The First HIV Clinic Visit

Before the first visit

After you are diagnosed with HIV, you will be referred to an HIV specialist.  These are infectious disease doctors, many of them who practice only with HIV patients.  This HIV specialist practice may also include nurse practitioners and physician assistants, who work closely with the HIV infectious disease doctors to provide you with the type of health care that you need.   

If you are not referred to an HIV specialist practice, do everything you can to be referred to one.  HIV specialists see large amounts of patients and know the latest HIV research; they know how to diagnose the complications of HIV disease, and have vast experience with the HIV drugs.  It is not possible to keep up with all of this if a physician sees only several HIV+ patients in their practice.  

Before you see the HIV specialist, you may be interviewed by a nurse or a social worker who works with the HIV specialist.  You will be sent for lab work and the results should be ready by the time you see your health care provider.  The following box contains a list of all the blood tests that will be ordered and the explanation for why the tests are needed.

   

Name of test	Reason for test
HIV antibody tests: ELISA and then, if positive, the Western Blot	Verify true HIV infection.  Some providers will insist on their own HIV test and not take an outside record of a positive test.
CD4 T-cell count	Find out the “stage” of your HIV infection.  This test answers the question of whether person has AIDS.
Plasma HIV RNA (Viral Load)	Find out how much HIV (virus) is in your blood.
HIV Genotype	Find out if your particular virus has “resistance” to the HIV medicines.  In other words, will all the medicines work?  If not, which ones won’t work?
Syphilis: RPR or VDRL	There are high rates of syphilis in HIV+ patients. Syphilis must be treated. Syphilis may be much worse in HIV+ person.
CBC (Complete Blood Count)	Find out if you have low red blood cells (anemia), low white blood cells (leukopenia), or low platelets (thrombocytopenia).  All are common in HIV+. The white blood count is needed to find out CD4 count. The HIV drug Zidovudine (also called Retrovir and abbreviated AZT) may cause anemia so you will want to avoid this drug if you have anemia.
Electrolytes	Check sodium (Na) and potassium (K) level
Blood urea nitrogen (BUN); creatinine (Cr); urinalysis (UA)	Check kidney function.  Kidney function can be affected by high blood pressure, cocaine use, diabetes, HIV itself, and some HIV medicines.  Some HIV medications must be adjusted if your kidney function is not good.
Transaminases (liver enzymes)--alanine transaminase (ALT), aspartate transaminase (AST), total bilirubin, and alkaline phosphatase	Find out whether your liver is functioning normal.  If your liver function is not good, some HIV medicines may not be used.  Liver function is mainly affected by alcohol use, medications, and certain diseases (especially Hepatitis B and C). Up to 3 out of 4 patients will have abnormal liver tests at the first visit and 1 out of 5 of these will have very abnormal results.
Fasting Glucose	Determine whether you have diabetes.  Test should be done after no food for at least 8 hours. Some HIV medicines may lead to blood sugar abnormalities.
Lipids (fats): total cholesterol, HDL (good cholesterol) LDL (bad cholesterol) and triglycerides.	Find out the level of unhealthy fats in your blood.

  

Lab Test	Reason for Test
HLA-B* 5701 (this test is not usually needed on the first visit but may be done to prepare for the future)	Determine if you may have a severe reaction to a drug called Abacavir (Ziagen/abbreviated ABC).  If you are HLA-B*5701+, you will want to avoid this drug.
Lipids (fats): total cholesterol; HDL (good cholesterol); LDL (bad cholesterol); and triglycerides.	Check for problems with wax-like fatty particles in the blood; these particles can clog arteries and lead to diseases like stroke and heart attack.
Fasting blood glucose (FBG)	Determine whether you have diabetes.  Test should be done after no food for at least 8 hours.  Some HIV medicines may lead to blood sugar abnormalities.
Hepatitis A total Antibody--(abbreviated Anti-HAV Ab)	Find out if you have immunity to Hepatitis A.  Hepatitis A is a virus that affects your liver.  If you have immunity, you are unable to get this infection, either because you have been vaccinated or you had Hepatitis A in your lifetime.
Hepatitis B surface Antibody--also called HBsAB or Anti-HBs	Find out if you have immunity to Hepatitis B.  Hepatitis B is a virus that affects your liver.  If you have immunity, you are unable to get this infection, either because you have been vaccinated or you had Hepatitis B in your lifetime.  If your number is more than or equal to 10, you are immune.
Hepatitis B core Antibody--abbreviated HBcAb	This will be positive if you ever had Hepatitis B infection.
Hepatitis B surface antigen--or HBsAg	Find out if you have chronic (ongoing) Hepatitis B infection.  In this case, the Hepatitis B may be “active” and affecting your liver.  Hepatitis B is treatable with medications, usually the same medicines you take for HIV.
Hepatitis C Antibody--abbreviated HCV Ab	Find out if you have Hepatitis C.  Hepatitis C is a liver infection.  In HIV negative persons, 2 out of every 100 people will have Hepatis C.  In men who have sex with men, up to 6 out of 100 will have Hepatitis C.  In people who inject (“shoot up”) street drugs like heroin or cocaine, up to 9 out of 10 will test positive for Hepatitis C. Hemophiliacs also have high risk.  If your CD4 count is less than 100, your Hepatitis C test may be negative, even if you have Hepatitis C.
Gonorrhea and Chlamydia--(abbreviated GC/CT) a urine test or culture of fluids from cervix (inside the vagina), throat, rectal area, or tip of penis.	This sexually transmitted infection is common in both men and women and one may not have any symptoms.   If one has gonorrhea or chlamydia, one is more likely to infect others with HIV.  These 2 infections are easily treated.
Pap smear (This test is done during the first or second visit.)	Test for cancer of either the cervix or the anus (rectal area) in both women and men.  Check at first visit, then in 6 months, then every year.   In HIV negative women, up to 11 out of 100 women will have abnormal cervical cells (which may be beginning cancer); in HIV positive women, up to 45 out of 100 will have these abnormal cervical cells.  As CD4 count goes down, the chance for cervical cells to become cancerous goes up.  Human papilloma virus (HPV), causes warts, and is thought to be the cause of cervical or anal cancer.  HPV will be worse with HIV infection. (HPV types 16, 18, 31, 33, and 39 are the types associated with cervical cancer.)

 During the first visit 

The first visit with your doctor, nurse practitioner, or physician’s assistant will usually include: 

1. Questions about any diseases, hospitalizations, mental (psychiatric) illness, or surgeries you have had in the past.  This will include many questions about how and when you think you got HIV infection.  It is also important to know whether you have ever tested positive or were treated for tuberculosis or syphilis.  This is called your past medical history or PMH.
2. Questions about your living situation like: a) whether you rent, own your own home, or are homeless; b) who you share your home with; whether you are married, single, have a significant other, etc.; c) whether your have a job and what type of work it is and what are your normal work hours; d) whether you use street drugs, alcohol, or tobacco; e) whether you have close family and friends you can rely on; f) questions about your sexual identity/behavior--gay, straight, bisexual, transgender, number of sex partners in past year, etc. Your provider will ask you whether you use condoms (or have your partner use a condom). g) whether you have (or are able to get) medical insurance coverage.  All this information is called your “social history” or SH.
3. Questions about diseases that run in your family--called your family history or FH; 
4.   A complete physical exam or PE. This usually involves taking off all your clothing or just moving clothing aside.  The main reason to take off everything is to look for sores or lumps in the genital or rectal area (private parts).  Many patients are embarrassed about these sores, and will not bring them up.  Some patients don’t even know that they may have sores in these private areas.  

A word about females

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In our clinic, we have women come back to the clinic for a separate visit just for her pap smear.  This is a good idea for several reasons.  The pap smear visit focuses on gynecological issues (GYN) and there will be discussion about birth control, future plans for having a baby, sexual partners, etc.  There is usually not enough time in the first visit to talk about all these things so a separate visit is necessary.  Some providers may include the pap smear in the first visit.  

From: Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents, January 10, 2011.  The Role of STD Detection and Treatment in HIV Prevention--CDC Fact Sheet, September 2010.