What are the key components to include when taking a medical history in an immunocompromised HIV (Human Immunodeficiency Virus) patient?

Critical History Components for HIV-Infected Immunocompromised Patients

When taking a history in an immunocompromised HIV patient, you must systematically document HIV-specific disease markers, complete antiretroviral treatment history with resistance patterns, geographic exposure risks for endemic infections, and comprehensive sexual/substance use practices—as these directly determine opportunistic infection risk, treatment selection, and mortality outcomes. 1

HIV-Specific Disease History

Current Disease Status

• Lowest CD4 count ever recorded (nadir CD4)—this determines lifetime risk for specific opportunistic infections regardless of current immune recovery 1
• Highest viral load ever documented—indicates disease severity and transmission risk 1
• Current CD4 count and viral load trends—essential for determining prophylaxis needs and treatment urgency 1

Complete Antiretroviral Treatment History

• Every antiretroviral regimen previously taken, including specific drug names and combinations 1
• Duration of each treatment regimen and reasons for discontinuation 1
• CD4 and viral load response to each regimen—identifies treatment successes and failures 1
• All documented drug resistance test results—critical for selecting future effective regimens 1
• Specific drug toxicities experienced, including hypersensitivity reactions to sulfonamides, NNRTIs, and abacavir 1
• Adherence patterns to prior regimens—predicts future treatment success 1

Opportunistic Infection and Complication History

AIDS-Defining Conditions

• Prior opportunistic infections: Pneumocystis pneumonia, toxoplasmosis, cryptococcal meningitis, CMV retinitis, disseminated MAC, Candida esophagitis 1, 2
• AIDS-defining malignancies: Kaposi sarcoma, non-Hodgkin lymphoma, primary CNS lymphoma, invasive cervical cancer 2
• HIV-associated complications: wasting syndrome, HIV encephalopathy, HIV-associated nephropathy 2, 3

Tuberculosis and Endemic Fungal Exposure

• All tuberculosis exposure history with dates and results of tuberculin skin tests 1
• Geographic residence and travel history specifically asking about:
  • Ohio and Mississippi River valleys (histoplasmosis risk) 1
  • Southwestern deserts (coccidioidomycosis risk) 1
• These infections can reactivate years after leaving endemic areas, even with immune reconstitution 1

Viral Coinfections

• Hepatitis B and C status with treatment history—affects antiretroviral selection and liver disease risk 1
• History of varicella-zoster (chickenpox or shingles)—indicates risk for severe reactivation 1

Sexual and Transmission Risk History

Detailed Sexual Practices

• Specific sexual activities: vaginal, receptive/insertive anal, receptive oral sex—determines anatomic sites requiring STI screening 1, 4
• Number and gender of partners (men, women, both) 1
• Condom use patterns with each type of sexual activity 1
• History of all sexually transmitted diseases with dates and treatments 1
• Partner HIV status and disclosure—addresses transmission risk and partner notification obligations 1

Common pitfall: Failing to ask about specific anatomic sites of sexual exposure leads to missed asymptomatic STIs, as infections are often site-specific and require targeted screening at each exposure site 4

Substance Use Assessment

• Injection drug use: current practices, needle source, needle-sharing behaviors 1
• Recreational drugs: marijuana, cocaine, methamphetamine, ecstasy, ketamine, poppers 1
• Prescription drug misuse and substances used primarily with sex 1
• Alcohol and tobacco use 1

Immunization Status

Required Vaccine History

• Pneumococcal vaccine (PPSV23 and PCV13) 1
• Hepatitis A and B vaccination status—offer if seronegative 1
• Tetanus-diphtheria-pertussis boosters 1
• Annual influenza vaccination 1
• For children: complete childhood vaccination schedule 1

Medication and Allergy Documentation

Complete Medication List

• All prescription medications including those for comorbidities 1
• Over-the-counter drugs and supplements—many interact with antiretrovirals 1
• Methadone or medication-assisted treatment 1
• Complementary and alternative therapies—herbal supplements can cause significant drug interactions 1

Allergy and Hypersensitivity History

• Dates and specific types of reactions to all medications 1
• Sulfonamide reactions—affects prophylaxis options 1
• NNRTI hypersensitivity 1
• Abacavir reactions—absolute contraindication to rechallenge 1

Comorbidity and Family History

Age-Related and Treatment-Related Conditions

• Cardiovascular disease risk factors: hypertension, diabetes, hyperlipidemia 1
• Family history of premature coronary disease: MI before age 55 in male first-degree relatives or before age 65 in female relatives 1
• Chronic kidney disease or renal insufficiency—affects antiretroviral selection 1, 3
• Peripheral neuropathy and gastrointestinal disease 1
• Lipodystrophy or metabolic complications from prior antiretrovirals 1, 3

Cancer Screening History

• For women: Pap smear history, mammogram dates, gynecologic problems 1
• For all patients: family history of malignancies 1

Social Support and Psychosocial Factors

Disclosure and Support Systems

• Who knows the patient's HIV status—family, partners, friends 1
• Coping mechanisms and emotional response to diagnosis 1
• Current support systems and participation in support groups 1
• Screening for intimate partner violence—particularly important in women, who have twice the depression rate and high rates of abuse 1

Practical Living Circumstances

• Housing stability 1
• Employment status and occupational exposures 1
• Legal guardianship status for minors 1
• Plans for having children and contraceptive use 1

Race, Ethnicity, and Cultural Factors

• Race and ethnicity 1
• Birthplace and primary language—affects health literacy and care access 1
• Sexual identity—transgender patients require specialized comanagement 1

Critical Documentation Pitfalls to Avoid

Incomplete geographic history: Patients can develop reactivation of histoplasmosis or coccidioidomycosis years after leaving endemic areas, even with CD4 recovery—always document lifetime residence and travel 1

Missing anatomic-site-specific sexual exposure: Failing to ask about receptive anal or oral sex leads to missed rectal and pharyngeal STIs that are often asymptomatic but increase HIV transmission risk 1, 4

Inadequate antiretroviral resistance documentation: Without complete resistance history, you risk selecting ineffective regimens that accelerate multi-drug resistance 1

Overlooking nadir CD4 count: Current CD4 may be normal with treatment, but patients with nadir CD4 <50 cells/µL require ophthalmologic screening for CMV retinitis and have different prophylaxis needs 1, 2