of childbearing age, a serologic test for syphilis, complete blood count (CBC) (or Hct alone) and hepatic transaminase enzymes if available, and a pelvic exam that includes screening for gonorrhea and chlamydia. When possible, a Pap smear for the screening of cervical cancer should be performed on all HIV-positive women at the time of diagnosis and yearly thereafter. All newly diagnosed patients should also have their CD4 count measured. If CD4 count technology is not available, assessing the patient’s stage of disease according to WHO standards may be helpful. See Appendices B and C for the WHO’s staging criteria for HIV infection.
The initial encounter with a newly diagnosed patient should also include an assessment of his need for and receptiveness to counseling. Counseling of patients and their sexual partners, as well as screening of patients’ family members and social contacts, is undertaken based on the consent of the patient. In addition, women of childbearing age are referred for family planning, and all couples are counseled on the use of condoms per Sections 2.3.2 and 2.5.1.