HIV antiretroviral treatment

Initiating treatment

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment
      
PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
- Initiating HIV antiretroviral treatment

HIV history:
  Date diagnosed: 
  HIV approximate date acquired: 
  Likely mode of acquisition: 
  Prior HIV care: 
    Treatment: 
    When started: 
    Nadir CD4 count: 
    Highest HIV viral load: 
    Prior HIV genotyping/resistance testing: 
    HIV-associated conditions:
      Opportunistic infections: 
      Malignancies:

Diagnostic investigation results:
[+] 
[~] 
[-] 
[?]

Patient's or carer's ideas, concerns and expectations:
-

PAST MEDICAL HISTORY
Relevant p[ast medical history:
[-] gastrointestinal conditions 
[-] liver disease 
  [-] hepatitis B
  [-] hepatitis C
  [-] other 
[-] tuberculosis 
[-] STIs/STDs 
[-] CVD
[-] hyperlipidaemia 
[-] diabetes mellitus 
[-] osteopenia/osteoporosis 
[-] kidney disease 
[-] cancer or abnormal cancer screening

Reproductive health history:
[-] pregnant
[-] planning pregnancy 
[-] birth control 
[-] sexually active

Mental health history:
-

Psychoactive substance use (past and present): 
[-] tobacco 
[-] cannabis 
[-] alcohol 
[-] opioids 
[-] cocaine 
[-] non-prescription

MEDICATIONS
Current medications:
-

Past medications:
-

ALLERGIES AND ADVERSE REACTIONS
Medication allergies or reactions:
-

FAMILY HISTORY
[-] Diabetes mellitus 
[-] Early CVD (1st degree relatives) 
[-] Cancer

IMMUNISATIONS
Immunisation history:
[-] DTPa
[-] Hepatitis A
[-] Hepatitis B 
[-] HPV 
[-] Influenza 
[-] Meningococcus 
[-] Mpox 
[-] Pneumococcus 
[-] RSV 
[-] Travel vaccines

[Vital signs]

Skin colour: 
Temp (deg.C): 
HR (bpm): 
Heart rhythm: 
BP seated (mmHg): 
BP standing (mmHg): 
BP lying (mmHg): 
Respiratory rate (/min): 
SpO2 (%):

PHYSICAL EXAMINATION
Relevant examination findings:
[+] 
[~] 
[-]

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Diagnostic investigations requested: [+] requested, [-] not requested
[+] HIV RNA viral load (quantitative NAAT assay) 
[+] HIV genotyping (resistance mutations) 
[+] CD4 count 
[?] HLA-B*57:01 antigen (if contemplating abacavir treatment) 
[+] FBC 
[+] LFTs 
[+] Electrolytes, eGFR, uric acid 
[+] HbA1c 
[+] Lipids - cholesterol, HDL-C, LDL-C, non-HDL cholesterol, Triglycerides 
[+] Hepatitis B and C serology 
  STI Screen: 
  [+] Chlamydia/gonorrhoea PCR (all exposed sites)
    - Sites: 
  [+] Syphilis serology 
  Tests of opportunistic infections: (especially if CD4 <200) 
  [+] Cytomegalovirus Ab 
  [+] Toxoplasma Ab 
  [+] Interferon-gamma release assay (IGRA) for Mycobacterium tuberculosis (Quantiferon Gold Assay)
  [+] Strongyloides

Referrals:
-

Patient information and advice:
-

HIV medication prescribed:
  Name: 
  Form: 
  Route: 
  Dose: 
  Frequency: 
  Duration: 
  Reason: 
  
  Name: 
  Form: 
  Route: 
  Dose: 
  Frequency: 
  Duration: 
  Reason:

Name: 
  Form: 
  Route: 
  Dose: 
  Frequency: 
  Duration: 
  Reason:

Other prescribed medication:
  Name: 
  Form: 
  Route: 
  Dose: 
  Frequency: 
  Duration: 
  Reason: 
  
  Name: 
  Form: 
  Route: 
  Dose: 
  Frequency: 
  Duration: 
  Reason:

Name: 
  Form: 
  Route: 
  Dose: 
  Frequency: 
  Duration: 
  Reason:

Immunisations: 
[-] DTPa
[-] Hepatitis A
[-] Hepatitis B 
[-] HPV 
[-] Influenza 
[-] Meningococcus 
[-] Mpox 
[-] Pneumococcus 
[-] RSV

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

Maintenance treatment

HIV medication adherence and problems:
-

Symptoms of possible medication toxicity::
[-] nausea
[-] diarrhoea

[Vital signs]

Height (cm): 
Weight (kg): 
BMI: 
BP (mmHg):

PHYSICAL EXAMINATION
Relevant examination findings:
[+] 
[~] 
[-]

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Diagnostic investigations requested:
[-] HIV RNA viral load (quantitative NAAT assay) 
* Week 4 (expect VL decrease by 1.0 log), then
* Every 4-8 weeks until VL is undetectable (usually at 8-12 weeks), then
* Every 3 months
* Every 6 months after ART for 12 months and VL <20 copies/mL
* Repeat if a significant change (0.5 log [3x] or 10 copies/mL)
[-] HIV genotyping
* Resistance mutations suspected

[-] CD4 count 
* Every 3 months CD4 <300 cells/uL
* Every 6 months CD4 >=300 cells/uL
* Repeat if a significant change (30%)

[-] HLA-B*57:01 antigen
* if contemplating abacavir treatment

[-] FBC 
* Week 2
* Every 3 months

[-] LFTs 
* Week 2
* Every 3-6 months

[-] Electrolytes, eGFR, uric acid 
* Week 2
* Every 3-6 months

[-] Urine albumin/creatinine ratio
* Every 3-6 months

[-] Lipids - cholesterol, HDL-C, LDL-C, non-HDL cholesterol, Triglycerides and CV Risk analysis
* Every 2 years

[-] HbA1c 
* Every 12 months (3 if abnormal)

[-] FRAX risk ASSESSMENT

* Every 2 years

[-] STI Screen
  - Chlamydia/gonorrhoea PCR (all exposed sites)
  - Syphilis serology 
* Every 12 months or as required

[-] Tests of opportunistic infections 
  - Hepatitis B and C
  - Cytomegalovirus Ab 
  - Toxoplasma Ab 
  - Strongyloides
  - Interferon-gamma release assay (IGRA) for Mycobacterium tuberculosis (Quantiferon Gold Assay)
* Every 12 months (especially if CD4 <200) or as required