Assessment

History: Medical

Assessment	At HIV diagnosis	Prior to starting ART	Follow-up frequency	Comment	Links
Complete medical history including:	+	+	First visit	On transfer of care repeat assessment	Prevention of CVD Hypertension: Diagnosis, Grading and Management Hypertension: Drug Sequencing Management
• Family history (e.g. premature CVD, diabetes, hypertension, CKD)	+		First visit	Premature CVD: cardiovascular events in a first degree relative (male < 55, female < 65 years)
• Concomitant medicines⁽ⁱ⁾	+	+	Every visit
• Past and current co-morbidities	+	+	Every visit
• Vaccination history	+		Annual	Measure antibody titres and offer vaccinations where indicated, see Vaccination

History: Psychosocial

Assessment	At HIV diagnosis	Prior to starting ART	Follow-up frequency	Comment	Link
Current lifestyle (alcohol use, smoking, diet, exercise, drug use)	+	+	6-12 months	Adverse lifestyle habits should be addressed more frequently Provide advice, support and counselling if needed	Substance use: Alcohol
Employment	+	+	Every visit
Social and Welfare	+	+	Every visit
Psychological morbidity	+	+	Every visit
Partner and children	+		Every visit	Test partner and children if at risk

History: Sexual and Reproductive Health

Assessment	At HIV diagnosis	Prior to starting ART	Follow-up frequency	Comment	Links
Sexual history	+		6-12 months	Risk of sexual transmission should be addressed	Sexual and Reproductive Health Sexual Dysfunction Treatment of Sexual Dysfunction
Safe sex	+		6-12 months	Risk of sexual transmission should be addressed
Partner status and disclosure	+		6-12 months	Recommend starting ART in serodifferent couples
Conception issues	+	+	6-12 months
Hypogonadism	+	+	As Indicated	Persons with complaints of sexual dysfunction
Menopause	+	+	Annual/as indicated	Screen for perimenopause symptoms in women ≥ 40 years

HIV Disease: Virology

Assessment	At HIV diagnosis	Prior to starting ART	Follow-up frequency	Comment	Links
Confirmation of HIV Ab pos	+		3-6 months	More frequent monitoring of HIV-VL at start of ART Perform genotypic resistance test before starting ART if not previously tested or if at risk of super-infection	Recommendations for Initiation of ART in persons with HIV with Chronic Infection Without Prior ART Exposure Initial Combination Regimen for ART-naive Adult persons with HIV Switch strategies for Virologically Suppressed Persons Virological Failure
Plasma HIV-VL	+	+	3-6 months
Genotypic resistance test and sub-type	+	+/-	At virological failure
R5 tropism (if available)		+/-	At virological failure	Screen if considering R5 antagonist in regimen

HIV Disease: Immunology

Assessment	At HIV diagnosis	Prior to starting ART	Follow-up frequency	Comment	Links
CD4 absolute count and %, CD4/ CD8 ratio (optional: CD8 and %)	+	+	3-6 months	Annual CD4 count if stable on ART and CD4 count > 350 cells/µL⁽ⁱⁱ⁾ CD4/CD8 ratio is a stronger predictor of serious outcomes	Recommendations for Initiation of ART in persons with HIV with Chronic Infection Without Prior ART Exposure Initial Combination Regimen for ART-naive Adult persons with HIV
HLA-B*57:01 (if available)	+	+/-		Screen before starting ABC containing ART, if not previously tested

Assessment

At HIV diagnosis

Prior to starting ART

Follow-up frequency

Comment

Links

CD4 absolute count and %, CD4/ CD8 ratio (optional: CD8 and %)

3-6 months

Annual CD4 count if stable on ART and CD4 count > 350 cells/µL⁽ⁱⁱ⁾ CD4/CD8 ratio is a stronger predictor of serious outcomes

Recommendations for Initiation of ART in persons with HIV with Chronic Infection Without Prior ART Exposure

Initial Combination Regimen for ART-naive Adult persons with HIV

HLA-B*57:01 (if available)

+/-

Screen before starting ABC containing ART, if not previously tested

Co-Infections: STIs

Assessment	At HIV diagnosis	Prior to starting ART	Follow-up frequency	Comment	Links
Syphilis serology	+		Annual/ as indicated	Consider more frequent screening if at risk	Sexual and Reproductive Health Primary HIV Infection (PHI)
STI screen	+		Annual/ as indicated	Screen if at risk and during pregnancy

Assessment

At HIV diagnosis

Prior to starting ART

Follow-up frequency

Comment

Links

Syphilis serology

Annual/ as indicated

Consider more frequent screening if at risk

Sexual and Reproductive Health

Primary HIV Infection (PHI)

STI screen

Annual/ as indicated

Screen if at risk and during pregnancy

Co-Infections: Viral Hepatitis

Assessment	At HIV diagnosis	Prior to starting ART	Follow-up frequency	Comment	Links
HAV screen	+		As indicated	Screen if ongoing risk (e.g. MSM); vaccinate if non-immune	Vaccination Viral Hepatitis Co-infections in persons with HIV Treatment and Monitoring of Persons with HBV/HIV Co-infection Treatment and Monitoring of Persons with HCV/HIV Co-infection Hepatitis D and E in persons with HIV
HBV screen	+	+	As indicated	Annual screen if ongoing risk; vaccinate if non-immune. Use ART containing TDF or TAF in vaccine non-responders
HCV screen	+		As indicated	Further screen based on risk behaviour and local epidemiology. Measure HCV-RNA if HCV Ab pos or if recently acquired infection suspected
HDV screen			As indicated	All Persons with positive HBs-Ag should also be screened for HDV co-infection
HEV screen			As indicated	Screen persons with symptoms consistent with acute hepatitis, unexplained flares of aminotransferases or elevated liver function tests, neuralgic amyotrophy, Guillain-Barré, encephalitis or proteinuria. Include anti-HEV IgG and IgM and NAT for HEV-RNA in blood and if possible in stool

Co-Infections: Tuberculosis

Assessment	At HIV diagnosis	Follow-up frequency	Comment	Links
CXR	+	Re-screen if exposure	Consider routine CXR in persons from high TB prevalence populations. Some national guidelines consider the ethnicity, CD4 count and ART usage to define indication for latent tuberculosis infection screening. Use of PPD/IGRA depending on availability and local standard of care. IGRA should, however, be tested before PPD if both are to be used, given the potential for a false positive IGRA after PPD. See Diagnosis and treatment of TB	Diagnosis and Treatment of TB ART: TB/HIV Co-infection
PPD	+	Re-screen if exposure
IGRA in selected high-risk populations (if available)	+	Re-screen if exposure

Assessment

At HIV diagnosis

Prior to starting ART

Follow-up frequency

Comment

Links

CXR

Re-screen if exposure

Consider routine CXR in persons from high TB prevalence populations.

Some national guidelines consider the ethnicity, CD4 count and ART usage to define indication for latent tuberculosis infection screening.

Use of PPD/IGRA depending on availability and local standard of care. IGRA should, however, be tested before PPD if both are to be used, given the potential for a false positive IGRA after PPD.

See Diagnosis and treatment of TB

Diagnosis and Treatment of TB

ART: TB/HIV Co-infection

PPD

Re-screen if exposure

IGRA in selected high-risk populations (if available)

Re-screen if exposure

Co-Infections: Others

Assessment	At HIV diagnosis	Follow-up frequency	Comment	Links
Varicella zoster virus serology	+		Offer vaccination where indicated	Vaccination
Measles/Rubella serology	+		Offer vaccination where indicated
Toxoplasmosis serology	+
CMV serology	+
Cryptococcus antigen	+/-		Consider screening for cryptococcus antigen in serum in persons with CD4 count < 100 cells/µL
Leishmania serology	+/-		Screen according to travel history/origin
Tropical screen (e.g. Schistosoma serology)	+/-		Screen according to travel history/origin
Influenza virus	+	Annual	In all persons with HIV, see Vaccination
Streptococcus pneumoniae	+		No recommendations available regarding the need for a booster dose, see Vaccination
Human papilloma virus	+	As indicated	Vaccinate all persons with HIV with 3 doses between ages 9 and 40. If HPV infection is established, efficacy of vaccine is questionable, see Vaccination
SARS-CoV-2			In a pandemic situation, vaccinate irrespective of CD4 count and HIV-VL according to national guidelines

Co-Morbidities

Assessment	At HIV diagnosis	Prior to starting ART	Follow-up frequency	Comment
Haematology: FBC	+	+	3-12 months
Haematology: Haemoglobinopathies	+			Screen at risk persons
Haematology: G6PD	+			Screen at risk persons
Body Composition: Body mass index	+	+	Annual	See Lifestyle Interventions
Cardiovascular Disease: Risk assessment ⁽ⁱⁱⁱ⁾	+	+	Annual	Should be performed in all men > 40 years and women > 50 years without CVD See Prevention of CVD
Cardiovascular Disease: ECG	+	+/-	As indicated	Consider baseline ECG prior to starting ARVs associated with potential conduction problems
Hypertension: Blood pressure	+	+	Annual	See: Hypertension: Diagnosis, Grading and Management Hypertension: Drug Sequencing Management
Lipids: TC, HDL-c, LDL-c, TG^(iv)	+	+	Annual	Repeat in fasting state if used for medical intervention (i.e. ≥ 8 h without caloric intake) See Dyslipidaemia
Glucose: Serum glucose	+	+	Annual	Consider oral glucose tolerance test / HbA1c if fasting glucose levels of 5.7-6.9 mmol/L (100-125 mg/dL) See Type 2 Diabetes: Diagnosis & Management
Pulmonary Disease: Respiratory symptoms and risk factors^(xii)	+	+	Annual	If severe shortness of breath is reported with preserved spirometry, echocardiography may be performed to rule out heart failure and/or pulmonary hypertension See Chronic Lung Disease in HIV
Pulmonary Disease: Spirometry			As indicated	Spirometry should be performed in all symptomatic persons^(xii) See Chronic Lung Disease in HIV
Liver Disease: Risk assessment^(v)	+	+	Annual	See: Management of PLWH with Increased ALT/AST Liver Cirrhosis: Classification and Surveillance Management of persons with HIV with Cirrhosis Non-Alcoholic Fatty Liver Disease (NAFLD) Diagnosis and Management of Hepatorenal Syndrome (HRS)/acute kidney injury (AKI) Dose adjustment of ARVs for Impaired Hepatic Function
Liver Disease: ALT/AST, ALP, Bilirubin	+	+	3-12 months	More frequent monitoring prior to starting and on treatment with hepatotoxic drugs See: Management of persons with HIV with Increased ALT/AST Liver Cirrhosis: Classification and Surveillance Management of persons with HIV with Cirrhosis Non-Alcoholic Fatty Liver Disease (NAFLD) Diagnosis and Management of Hepatorenal Syndrome (HRS)/Acute kidney Injury(AKI) Dose adjustment of ARVs for Impaired Hepatic Function
Liver Disease: Staging of liver fibrosis			12 months	In HCV and/or HBV co-infected persons and/or persons with HIV at risk for NAFLD (as per algorithm on page 82) > every 2-3 years (e.g. FibroScan, serum fibrosis markers) See: Liver Cirrhosis: Classification and Surveillance Management of persons with HIV with Cirrhosis Treatment of HCV in Persons with HCV/HIV Co-infection Viral Hepatitis Co-Infections in persons with HIV
Liver Disease: Hepatic ultrasound			6 months	Persons with liver cirrhosis^(xiii) See: Management of persons with HIV with Cirrhosis General recommendations for persons with Viral Hepatitis/HIV co-infection Treatment of HCV in Persons with HCV/HIV Co-infection
Renal Disease: Risk assessment^(vi)	+	+	Annual	More frequent monitoring if eGFR < 90mL/min, CKD risk factors present^(vi) and/or prior to starting and on treatment with nephrotoxic drugs^(ix) See: Kidney Disease: Definition, Diagnosis and Management ARV-associated Nephrotoxicity Indications and Tests for Proximal Renal Tubulopathy (PRT) Dose adjustment of ARVs for Impaired Renal Function
Renal Disease: eGFR (CKD-EPI)^(vii)	+	+	3-12 months
Renal Disease: Urine dipstick analysis^(viii)	+	+	Annual	Every 6 months if eGFR < 60 mL/min or rapid decline in eGFR, if proteinuria ≥ 1+ and/or eGFR < 60 mL/min perform UA/C or UP/C^(viii) See: Kidney Disease: Definition, Diagnosis and Management ARV-associated Nephrotoxicity Indications and Tests for Proximal Renal Tubulopathy (PRT) Dose adjustment of ARVs for Impaired Renal Function
Bone Disease: Bone profile: calcium, PO₄, ALP	+	+	6-12 months	See: Bone Disease: Screening and Diagnosis Approach to Fracture Reduction in PLWH
Bone Disease: Risk assessment^(x) (FRAX®^(xi) in persons > 40 years)	+	+	2 years	Consider DXA in specific persons See: Bone Disease: Screening and Diagnosis Approach to Fracture Reduction in persons with HIV
Vitamin D: 25(OH) vitamin D	+		As indicated	Screen at risk persons See Vitamin D Deficiency: Diagnosis and Management
Cognitive Impairment: Screening questionnaire	+	+	As indicated	Screen all persons without highly confounding conditions. If abnormal or symptomatic, see algorithm Cognitive Impairment for further assessment.
Anxiety: Questionnaire	±	±	As indicated	Consider screening at each routine HIV clinic visit See: Anxiety Disorders: Screening and Diagnosis Anxiety Disorders: Management
Depression: Questionnaire	+	+	As indicated	Consider screening at each routine HIV clinic visit See: Depression: Screening, Diagnosis, Management Classification, Doses, Safety and Adverse Effects of Antidepressants
Older persons: Polypharmacy review			Annual	Perform periodic medicines review See: Managing Older persons with HIV
Older persons: Frailty			Annual	Screen with Gait walking speed, Short Physical Performance Battery (SPPB), FRAIL Scale (FS) or Clinical Frailty Scale (CFS) See: Frailty
Older persons: Falls			Annual	See: Falls
Cancer: Mammography			1-3 years	Women 50-74 years See: Cancer: Screening Methods
Cancer: Cervical PAP or liquid based cytology			1-3 years	Women with HIV > 21 years, as per national guidelines See: Cancer: Screening Methods
Cancer: Rectal exam, anal cytology and anoscopy			1-3 years	MSM and persons with HPV-associated dysplasia See: Cancer: Screening Methods
Cancer: Ultrasound and alpha-foetoprotein			6 months	Controversial; persons with cirrhosis and persons with HBV co-infection at high risk of HCC^(xiii) See: Cancer: Screening Methods Management of persons with HIV with Cirrhosis Viral Hepatitis Co-infections in persons with HIV
Cancer: Prostate cancer (PSA)			1-2 years	Controversial; men > 50 years with a life expectancy >10 years See: Cancer: Screening Methods
Cancer: Others			As indicated	Lung cancer and colorectal cancer screening according to local screening programmes See: Cancer: Screening Methods

If a person has been stable on ART for 6 months or more, with no other significant issues, clinicians could consider using alternative modalities such as email/phone/or other electronic means (Good Practice Point, GPP).
This form of consultation can have the same validity as a face-to-face consultation if properly instituted in a clinical protocol.
The European Union funded EmERGE project is currently looking at such interventions https://www.emergeproject.eu

Footnotes

Review all concomitant medicines which may potentially interact with ARVs or increase co-morbidities, see

Drug-drug Interactions between ARVs and non-ARVs
Drug-drug Interactions between Analgesics and ARVs
Drug-drug Interactions between Anticoagulants/Antiplatelet Agents and ARVs
Drug-drug Interactions between Antidepressants and ARVs
Drug-drug Interactions between Antihypertensives and ARVs
Drug-drug Interactions between Anti-infective Drugs for Ols and STIs and ARVs
Drug-drug Interactions between Anti-malarial Drugs and ARVs
Drug-drug Interactions between Anti-tuberculosis Drugs and ARVs
Drug-drug Interactions between Anxiolytics and ARVs
Drug-drug Interactions between Bronchodilators (for COPD) and ARVs
Drug-drug Interactions between Contraceptives and ARVs
Drug-drug Interactions between Corticosteroids and ARVs
Drug-drug Interactions between COVID-19 Therapies and ARVs
Drug-drug Interactions between Hormone Replacement Therapy (HRT) and ARVs
Drug-drug Interactions between Immunosuppressants (for SOT) and ARVs
Drug-drug Interactions between Pulmonary Antihypertensives and ARVs
Drug-drug Interactions between Viral Hepatitis Drugs and ARVs
and http://www.hiv-druginteractions.org
If stable on ART with undetectable HIV-VL and CD4 count > 350 cells/μL, suggest annual
CD4 count
SCORE2 (40-69y) or SCORE2-OP (>70y) is the principal tool for cardiovascular disease risk estimation in primary prevention in “apparently heathy people”. The cardiovascular disease risk estimation calculator can be found here: www.heartscore.org/en_GB/ Of note, if an individual receives medicines to control dyslipidaemia and/ or hypertension, the estimation should be interpreted with caution
A calculator for LDL-cholesterol in cases where TG is not high can be found at https://www.mdcalc.com/ldl-calculated
Risk factors for chronic liver disease include alcohol, viral hepatitis, obesity, diabetes, insulin resistance, hyperlipidaemia and hepatotoxic drugs
Risk factors for CKD: hypertension, diabetes, CVD, family history, black African ethnicity, viral hepatitis, low current CD4 count, smoking, older age, concomitant nephrotoxic drugs
eGFR: use CKD-EPI formula based on serum creatinine, gender, age and ethnicity because eGFR quantification is validated > 60 mL/min. The abbreviated modification of diet in renal disease (aMDRD) or the Cockroft-Gault (CG) equation may be used as an alternative; see https://www.chip.dk/Tools-Standards/Clinical-risk-scores
Some experts recommend UA/C (urinary albumin creatinine ratio) or UP/C (urinary protein creatinine ratio) as a screening test for proteinuria in all persons. UA/C predominantly detects glomerular disease. Use in persons with diabetes. UP/C detects total protein secondary to glomerular and tubular disease and can be used for screening for ARV toxicity. See: Kidney Disease: Definition, Diagnosis and Management
Different models have been developed for calculating a 5-year CKD risk score while using different nephrotoxic ARVs, integrating HIV independent and HIV-related risk factors
Classic risk factors: older age, female gender, hypogonadism, family history of hip fracture, low BMI (≤ 19 kg/m² ), vitamin D deficiency, smoking, physical inactivity, history of low impact fracture, alcohol excess (> 3 units/day), steroid exposure (minimum 5 mg for > 3 months)
WHO fracture risk assessment (FRAX®) tool: http://www.shef.ac.uk/FRAX
Respiratory symptoms: shortness of breath, chronic cough and sputum. Risk factors: tobacco, occupation, in- and outdoor pollution and host factors including previous PCP or TB, recurrent pneumonia and Alpha-1 antitrypsin deficiency. A diagnosis of COPD should be considered in persons over the age of 35 years who have a risk factor (current or ex-smoker) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter ‘bronchitis’ or wheeze
HCC screening is indicated in all cirrhotic HBV or HCV co-infected persons (even if HCV infection has been cured and HBV replication is medically suppressed) in a setting where treatment for HCC is available. Although the cost-effectiveness of HCC screening in persons with F3 fibrosis* is uncertain, surveillance may be considered based on an individual risk assessment (https://easl.eu/publication/easl-clinical-practice-guidelines-management-of-hepatocellular-carcinoma/). In HBV-positive non-cirrhotics, HCC screening should follow current EASL guidelines. Risk factors for HCC in this population include family history of HCC, ethnicity (Asians, Africans), HDV and age > 45 years. EASL guidelines propose using the PAGE-B score in Caucasians to assess the HCC risk. See: Drug Classes To Avoid in Older Persons with HIV , Kidney Disease: Definition, Diagnosis and Management, and The use of Patient Reported Outcome Measures (PROMs) in HIV Clinical Care

* See table on cut-off values of non-invasive tests for the detection of significant fibrosis and cirrhosis, see: Tests: Fibrosis/Cirrhosis. The combination of blood biomarkers, the combination of liver stiffness measurement and blood tests assessments may improve accuracy, see (https://easl.eu/publication/easl-recommendations-treatment-of-hepatitis-c/, free registration needed to get access)