IM6.7-8 | HIV Clinical Evaluation — Summary & Reflection

KEY TAKEAWAYS

HIV clinical evaluation requires a structured, sensitive history covering: presenting complaint (OLDCARTS + HIV-specific probes per symptom); HIV diagnosis history (date, mode of testing, initial staging); ART history (current regimen, adherence, prior changes); OI history; sexual and transmission risk history (all four modes: sexual, parenteral, vertical, occupational); social history including nutritional status, disclosure, and support; and functional status (WHO performance scale).

The HIV physical examination must include: oral cavity (candidiasis — removable; oral hairy leucoplakia — non-removable; KS on palate); lymph nodes (PGL vs TB lymphadenitis vs lymphoma); fundoscopy (CMV retinitis at CD4 <50, papilloedema in cryptococcal meningitis); respiratory (disproportionate hypoxia = PCP); neurological (focal deficit = toxoplasmosis, global + raised ICP = cryptococcus); skin (KS, PPE, molluscum, herpes zoster).

Differential diagnosis in HIV is CD4-contextualised: apply the symptom-CD4 matrix. Key pairings — fever + CD4 <50 → MAC, CMV; headache + focal deficit + CD4 <100 → toxoplasmosis; headache + minimal meningism + raised ICP + CD4 <100 → cryptococcal meningitis; insidious dyspnoea + bilateral infiltrates + CD4 <200 → PCP; profuse watery diarrhoea + CD4 <200 → Cryptosporidium.

Adherence history uses non-judgemental, normalising language and specific dose-recall questions. Under NACO HIV/AIDS Act 2017, patient confidentiality is legally protected.

REFLECT

Return to the 38-year-old man with confusion, seizures, and oral candidiasis in the opening hook. You have now built the full history-taking framework and the differential diagnosis reasoning tools. Reflect on this question: if the patient's wife had not mentioned the co-trimoxazole, would you still have suspected HIV from the clinical presentation alone? What combination of clinical features — oral candidiasis, wasting, bilateral lymphadenopathy, subacute neurological deterioration in a man his age — should independently trigger HIV as the unifying diagnosis, without relying on a medication clue? Now consider the sensitivity required in this moment: this may be the first time his family is hearing the word 'HIV' in the context of someone they love. How does your preparation in non-judgemental communication affect your first words to his wife as you take the history? The clinical reasoning and the human communication are inseparable in HIV medicine.