Assessment of PLWH at Initial & Subsequent Visits

History: Medical

Assessment At HIV diagnosis Prior to starting ART Follow-up frequency Comment
Complete medical history including: + + First visit On transfer of care repeat assessment
• 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

Links:
Prevention of CVD
Hypertension: Diagnosis and Grading
Hypertension: Drug Sequencing Management
Type 2 Diabetes: Diagnosis & Management
Kidney Disease: Definition, Diagnosis and Management

History: Psychosocial

Assessment At HIV diagnosis Prior to starting ART Follow-up frequency Comment
Current lifestyle (alcohol use, smoking, diet, exercise, drug use) + + 6-12 months Adverse lifestyle habits should be addressed more frequently

Provide advice and support if needed
Provide counseling if needed

 


Test partner and children if at risk

Employment + + Every visit
Social and Welfare + + Every visit
Psychological morbidity + + Every visit
Partner and children +   Every visit

Link: Lifestyle Interventions

History: Sexual and Reproductive Health

Assessment At HIV diagnosis Prior to starting ART Follow-up frequency Comment
Sexual history +   6-12 months Address issues concerning sexual dysfunction
Risk of sexual transmission should be addressed
Safe sex +   6-12 months
Partner status and disclosure +   6-12 months Recommend starting ART in serodifferent couples
Conception issues + + 6-12 months  
Hypogonadism (including menopause) + + As Indicated Persons with complaints of sexual dysfunction

Links:
Sexual and Reproductive Health
Sexual Dysfunction
Treatment of Sexual Dysfunction in Men

Post-Reproductive Health: Menopause

Assessment At HIV diagnosis Prior to starting ART Follow-up frequency Comment
  + + Annual/as indicated Screen for perimenopause symptoms in women ≥ 40 years.

Links:
Sexual and Reproductive Health

HIV Disease: Virology

Assessment At HIV diagnosis Prior to starting ART Follow-up frequency Comment
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
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

Links:

Recommendations for Initiation of ART in PLWH with Chronic Infection Without Prior ART Exposure
Initial Combination Regimen for ART-naive Adult PLWH
Primary HIV Infection (PHI)
Switch strategies for Virologically Suppressed Persons
Virological Failure
ARV Adverse Effects & Drug Classes

HIV Disease: Immunology

Assessment At HIV diagnosis Prior to starting ART Follow-up frequency Comment
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
HLA-B*57:01 (if available) + +/-   Screen before starting ABC containing ART, if not previously tested

Links:
Recommendations for Initiation of ART in PLWH with Chronic Infection Without Prior ART Exposure
Initial Combination Regimen for ART-naive Adult PLWH
Primary HIV Infection (PHI)
Switch strategies for virologically suppressed persons
Virological Failure
ARV Adverse Effects & Drug Classes

Co-Infections: STIs

Assessment At HIV diagnosis Prior to starting ART Follow-up frequency Comment
Syphilis serology +   Annual/ as indicated Consider more frequent screening if at risk
STI screen +   Annual/ as indicated Screen if at risk and during pregnancy

 Links: 

Sexual and Reproductive Health
Primary HIV Infection (PHI)

Co-Infections: Viral Hepatitis

Assessment At HIV diagnosis Prior to starting ART Follow-up frequency Comment
HAV screen +   Annual/ as indicated Screen at risk (e.g. MSM); vaccinate if non-immune
HBV screen + + Annual/ as indicated

Annual screen in susceptible persons; vaccinate if
non-immune. Use ART containing TDF or TAF in vaccine non-responders

HCV screen +   Annual/ as indicated

Annual screen if ongoing risk (e.g. MSM, IVDU)
Measure HCV-RNA if HCV Ab pos or if acute 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

Links:
Vaccination
Viral Heaptitis Co-infections in PLWH
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 PLWH

Co-Infections: Tuberculosis

Assessment At HIV diagnosis Prior to starting ART Follow-up frequency Comment
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 in PLWH

PPD +   Re-screen if exposure
IGRA in selected high-risk populations (if available) +   Re-screen if exposure

Links:
Diagnosis and Treatment of TB in PLWH
ART: TB/HIV Co-infection

Co-Infections: Others

Assessment At HIV diagnosis Prior to starting ART Follow-up frequency Comment
Varicella zoster virus serology +     Offer vaccination where indicated
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. See Cryptococcal Meningitis
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 PLWH, see Vaccination
Streptococcus pneumoniae +     No recommendations available regarding the need for a booster dose, see Vaccination
Human papilloma virus +   As indicated Vaccinate all PLWH with 3 doses between ages 9 and 40. If HPV infection is established, efficacy of vaccine is questionable, see Vaccination

Links:  
Vaccination
Primary Prophylaxis of OIs

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 (Framingham score(iii)) + + 2 years

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. ≥ 8h 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 PLWH with Cirrhosis
Non-Alcoholic Fatty Liver Disease (NAFLD)
Diagnosis and Management of Hepatorenal Syndrome (HRS)
Dose adjustment of ARVs for Impaired Renal 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 PLWH with Increased ALT/AST
Liver Cirrhosis: Classification and Surveillance
Management of PLWH with Cirrhosis
Non-Alcoholic Fatty Liver Disease (NAFLD)
Diagnosis and Management of Hepatorenal Syndrome (HRS)
Dose adjustment of ARVs for Impaired Renal Function

Liver Disease: Staging of liver fibrosis     12 months

In HCV and/or HBV co-infected persons (e.g. FibroScan, serum fibrosis markers)

See: 
Liver Cirrhosis: Classification and Surveillance
Management of PLWH with Cirrhosis
Treatment of HCV in Persons with HCV/HIV Co-infection
Viral Hepatitis Co-Infections in PLWH
Liver Disease: Hepatic ultrasound     6 months

Persons with liver cirrhosis(xiii)

See: 
Management of PLWH 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 PLWH

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 Neurocognitive Impairment for further assessment.

Depression: Questionnaire + + As indicated

Screen at risk persons

See:
Depression: Screening, Diagnosis, Management
Classification, Doses, Safety and Adverse Effects of Antidepressants

Cancer: Mammography     1-3 years

Women 50-70 years

See: 
Cancer: Screening Methods 
Management of P PLWH with Cirrhosis
Virall Hepatitis Co-infections in PLWH
Cancer: Cervical PAP or liquid based cytology     1-3 years

Women > 21 years

See: 
Cancer: Screening Methods 
Management of PLWH with Cirrhosis
Viral Hepatitis Co-infections in PLWH
Cancer: Rectal exam and anoscopy     1-3 years

MSM and persons with HPV-associated dysplasia. Evidence of benefit not known

See: 
Cancer: Screening Methods
Management of PLWH with Cirrhosis
Viral Hepatitis Co-infections in PLWH
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 PLWH with Cirrhosis
Viral Hepatitis Co-infections in PLWH
Cancer: Others       

Controversial

See: 
Cancer: Screening Methods
Management of PLWH with Cirrhosis
Viral Hepatitis Co-infections in PLWH

 

If PLWH have 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 (Graduate partnership programme, 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

Notes:

  1. Review all concomitant medicines which may potentially interact with ARVs or increase co-morbidities, see
    Drug-drug Interactions between Antidepressants and ARVs
    Drug-drug Interactions between Antihypertensives and ARVs
    Drug-drug Interactions between Analgesics and ARVs
    Drug-drug Interactions between Anticoagulants/Antiplatelet Agents and ARVs
    Drug-drug Interactions between Antimalarial Drugs and ARVs
    Drug-drug Interactions between Bronchodilators (for COPD) and ARVs
    Drug-drug Interactions between Immunosuppressants (for SOT) and ARVs
    Drug-drug Interactions between Pulmonary Antihypertensives and ARVs
    Drug-drug Interactions between Corticosteroids and ARVs
    Drug-drug Interactions between Contraceptives and ARVs
    Drug-drug Interactions between DAAs and ARVs
    and http://www.hiv-druginteractions.org
  2. If stable on ART with undetectable HIV-VL and CD4 count > 350 cells/μL, suggest annual
    CD4 count.
  3. A risk equation developed from HIV populations is available, see https://www.chip.dk/Tools-Standards/Clinical-risk-scores. Of note, if an individual receives medicines to control dyslipidaemia and/or hypertension, the estimation should be interpreted with caution.
  4. A calculator for LDL-cholesterol in cases where TG is not high can be found at https://www.mdcalc.com/ldl-calculated.
  5. Risk factors for chronic liver disease include alcohol, viral hepatitis, obesity, diabetes, insulin resistance, hyperlipidaemia and hepatotoxic drugs.
  6. Risk factors for CKD: hypertension, diabetes, CVD, family history, black African ethnicity, viral hepatitis, low current CD4 count, smoking, older age, concomitant nephrotoxic drugs.
  7. 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.
  8. 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
  9. 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 [6], [7].
  10. 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).
  11. WHO fracture risk assessment (FRAX®) tool: http://www.shef.ac.uk/FRAX.
  12. 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.
  13. 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, however this score has not been validated in PLWH. See: Cancer Screening, Liver Cirrhosis: Management, and Viral Hepatitis Co-Infection

* 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/).