Baseline Clinical Evaluation for Adults and Adolescents, Pregnant Women, and Children < 10 years
2023 ART Guidelines
Recognise the Client with Respiratory, Neurological, or Abdominal Danger Signs Needing Urgent Care
Additional TB Investigations for Symptomatic Clients
Screen for Symptoms of Meningitis
Screen for Active Depression, Other Mental Health Issues or Substance Abuse
Screen for Major Chronic Non-Communicable Diseases (NCDs) (Diabetes, Hypertension, Epilepsy)
Screen for Pregnancy and Ask if Planning to Conceive
Symptom Screen for Sexually Transmitted Infections (STIs)
The baseline clinical evaluation of a client about to start ART requires a thorough history and clinical examination.
The minimum components of the baseline clinical evaluation are outlined below.
Click here to open the original PDF view of the information detailed below.
Recognise the client with respiratory, neurological, or abdominal danger signs needing urgent care
Purpose: To identify opportunistic infections and conditions needing urgent care or referral See also the section on "Advanced HIV Disease" in the 2023 Consolidated ART Guideline.
Adolescents (10-19 years) and Adults: Identify respiratory, neurological, or abdominal danger signs as outlined in Adult Primary Care (APC) guideline.
Pregnant Women: Identify danger signs as outlined in the Maternity Care guidelines.
Children (< 10 years): Identify danger signs as classified in the IMCI Chart booklet.
Nutritional Assessment
Purpose: To identify recent weight loss that may indicate an active opportunistic infection (OI) or other pathology. To identify underweight/ obese clients requiring nutritional and lifestyle support.
Adolescents (10-19 years) and Adults: Measure weight and height and determine BMI (kg/m2 ):
< 18.5 = underweight;
18.5 to 25 = normal;
> 25 to < 30 = overweight;
≥30 = obese.
Pregnant Women: Measure mid upper arm circumference (MUAC) .Women with MUAC < 23 cm require additional nutritional support/ referral.
Children (< 10 years): Plot weight, height and head circumference (if < 2 years) on growth chart, and measure MUAC to identify moderate and severe malnutrition.
Test for TB
Purpose: To identify clients who require treatment for TB. To identify clients who do not have active TB and who may be eligible for TPT see TB Preventive Therapy
Adolescents (10-19 years) and Adults: At enrolment into care/ ART start:
- TB symptom screen and clinical examination.
- Routine MTB/Rif Ultra (Xpert) on all PLHIV at enrolment into ART care (regardless of TB symptoms).
Pregnant Women: For all HIV-positive women at first visit in antenatal clinic, do a:
- TB symptom screen and clinical examination.
- Routine MTB/ Rif Ultra (Xpert) (regardless of TB symptoms).
Children (< 10 years): Identify symptoms of cough, night sweats, fever, failure to thrive as outlined in the TB screening tool. Attempt sputum testing (and Xpert) where feasible. Enquire about TB contacts.
Additional TB Investigations for Symptomatic Clients:
For symptomatic PLHIV admitted to hospital
[in addition to the MTB/Rif Ultra (Xpert)]
- Do a U-LAM test
- Do a chest X-ray if clinically indicated
- Do other investigations for extra-pulmonary TB if clinically indicated
Enquire about TB contacts.
For symptomatic PLHIV seen in an outpatient setting
[in addition to the MTB/Rif Ultra (Xpert)]
- Do a U-LAM test if:
- CD4 count <200 within the last 6 months, or
- advanced HIV disease, or
- current serious illness.
- Do a chest X-ray if clinically indicated .
Screen for symptoms of meningitis
Purpose: To diagnose and treat clients with cryptococcal and other forms of meningitis and reduce associated morbidity and mortality.
Adolescents (10-19 years) and Adults, Pregnant Women & Children (< 10 years): Identify symptoms of headache, confusion or visual disturbances. With cryptococcal meningitis, clients may only present with a recurrent headache. Other symptoms may include fever, neck stiffness or coma. Do/refer the client for a lumbar puncture. Defer ART if meningitis is confirmed as outlined in Medical Indications to Defer ART.
Screen for active depression, other mental health issues or substance abuse
Purpose: Mental health conditions and substance use can affect adherence and the client's quality of life. In general, ART can be initiated, and cautiously monitored see also "Mental Health Assessment".
Adolescents (10-19 years) and Adults & Pregnant Women: Screen for symptoms of depression, psychosis, and substance abuse.
Children (< 10 years): Screen for symptoms of depression in older children.
Screen for major chronic non-communicable diseases (NCDs) (diabetes, hypertension epilepsy)
Purpose: To identify and manage clients with major chronic NCDs and/or comorbidities. To identify and prevent potential drug interactions with ART e.g. metformin and anti-epileptic medications.
Adolescents (10-19 years) and Adults: Do blood pressure (BP), and urine dipstix for proteinuria and glucose. Identify other risk factors (smoking, increased waist circumference, age) and determine cardiovascular (CVS) risk. Manage NCDs and CVS risk factors as outlined in the PHC EML.
Pregnant Women: Do blood pressure (BP), and urine dipstix for proteinuria and glucose.
Children (< 10 years): Identify the child with epilepsy and be aware of potential drug interactions of anti-epileptic treatment and ART.
Screen for pregnancy and ask if planning to conceive
Purpose: To identify pregnancy and facilitate early referral for antenatal care (ANC) and measures to prevent vertical transmission. To assess fertility intentions and contraceptive needs if not pregnant.
Adolescents (10-19 years) and Adults: Ask if the client is currently using contraception and if her last menstrual period occurred at the expected time. If she answered “no” to either question, do a urine pregnancy test.
Symptom screen for sexually transmitted infections (STIs)
Purpose: To identify and treat STIs in sexually active clients.
Adolescents (10-19 years) and Adults & Pregnant Women:: STI screening should include the following three questions:
“Do you have any genital discharge?”
“Do you have any genital ulcers?”
“Has/have your partner(s) been treated for an STI in the last 8 weeks?
Neurodevelopmental screen
Purpose: To identify children with neurodevelopmental delay requiring intervention/referral and follow-up.
Children (< 10 years): Screen for developmental delays as outlined in the child's Road to Health Booklet (RTHB).
WHO clinical stage
After the baseline clinical evaluation has been completed by means of a thorough history and clinical examination, the client’s WHO clinical stage can be determined:
At ART initiation, WHO clinical stage helps us to:
- Understand the severity of the client’s clinical condition and the associated risk of mortality
- Determine the urgency and timing of ART initiation
- Determine if cotrimoxazole prophylaxis (CPT) is indicated see Indications for Starting and Stopping Cotrimoxazole Preventive Therapy
2023 ART Clinical Guidelines for the Management of HIV in Adults, Pregnancy and Breastfeeding, Adolescents, Children, Infants and Neonates
June 2023 Version 4
Upload date: 28/07/2023