Diagnosis and Evaluation

History  TOP

• Living conditions – Ask where patient is staying. Explore access to food, water, restrooms, place to store medications, exposure to toxins, allergens, infection; threats to health/safety. Be alert to possible homelessness.
• History of homelessness – What precipitated it: whether first time, episodic, chronic. History of foster care (“Has your child ever had to live away from you?”)
• Psychosocial History – Obtain a detailed social history. Ask about the patient’s family, extended family and current social supports to determine the patient’s degree of isolation. Ask if they have thought about who might make decisions for them if they get very sick and have to go to the hospital.
• Regular activities – Ask if the patient has any sort of schedule or daily routine. How many meals did you eat yesterday? Do you get up at a certain time? Explore evidence of consistency in the patient’s life to assess whether a medical regimen can be integrated into his/her regular schedule of activities.
• Previous providers – What worked well? Does patient have regular source of primary care?
• Mental health history – Ask whether the patient has ever been treated or hospitalized for a mental health or substance use problem and if s/he is currently taking psychotropic medications. Explore the patient’s strengths and weaknesses, stressing positive assets.
• History of abuse/current risk – Assess for a history of emotional, physical or sexual abuse and exploitation. Ask all patients if they have ever been physically hurt, afraid of being hurt, or made to do things sexually they didn’t want to do. Assess for violence, abusive relationships, and patient safety.
• Alcohol/nicotine/other drug use – Ask about current and previous use of alcohol and drugs, including nicotine. (amount, frequency, duration) Look for signs of substance abuse/dependence. Obtain a history of intravenous drug use and alcohol consumption to assess the patient’s risk for HIV, hepatitis, and liver damage. Asking questions in a nonjudgmental manner establishes rapport and makes it easier for patient to talk about substance use.
• Legal/history of violence – Legal problems, violence against persons or property, domestic/interpersonal violence, history of arrest/incarceration, treatment while incarcerated.
• Work history – Longest time held a job, occupational injuries, vocational skills and interests.
• Literacy – If “trouble reading,” offer help with intake form; assess ability to read English.
• Nutrition/ hydration – Diet, food resources, preparation skills, liquid intake.
• Community – Ask questions to elicit information about the patient’s cultural heritage and religious or spiritual history and affiliation. Some patients can be contacted through faith communities. Ask about attitudes of the patient’s family, friend, community and cultural group toward HIV risk behaviors and person.

Physical Examination  TOP

• Comprehensive exam – At 1st encounter if possible, following standard clinical guidelines.
• Serial, focused exams – For patients uncomfortable with full-body, unclothed exam at 1st visit.
• Dental assessment – Age appropriate teeth, obvious caries, dental/referred pain, diabetes patients.
• Special populations – Victims of abuse, sexual minorities.
• Homeless women – Female patients should have the option of being examined by a health care provider of the same sex. High percentages of poor and homeless women have been victims of physical or sexual abuse. Close evaluation to detect carcinoma insitu, pregnancy detection and other gynecological evaluations should be performed.
• Signs & Symptoms of HIV – These may include oral thrush, shingles, dermatitis, Kaposi’s sarcoma, tuberculosis, diarrhea, and recurrent fevers. Symptoms of dehydration and weight loss can be exacerbated by homelessness.
• Neurological/psychiatric evaluation – A thorough neurological examination and mental health evaluation are critical.

Diagnostic Tests  TOP

• HIV test – Offer testing to client, and to partners and children of the HIV-positive client; encourage use of oral and rapid testing technologies. Offer pre- and post-test counseling in accordance with CDC guidelines.
• Confirmatory HIV test – If HIV test is positive, confirm result using Western blot or immunofluroescence assay.
• Baseline labs – Perform baseline laboratory tests as specified in standard clinical guidelines, including a CBC, electrolytes, glucose, BUN, creatine, liver function tests (LFTs), lipid studies and urinalysis. Pay attention to LFTs, as this population is at high risk for liver damage secondary to hepatitis and/or alcoholic cirrhosis.
• Viral load – Perform a virologic test (e.g., HIV RNA) to determine viral load only on clients with confirmatory HIV positive test.
•  • Resistance assay– Consider drug resistance testing (genotyping or phenotyping) for clients with acute HIV infection, treatment naïve clients, and those who have failed or not responded optimally to antiretroviral treatment regimens.
• Tuberculosis testing (PPD) – For those who test positive, follow up with a baseline chest X-ray and symptom screen every 6 months, re-check clients who test negative every 6 months.
• Hepatitis C test – Due to the high prevalence of hepatitis C in this population, a hepatitis C test should be done on initial screening for every HIV infected person, and is especially recommended for injection drug users and their partners.
• Pap smear – To be done twice in the first year after HIV diagnosis, and yearly after that. Women who have frequent STI’s, multiple partners, or who exchange sex for goods should have a Pap smear every 6 months. HIV-infected women with abnormal Pap smears or inflammation that does not respond to treatment should be referred for colposcopy.
• Pregnancy test – Offer pregnancy testing (UCG urine test) to heterosexually active female clients of childbearing age.