Antiretroviral Lab Monitoring

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ANTIRETROVIRAL LAB MONITORING
Laboratory Monitoring Schedule for Patients Before
and After Initiation of Antiretroviral Therapy
  Baseline Initiation
or
modifica-
tiona
Follow-up
2−8 weeks
after
initiation or
modification
Every
3−6 months
Every
6 months
Every
12 months
Treatment
failure
Clini-
cally
indi-
cated
Delayed
initiation
HIV serology If diagnosis has not been confirmed                
CD4 count   During first 2yrs of ART or if viremia develops while patient on ART or CD4 count <300 cells/mm³   After 2yrs on ART with consistently suppressed viral load: if CD4 count 300−500 cells/mm³, monitor every 12 months. CD4 count >500 cells/mm³, monitoring is optional Every 3−6mos
HIV viral load b c c   Repeat testing is optional
Resistance testing d         d
HLA-B*5701 testing   If consi-
dering ABC
             
Tropism testing   If consi-
dering CCR5 antagonist
        If consi-
dering CCR5 antagonist or CCR5 antagonist-based regimen failed
 
Hepatitis B serologye May repeat if nonimmune and no chronic HBV infection       May repeat if nonimmune and no chronic HBV infection    
Hepatitis C serology with confirmation of positive results May repeat if at-risk with negative baseline result       May repeat if at-risk with negative baseline result    
Basic chemistryf,g       Every 6−12mos
ALT, AST, T. bilirubin       Every 6−12mos
CBC with differential If on ZDV If on ZDV or CD4 testing done     Every 3−6mos
Fasting lipid profile     If abnormal at last measure-
ment
If normal at last measure-
ment
  If normal at baseline, annually
Fasting glucose or hemoglobin A1C   If abnormal at last measure-
ment
  If normal at last measure-
ment
  If normal at baseline, annually
Urinalysisg,h     If on TAF or TDFh    
Pregnancy test   In women with child-bearing potential            
NOTES

This table pertains to laboratory tests done to select an ARV regimen and monitor for treatment responses or ART toxicities. Please refer to the HIV Primary Care guidelines for guidance on other laboratory tests generally recommended for primary health care maintenance of HIV patients.

a. If ART initiation occurs soon after HIV diagnosis, repeat baseline testing is not necessary.

b. If HIV RNA is detectable at 2−8 weeks, repeat every 4−8 weeks until suppression to <200 copies/mL, then every 3−6 months.

c. Viral load typically is measured every 3−4 months in patients on ART. However, for adherent patients with consistently suppressed viral load and stable immunologic status for ≥2yrs, may extend monitoring to 6-month intervals.

d. Standard genotypic drug-resistance testing in ART-naive patients should focus on mutations in the reverse transcriptase and protease genes. Also test for mutations to integrase strand transfer inhibitors if resistance is a concern. In ART-naive patients, if resistance testing was performed at entry into care, repeat testing before initiation of ART is optional. For virologically suppressed patients who are switching therapy for toxicity or convenience, viral amplification will not be possible and therefore resistance testing should not be performed. Results from prior resistance testing can be used to help in the construction of a new regimen.

e. If HBsAg (+), TDF or TAF plus either FTC or 3TC should be used as part of the ARV regimen to treat both HBV and HIV infections. If HBsAg, and HBsAb, and anti-HBc are negative at baseline, hepatitis B vaccine series should be administered.

f. Serum Na, K, HCO3, Cl, BUN, creatinine, glucose (preferably fasting), and creatinine-based estimated GFR. Monitor serum phosphorus in patients with CKD who are on TAF- or TDF-based regimens.

g. For patients with renal disease, consult the Guidelines for the Management of Chronic Kidney Disease in HIV-Infected Patients: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. More frequent monitoring may be indicated for patients with evidence of kidney disease (eg, proteinuria, decreased glomerular dysfunction) or increased risk of renal insufficiency (eg, patients with diabetes, hypertension).

h. Assess urine glucose and protein before initiating TAF- or TDF-based regimens, and monitor during treatment.

 

Acronyms: 3TC = lamivudine, ABC = abacavir, ALT = alanine aminotransferase, ART = antiretroviral therapy, AST = aspartate aminotranserase, CBC = complete blood count, CKD = chronic kidney disease, CrCl = creatinine clearance, EFV = efavirenz, FTC = emtricitabine, GFR = glomerular filtration rate, HBsAb = hepatitis B surface antibody, HBsAg = hepatitis B surface antigen, HBV = hepatitis B virus, TAF = tenofovir alafenamide, TDF = tenofovir disoproxil fumarate, ZDV = zidovudine

REFERENCES

Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf. Accessed August 10, 2017 [Table 3].

(Rev. 8/2017)

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