Age based scores/tests as per monitoring guidelines
- FRAX for all>50 and post-menopausal women (or otherwise at risk)
- QRISK for all >40
- Cervical screening age 25-65
- Rubella in women of childbearing age
Blood tests at initial baseline appointment
- Confirmation of HIV status, testing for primary HIV infection
- HIV VL, HIV resistance test
- CD4
- Hepatitis A, B, C
- Measles, varicella Abs
- Full STI screen including syphilis
- General: FBC, LFT, renal, bone
- (Dipstick urine and UPCR if any protein)
- (HLAB5701, viral tropism if CCR5 being considered, IGRA if appropriate)
Frequency of monitoring if not on ART depending on CD4
- If CD4>500 annually do: HIV VL, CD4, FBC/renal/liver, STI, hepatitis, cervical smear
- If CD4 <500 do 6 monthly CD4
- If CD4<350 do 3 monthly CD4, STI/hepatitis for higher risk
Also annual lipids in patients>40/smoker/BMI>30
QRISK if>40
FRAX if >50 every 3 years
Monitoring in the first 6 months after starting ART
- See them at 2-4 weeks, 3 months and 6 months and do:
- Take history, adherence/tolerability check
- Renal/liver/urinalysis (FBC only if unwell or has started zidovudine in which case test after 6 weeks, 12 weeks then 3 monthly)
- If baseline CD4<350 check at 3 months and repeat at 6 months if still <350
- Measure HIV VL at 1, 3, and 6 months
(If VL does not fall at least 10-fold or 1 Log after 1 month, repeat at 2 months post ART start)
Monitoring of patients established on ART with VL<20
- VL every 6 months (could be up to 12 if on PI)
- If CD4<200 then repeat every 3-6 months
- If CD4 200-350 test annually
- If CD4>350 on 2 occasions >1 year apart, no further required
- 6-12 monthly: FBC/renal/liver/bone/urine dip
- Annually: UPCR if protein in dipstick, metabolic assessment (if aged>40): lipids and Hba1c
Monitoring of low level viraemia
- VL>50 adherence check then if repeat <50 no further action (one off blip, not associated with increased risk VF)
- VL repeat 50-200: adherence check/DDI, do resistance test
- If stable at 50-200 do 3-4 monthly VL
- Resistance testing if gradual increase inVL, no need for repeat more than once a year if VL stable
- VL >200: if second result above 200 take action
- Careful assessment of patients with frequent ‘blips’ and/or one off measurements above 200 as these can sometimes be associated with viral rebound and virological failure
What tests to do if see undetectable HIV VL not on treatment?
- Review HIV 1 and 2 serology
- Check VL on another assay
Frequency of patient review based on CD4
CD4<350: 3-6 monthly
CD4 350-500: 6 monthly
CD4>500: 6-12 monthly
Screening for complications in hepatitis B and C
- In cirrhotics do 6 month HCC screening and then endoscopy at diagnosis, if no varices then repeat 2-3 yearly
Treatment monitoring in hepatitis B
- All patients with both HIV and Hep B should be on treatment for Hep B with ideally TDF/TAF, if cannot use these then entecavir
- LFTs 3 monthly in the first year and then 6-12 months
- HBV DNA 4-6 monthly in the first month then 12 monthly
- HBsAg checked yearly to see if loss of antigen
- Quantitative HBsAg<1000 predicts loss
HBV reactivation prevention (e.g. HBsAg negative, anti-HBc positive undergoing immunosuppression)
- If severe immunosuppressive therapy such as chemo for lymphoma or stem cell or solid organ transplant, ensure TDF/TAF
- If B cell depleting agents like rituximab/alemtuzumab then TDF/TAF or if contraindicated entecavir/3tc/ftc
- In those not on HBV active ART who receive other forms of immunosuppression e.g. anti-TNF alpha, monitor HBV DNA and HBsAg
Definition of SVR
Undetectable HCV at 12 weeks after end of therapy
HCV confirmed, repeat HCV RNA at week 4, what log reduction might you repeat RNA at week 12 rather than immediate treatment?
- If >2 log reduction in RNA by week 4, can consider repeating RNA at week 12 to see if spontaneously cleared
- If negative at week 12, confirm fully with RNA at 24 and 48 weeks
