1: Assessment of Initial & Subsequent Visits
History: Medical
Assessment | At HIV diagnosis | Prior to starting ART | Follow-up frequency | Comment | Links |
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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 | ||
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 |
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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 |
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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 |
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Sexual history | + | 6-12 months |
Risk of sexual transmission should be addressed |
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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 |
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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. |
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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 |
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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 |
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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 |
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Syphilis serology | + | 3-12 months | Consider more frequent screening if at risk | ||
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 |
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HAV screen | + | As indicated | Screen if ongoing risk (e.g. MSM); vaccinate if non-immune | Immunisation in Persons with HIV
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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 |
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HCV screen | + | As indicated |
Further screen based on risk behaviour and local epidemiology
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HDV screen | As indicated |
All persons with positive HBs-Ag should also be screened for HDV co-infection |
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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 |
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CXR | + | Re-screen if exposure |
Consider routine CXR in persons from high TB prevalence populations.
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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 |
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Varicella zoster virus serology | + | Offer vaccination where indicated | Immunisation in Persons with HIV |
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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 |
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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 |
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) |
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 |
Pulmonary Disease: Spirometry | As indicated |
Spirometry should be performed in all symptomatic persons(v) |
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Liver Disease: Risk assessment(vi) | + | + | Annual |
See: |
Liver Disease: ALT/AST, ALP, Bilirubin | + | + | 3-12 months |
More frequent monitoring prior to starting and on treatment with hepatotoxic drugs See: |
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 |
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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 |
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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: |
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: |
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: |
Vitamin D: 25(OH) vitamin D | + | As indicated |
Screen at risk persons |
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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 |
Depression: Questionnaire | + | + | As indicated |
Consider screening at each routine HIV clinic visit See: |
Older persons: Polypharmacy review | Annual |
Perform periodic medicines review |
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Older persons: Frailty | Annual |
Screen with Gait walking speed, Short Physical Performance Battery (SPPB), FRAIL Scale (FS) or Clinical Frailty Scale (CFS) See: Frailty |
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Older persons: Falls | Annual | See: Falls | ||
Cancer: Mammography | 1-3 years |
Women 50-74 years See:Cancer: Screening Methods |
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Cancer: Cervical PAP or liquid based cytology | 1-3 years |
Women with HIV > 21 years, as per national guidelines See:Cancer: Screening Methods |
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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 |
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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 |
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Cancer: Prostate cancer (PSA) | 1-2 years |
Controversial; men > 50 years with a life expectancy >10 years |
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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
- 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
- Risk factors for chronic liver disease include alcohol, viral hepatitis, obesity, diabetes, insulin resistance, hyperlipidaemia and hepatotoxic drugs
- 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
- Risk factors for CKD: hypertension, diabetes, CVD, family history, black African ethnicity, viral hepatitis, low current CD4 count, smoking, older age, concomitant nephrotoxic drugs
- 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
- 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
- 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: 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)