id.hiv-initial.chronic.v1

HIV — initial evaluation & rapid ART start

infectious_diseasechronicadultoutpatienttransition

Start encounter →Print handoutPRODUCTION

Manifest is a Batch-23 scaffold — atoms / phenotypes / regimen drug list not yet authored. PMIDs empty until WebSearch verification of DHHS / IAS-USA web-only releases (no stable PMIDs). Regimen axis intentionally empty — Biktarvy / Dovato / DTG-3TC / TAF-FTC + alternatives require manifest backing. Pregnancy + perinatal management routed to a separate dossier when authored.

Entry points (4)

lab_abnormality
Positive HIV screen (4th-gen Ag/Ab) + confirmatory (DHHS 2024; CDC 2014 algorithm)
hiv_screen_positive
lab_abnormality
OI presentation (PCP, candidiasis, KS) without prior diagnosis (DHHS 2024 OI guidelines)
opportunistic_infection_presentation
symptom
Mononucleosis-like illness with risk factors (DHHS 2024 — acute HIV)
acute_retroviral_syndrome
problem_list
Existing HIV without engagement in care (IAS-USA 2024 — re-engagement)
hiv_existing_diagnosis_unstable

Required inputs (15)

hiv_confirmatoryrequired
lab • used at ENTRY
Differentiate antibody screen positive from active infection — Geenius / RNA confirmatory (DHHS 2024; CDC 2014 algorithm)
hiv_viral_loadrequired
lab • used at INITIAL_WORKUP
Treatment-naïve baseline; suppression target <50 by 6 months (DHHS 2024; IAS-USA 2024)
cd4_countrequired
lab • used at INITIAL_WORKUP
OI prophylaxis thresholds — PCP <200, MAC <50, toxo <100; staging (DHHS 2024 OI guidelines)
hiv_genotyperequired
lab • used at INITIAL_WORKUP
Baseline resistance testing; informs regimen if transmitted resistance (DHHS 2024; IAS-USA 2024)
hbv_serologiesrequired
lab • used at CONTEXT
HBV co-infection — TDF/TAF active dual-coverage; reactivation risk if dropped (DHHS 2024)
hcv_serologiesrequired
lab • used at CONTEXT
Co-infection screening; influences DAA + ART selection (DHHS 2024; AASLD/IDSA 2024)
creatininerequired
lab • used at TREATMENT
TDF nephrotoxicity / TAF preferred for eGFR <60 (DHHS 2024)
lftrequired
lab • used at INITIAL_WORKUP
Baseline before integrase / NNRTI-based regimens (DHHS 2024)
lipid_panel
lab • used at MONITORING
ART (especially boosted PI) cardiometabolic monitoring baseline (DHHS 2024; D:A:D study)
a1c
lab • used at MONITORING
Baseline metabolic risk; INSTI-associated weight gain monitoring (DHHS 2024)
syphilis_rprrequired
lab • used at INITIAL_WORKUP
STI co-screen mandated (DHHS 2024; CDC STI guidelines 2021)
gc_chlamydia_ngurequired
lab • used at INITIAL_WORKUP
STI co-screen at all exposure sites (DHHS 2024; CDC STI guidelines 2021)
tb_screenrequired
lab • used at INITIAL_WORKUP
IGRA / TST + CXR; LTBI prophylaxis prevents disease (DHHS 2024; WHO 2024)
pregnancy_test
lab • used at CONTEXT
Determines regimen + perinatal counseling — dolutegravir safety reassuring per Tsepamo / IMPAACT 2010 (DHHS 2024; WHO 2024)
mental_health_substance_use
history • used at CONTEXT
Adherence determinants; warm hand-off to behavioral health (DHHS 2024)

12-phase flow (12)

1FRAME
Chronic adult HIV initial evaluation + rapid ART start (DHHS 2024; START NEJM 2015; TEMPRANO NEJM 2015). Pregnancy, pediatrics, advanced disease, PEP/PrEP routed to sibling engines
advance: scope confirmed
2ENTRY
Confirm reactive screen with confirmatory — Geenius / multispot or HIV RNA in acute window (DHHS 2024; CDC 2014 algorithm)
inputs: hiv_confirmatory
advance: confirmed positive
3CONTEXT
Risk factors, partners, mental health, pregnancy, prior ART, OI history, HBV/HCV co-infection, current meds for DDI (DHHS 2024)
inputs: hbv_serologies, hcv_serologies, pregnancy_test, mental_health_substance_use
advance: psychosocial + co-morbid panel complete
4RED_FLAGS
AIDS-defining OI, severe mental illness, perinatal exposure, acute retroviral syndrome with neuro features → expedited care (DHHS 2024 OI guidelines)
inputs: cd4_count
advance: red flags addressed
5INITIAL_WORKUP
CD4, VL, genotype, HBV/HCV/syphilis/GC-CT/TB, CBC, CMP, urinalysis, lipid + A1c, vaccine history; baseline DEXA if indicated (DHHS 2024 pre-ART workup; IAS-USA 2024)
inputs: cd4_count, hiv_viral_load, hiv_genotype, creatinine, lft, syphilis_rpr, gc_chlamydia_ngu, tb_screen
actions: panel.cbc, panel.lft, panel.renal
advance: baseline panel complete; rapid ART decision made
6BRANCHING_WORKUP
OI workup if CD4 <200 — PCP, toxo, MAC (DHHS 2024 OI guidelines); cervical / anal HPV screening; HCC surveillance if HBV/HCV co-infection + cirrhosis
inputs: cd4_count
actions: workup.hiv_initial
advance: OI / cancer screening triaged
7DIFFERENTIAL
Acute vs chronic, controller vs progressor, transmitted-resistance candidate, OI-driven presentation (DHHS 2024)
inputs: hiv_viral_load, cd4_count
advance: staging clear
8RISK_STRATIFICATION
CD4 <200 = AIDS staging + OI prophylaxis (DHHS 2024); cardiovascular + bone + renal baseline; adherence risk (IAS-USA 2024)
inputs: cd4_count
advance: risk profile assigned
9TREATMENT
Rapid ART start at confirmation (DHHS 2024 — supported by START NEJM 2015 + TEMPRANO NEJM 2015): Biktarvy OR Dovato when no HBV / VL <500K / no resistance (DHHS 2024; IAS-USA 2024); OI prophylaxis TMP-SMX <200, azithro <50 (DHHS 2024 OI); LTBI Rx; vaccinate per CD4 (WHO 2024)
inputs: cd4_count, creatinine, pregnancy_test
advance: ART + OI prophylaxis + vaccinations initiated; partner notification + linkage made
10DISPOSITION
Outpatient HIV clinic; admit only for OI / IRIS / decompensation (DHHS 2024)
advance: continuity arranged
11MONITORING
VL at 4-8 wk, then q3mo until suppressed; CD4 q6mo until >300 stable then annually; lipid/A1c/renal q6-12mo; genotype on virologic failure (DHHS 2024; IAS-USA 2024)
inputs: hiv_viral_load, cd4_count, creatinine
actions: panel.renal, panel.lft
advance: undetectable VL by 6 months
12FOLLOWUP
Engagement support, U=U education (PARTNER NEJM 2016), partner PrEP, sexual health, mental health, comorbidity prevention (DHHS 2024)
advance: lifetime care plan documented