student

1. THE BASELINE ASSESSMENT
Care of patients with HIV/AIDS:

2. Unifying Concepts
• The baseline assessment is an organized
systematic approach which will assist the
team to develop an appropriate care plan
for each patient
• Assessment of HIV-infected patients includes
both clinical and non-clinical (psychosocial)
components

3. Unifying Concepts
• For optimal treatment outcomes, the
clinician and patient must be actively
involved in developing the schedule for
monitoring of disease progression and
available option for treatment
• All patients are expected to undergo
baseline assessments and routine laboratory
assays

4. The Baseline Assessment
• Documented evidence of a Positive HIV test
result
• Medical history
• Physical examination
• Clinical staging
• Laboratory testing
• Preparation of the patient ART care plan

5. Symptom/Sign Checklist
• Patient self-appraisal – how is s/he feeling? Is
there a presenting complaint?
• Structured symptom checklist including
– Weight change
– Weakness or fatigue
– Respiratory symptoms (cough, difficulty breathing)
– GI symptoms (poor appetite, thrush, nausea, vomiting, diarrhea, abdominal pain)
– Genital symptoms
– Neurologic symptoms (headache, memory problems, neuropathy, visual problems)
– Pain
– Rash

6. Symptom/Sign Checklist

7. Baseline Medical History
• When was the patient diagnosed with HIV?
• Does the patient have significant medical illnesses
other than HIV?
• Has the patient had complications of HIV infection?
• Has the patient been hospitalized? When? Why?
• Has the patient had surgery? When? What type?
• Does the patient have a history of mental illness?
• Is the patient allergic to any medications?

8. Baseline Medical History
Medication History
• What medications does the patient take now?
• Does the patient take non-prescription medications
(e.g. from a traditional healer?)
• Has the patient had difficulty adhering to
medications in the past?

9. Baseline Medical History
Gynecological/ obstetrical history for women:
• Did the patient participate in PMTCT?
– What medications did she receive?
– Were there any difficulties?
• Does the patient use contraception? What type?
• Has the patient been pregnant before? Parity?
• What are her infant feeding practices?
• Has she had any sexually transmitted infections?

10. Baseline Medical History
Adherence History
• Has the patient previously missed clinical
appointments (e.g. for antenatal care)?
• Assess family/household support

11. The Baseline Physical Examination

12. The Baseline Physical Examination
• Vital signs: BP, PR, Temp, weight, Height, head
circumference
• Developmental & Nutritional status, Immunization
• General appearance, Skin, HEENT
• Respiratory
• Cardiovascular
• Gastrointestinal
• Urogenital
• Neurologic / psychiatric

14. Clinical Staging of HIV/AIDS

15. HIV Disease Stage
• HIV disease stage provides reliable
information about prognosis
• Disease stage is characterized by:
•Current and prior complications of HIV
• This can be evaluated by the medical history and physical
examination
•Degree of immune suppression
• This can be evaluated by the CD4 count

16. ADULTS AND ADOLESCENTS
Clinical Stage 1: Asymptomatic
• Asymptomatic
• Persistent Generalized lymphadenopathy
Performance scale 1: asymptomatic, normal activity
Clinical stage 4: Severe disease
• HIV wasting syndrome
• Pneumocystis Jiroveci Pneumonia (PCP)
• Toxoplasmosis of the Central Nervous System
• Cytomegalovirus disease of an organ other than liver, spleen or lymph
node
• Herpes simplex virus infection, mucocutaneous (>1 month) or visceral
• Progressive multifocal leucoencephalopathy
• Any disseminated endemic mycosis
• Candidiasis of esophagus, trachea and bronchi
• Extrapulmonary tuberculosis
• Kaposi’s sarcoma
• HIV encephalopathy
• Atypical disseminated leishmaniasis
• Disseminated non-tuberculous mycobacterial infection
• Chronic cryptosporidiosis
• Chronic isosporiasis
• Recurrent septicaemia
• Invasive cervical carcinoma
• HIV-associated nephropathy or cardiomyopathy
And/or performance scale 4: bedridden>50% of the day during last month
Clinical Stage 2: Mild disease
• Weight loss, <10% of body weight
• Minor mucocutaneous manifestations (seborrhoeic dermatitis, fungal
nail infections, recurrent oral ulcerations and angular chelitis)
• Herpes zoster within the last five years
• Recurrent upper respiratory tract infection (i.e. bacterial sinusitis)
And/or performance scale 2: symptomatic, normal activity
Clinical Stage 3: Advanced disease
• Weight loss > 10% of body weight
• Unexplained chronic diarrhoea> 1 month (14 days in children)
• Unexplained persistent fever (above 37.5°C. Continuous or
intermittent for longer than 1 month)
• Oral candidiasis (after 6 weeks of life in children)
• Oral hairy leukoplakia
• Pulmonary tuberculosis within the past year
• Severe bacterial infections (i.e. pneumonia, pyomyositis)
• Acute necrotizing stomatitis, gingivitis, or periodontitis †
• Unexplained anaemia (below 8 g per dl), neutropaenia and chronic
thrombocytopaenia †
And/or performance scale 3: Bedridden <50% of the day during the last
month
WHO Clinical Staging
Appendix
WHO Clinical Staging

17. HIV Disease Stage
Clinical Stage One:
– Asymptomatic or
– Persistent generalized lymphadenopathy
Performance scale 1: Asymptomatic, normal
activity

18. HIV Disease Stage
Clinical Stage Two:
– Weight loss < 10% of body weight
– Minor mucocutaneous manifestations (seborrheic
dermatitis, fungal nail infections, recurrent oral
ulcerations, angular chelitis)
– Herpes zoster within the past 5 years
– Recurrent upper respiratory tract infections
And/or performance scale 2: Symptomatic,
normal activity

19. seborrheic dermatitis Stage 2

20. Herpes Zoster (acute & chronic) stage 2

21. HIV Disease Stage
• Clinical Stage Three:
– Weight loss > 10% of body weight
– Unexplained chronic diarrhea (> 1 month)
– Unexplained prolonged fever (intermittent or constant)
> 1 month
– Oral candidiasis (thrush)
– Oral hairy leukoplakia
– Pulmonary tuberculosis within the past year
– Severe bacterial infection (pneumonia, pyomyositis)
And/or performance scale 3: bed-ridden < 50% of the day
during the past month

22. Oral Candidiasis = Stage 3

23. Oral Hairy Leukoplakia = Stage 3

24. HIV Disease Stage
• Clinical Stage Four:
– HIV wasting syndrome
– Pneumocystis pneumonia
– CNS toxoplasmosis
– Cryptosporidiosis with diarrhea > 1 month
– Extrapulmonary cryptococcosis
– Cytomegalovirus (CMV) disease of an organ other than
liver, spleen, or lymph nodes
– Visceral Herpes simplex virus (HSV) infection or
mucocutaneous HSV infection > 1 month
continued…

25. HIV Disease Stage
• Clinical Stage Four, continued:
– Progressive multifocal leukencephalopathy (PML)
– Any disseminated endemic mycosis (e.g. histoplasmosis,
coccidiodomycosis)
– Candidiasis of the esophagus, trachea, bronchi or lungs
– Disseminated atypical mycobacterium
– Non-typhoid Salmonella septicemia
– Extrapulmonary tuberculosis
– Lymphoma
– Kaposi’s sarcoma
– HIV encephalopathy
And/or performance scale 4: bed-ridden > 50% of the day
during the last month

26. Severe Malnutrition stage 4

27. Severe Malnutrition stage 4

28. Disseminated skin KS = stage 4

29. Esophageal Candidiasis = Stage 4
www.medinfo.ufl.edu/cme/grounds/ forsmark/slide7.html

30. Bedridden > 50% of the day = Stage 4
Gideon
Mendel
©
2002

31. The Baseline Laboratory Assessment
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32. Baseline Laboratory Assessment
• Every HIV-infected patient enrolled in the clinic
should have a baseline CD4 count
• Patients whose medical history or physical
examination suggests the need for further laboratory
investigation will have the relevant tests, where
available, at the discretion of their treating clinician
– e.g. history of jaundice  liver function tests
– e.g. pallor on examination  hemoglobin

33. Baseline Laboratory Assessment
• All patients who are eligible for
antiretroviral therapy should also have
where available:
– liver function tests
– tests of renal function
– complete blood count
• Patients who are not currently eligible
for ART do not require additional routine
baseline testing

34. Pre-
treatment
Every
Visit
Month 1 Month
3
Month 6 Every 24
Weeks
Month 12 Annually
WHO clinical Staging
x x
Adherence Counseling
x x
Clinical Screening for TB
x x
CD4+
x x x x
Hb/PCV (CBC)
x** x
HbsAg and HCV
x**
Urinalysis
x** x
HIV-1 RNA (Viral Load)
x* x x x
Creatinine/ Urea
x** x
AST, ALP
x** x
FBS, Amylase, Pregnancy Test,
Lipid Profile, Sputum AFT, Chest X-
Ray, Pap smear
As clinically indicated
Recommended Schedule for baseline lab Monitoring of Patients
Appendix
• *Desirable at baseline. However, Viral Load monitoring should commence at month 6
• **Desirable where available

35. THANK YOU