Baseline Assessment Prior to Initiating ART and On-treatment Monitoring

Baseline Assessment Prior to Initiating ART and On-treatment Monitoring

Prior to initiating ART, every HIV-infected patient entering into care should have a complete medical history, physical examination, and laboratory evaluation and should be counseled regarding the implications of HIV infection and the benefits of ART in suppressing the virus, restoring and maintaining immune function, reducing morbidity and mortality, improving quality of life, and preventing HIV transmission.

Complete medical history, physical examination, and laboratory evaluation are equally important in the case of previously treated patients who enter care with a new provider.

This section provides a basic overview of baseline assessment and on-treatment monitoring requirements. Further information may be found in the detailed guidelines set for by governmental and nongovernmental entities including the World Health Organization (WHO) and regional governmental and nongovernmental organizations including the European AIDS Clinical Society (EACS), and the United States (US) Department of Health and Human Services (DHHS).1-3

The following laboratory tests may be used to stage HIV disease and to assist in the selection of an appropriate ART regimen:

• HIV antibody testing (if prior documentation is not available or if HIV RNA is below the assay’s limit of detection)
• CD4 T-cell count (CD4 count)
• Plasma HIV RNA (viral load)
• Complete blood count, chemistry profile, transaminase levels, blood urea nitrogen (BUN), and creatinine, urinalysis, and serologies for hepatitis A, B, and C viruses
• Fasting blood glucose and serum lipids
• Genotypic resistance testing at entry into care, regardless of whether ART will be initiated immediately. For patients who have HIV RNA levels <500 to 1,000 copies/mL, viral amplification for resistance testing may not always be successful

Special Considerations for Some ART agents

• A viral tropism assay should be performed before initiating treatment with a CCR5 antagonist or if virologic failure occurs while a patient is receiving a CCR5 antagonist
• HLA-B*5701 testing must be performed before initiation of abacavir, and abacavir should be used only in patients who are HLA-B*5701 negative and with pre-treatment HIV RNA <100,000 copies/mL
• As the treatment of hepatitis B or hepatitis C virus co-infection may impact the choice of ART, patients should be screened for these co-infections before initiating ART

Laboratory monitoring while on ART

• CD4 Count and viral load testing should continue periodically for the duration of ART. See guidelines for specific recommendations regarding frequency of laboratory monitoring)1-4
• Resistance testing when considering a change in regimen; however, if viral load remains <500 to 1,000 copies/mL, viral amplification for resistance testing may not always work

References:

  1. World Health Organization. Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach. Geneva: World Health Organization; 2013 Jun.
  2. European AIDS Clinical Society. Guidelines Version 8.0. October 2015.
  3. Department of Health and Human Services. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. January 2016.