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1: Assessment of Initial & Subsequent Visits

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  
Current or previous PrEP use + + First visit
Past and current
co-morbidities
+ + Every visit  
Vaccination history +   Annual Measure antibody titres and offer vaccinations where indicated, see Immunisation in Persons with HIV

 

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

Chemsex

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
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 seropositive status +   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 + + 3-12 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 %) + + 3-12 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 +   3-12 months Consider more frequent screening if at risk

Sexual and Reproductive Health


Primary HIV Infection (PHI)


Sexually Transmitted Infections

STI screen +   3-12 months 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 Immunisation in Persons with HIV


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

Consider ART containing TDF or TAF in people who are vaccine non-responders

HCV screen +   As indicated

Further screen based on risk behaviour and local epidemiology


Measure HCV-RNA if HCV antibody positive or if recently acquired infection is 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 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 Prior to starting ART Follow-up frequency Comment Links
Varicella zoster virus serology +     Offer vaccination where indicated Immunisation in Persons with HIV

 

Measles/Rubella serology +     Offer vaccination where indicated
Toxoplasmosis serology +      
CMV serology +      
Cryptococcus antigen +/-     Perform 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 Immunisation in Persons with HIV
Streptococcus pneumoniae +     No recommendations available regarding the need for a booster dose, see Immunisation in Persons with HIV
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 Immunisation in Persons with HIV
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 adults > 40 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(v) + + 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(v)

See Chronic Lung Disease in HIV

Liver Disease: Risk assessment(vi) + + Annual

See:
Management of PLWH with Increased ALT/AST

Liver Cirrhosis: Classification and Surveillance

Management of persons with HIV with Cirrhosis

Metabolic Dysfunction-Associated Steatotic Liver-Disease (MASLD)

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

Metabolic Dysfunction-Associated Steatotic Liver-Disease (MASLD)

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(vii)

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(viii) + + Annual

More frequent monitoring if eGFR < 90mL/min, CKD risk factors present(viii) 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)(x) + + 3-12 months
Renal Disease: Urine dipstick analysis(xi) + + 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(xi)

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
Bone Disease: Risk assessment(xii) (FRAX®(xiii) in persons > 40 years) + + 2 years

Consider DXA in specific persons 

See: 
Bone Disease: Screening and Diagnosis

Approach to Fracture Reduction

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     1-2 years

MSM and TW age > 35y, MSW and CisW age >45 y or previous vulvar HSIL or cancer

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(vii)

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

  1. 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

  2. If stable on ART with undetectable HIV-VL and CD4 count > 350 cells/μL, suggest annual
    CD4 count
  3. 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 
  4. A calculator for LDL-cholesterol in cases where TG is not high can be found at https://www.mdcalc.com/ldl-calculated
  5. 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
  6. Risk factors for chronic liver disease include alcohol, viral hepatitis, obesity, diabetes, insulin resistance, hyperlipidaemia and hepatotoxic drugs
  7. 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
  8. Risk factors for CKD: hypertension, diabetes, CVD, family history, black African ethnicity, viral hepatitis, low current CD4 count, smoking, older age, concomitant nephrotoxic drugs
  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
  10. 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
  11. 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
  12. 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)
  13. WHO fracture risk assessment (FRAX®) tool: frax.shef.ac.uk/FRAX/index.aspx

* 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)