A detailed clinical evaluation is essential prior to initiating ART and should aim to:

• assess the clinical staging of HIV infection
• identify past HIV related illnesses
• identify current HIV related illnesses that will require treatment
• identify co-existing medical conditions that may influence the choice of therapy

The standard detailed medical history should include questions on the following:

• when the diagnosis of HIV infection was first established
• the current symptoms and concerns of the patient
• symptoms of all past illnesses and if known the diagnosis and treatment given
• a history of symptoms of or previous treatment for tuberculosis
• a history of possible contact with tuberculosis
• past symptoms of sexually transmitted infections
• the possibility of pregnancy in a woman
• social habits and sexual history

The following are important components of the physical examination:

• patient’s weight
• skin and lymphnodes:

→ herpes zoster, Kaposi’s sarcoma, lympadenitis, HIV dermatitis

• oropharyngeal mucosa

→ candidiasis, Kaposi’s sarcoma, leucoplakia

• examination of the heart and lungs including examination of a Chest x-ray
• examination of the abdominal system particularly for liver and spleen size
• examination of neurological and musculoskeletal systems for:

→ mental state, motor or sensory deficits.

• whenever possible examine the optic fundus

→ retinitis or papilloedema

• examination of the genital tract

Table 4. Initial laboratory evaluation for ART

The initial laboratory evaluation should provide the following:

1. confirmation of diagnosis of HIV infection

→ HIV testing should be done or repeated, particularly where no prior documentation is available and especially if the patient is asymptomatic

2. indicators of the patients immune status

→ CD4+ cell counts* are good indicators of immune function in HIV infection.

* A number of alternative techniques to the convetional cytofluorometry method of measuring CD4+ cells should be available soon and these will allow for reduction in the cost of CD4+ cell measurements.

→ The total lymphocyte count correlates very well with CD4 cell counts, particularly in advanced HIV disease, and can be used as an indicator of immune function.

3. information on the patients baseline haematological, hepatic and renal function

→ The baseline blood count complete with examination of a peripheral blood film is necessary because of the frequent occurrence of anaemia, neutropenia and thrombocytopenia both as complications of HIV infection and as adverse effects of ART.

→ Biochemical tests of liver function are needed to exclude co-existing hepatitis and as baseline references in case of ART drug induced hepatic toxicity. A complete urine analysis comprised of a test for glycosuria, proteinuria and careful microscopy of the urine sediment is adequate initial screening for baseline renal function.

4. screening for tuberculosis

→ Tuberculosis is the most common OI in HIV infection in developing countries and must be actively excluded and/or treated. Examination of a chest X-ray is therefore considered an essential part of initial clinical evaluation.

5. diagnosis of other intercurrent illnesses

→ Several “supplementary” laboratory investigations, for the diagnosis of HIV related or other illnesses that may require treatment, will be indicated by findings from the patient’s history and physical examination. Examples are histological examination of skin lesions to confirm Kaposi’s Sarcoma, aspiration or biopsy of enlarged lymph nodes and screening tests for sexually transmitted infections (STIs). This list is by no means exhaustive.

3.3.1. HIV-RNA TESTING

Plasma HIV-1 RNA assays/viral load assays are useful for indicating the prognosis of HIV infection, for indicating when asymptomatic patients should be treated and as a reference for subsequent monitoring of the virological response to therapy. In settings where resources are limited the availability and the cost of these assays are important considerations for the patient. Though desirable, there is no need to routinely perform a viral load assay as part of the initial laboratory evaluation of a patient who is symptomatic.

Some of the first generation viral load assays give falsely low results of viral load on samples from patients with subtype A/E infections and do not detect HIV-1 group O or HIV-2 RNA. The relative regional prevalence of HIV subtypes should therefore be taken into consideration when recommending viral load assays.