HIV Lab Monitoring Guidelines PDF

# Lab monitoring | Monitoring parameter | Goal | When to check | |---|---|---| | VL | Undetectable (< 20 c/mL) | • Baseline • 4-8 wks after initiating ART • Recheck q 4-8 wk until undetectable • q 3-6 mo once undetectable | | CD4 (+ CBC with diff) | As high as possible •>200 cells/mm³ | • Baseli...

# Lab monitoring | Monitoring parameter | Goal | When to check | |---|---|---| | VL | Undetectable (< 20 c/mL) | • Baseline • 4-8 wks after initiating ART • Recheck q 4-8 wk until undetectable • q 3-6 mo once undetectable | | CD4 (+ CBC with diff) | As high as possible •>200 cells/mm³ | • Baseline, then q 3-6 mo. • may reduce to q 12 mo if CD4 >300 • optional if CD4 >500 & on ART | | Lytes, SCr, glucose, AST, ALT, Tbili, Lipid profile | Normal | • Baseline • 4-8 wks after initiating ART • q 3-6 mo. Thereafter | | Serum PO4 (for pts with CKD, DM on TDF) | Normal | • Baseline • yearly thereafter | # Predicting Ol risk -> Risk of Ols increase as CD4 count decreases -> Generally once CD4 < 200, Ol prophylaxis should be started -> REMEMBER some patients get sick from non-Ol pathogens too -> AB prophylaxis reduces incidence of Ol > * Primary prevention: Prevent first disease ep. > * Secondary ppx: preventing reactivation or recurrence of an infection after it has been treated > > * Sometimes necessary to use secondary ppx until CD4 increases above infection threshold # Common Ol's -> CD4 < 400 * **Thrush** * Candida Albicans * Yeast * GI tract; oropharyngeal and vaginal infections * Easily removable “plaque” on tongue * RX; Fluconzole * Nystatin * **Oral Hairy Leukoplasia** * Virus-Can cause other infections + malignancies * Non-Hodgkin Lymphoma * White hairy patches on tongue * Looks IDENTICAL to thrush * But much harder to remove -> CD4 < 200 * **TB** * Mycobacterium TB * Reactivation occurs v. soon after HIV infection-any CD4 * Routine testing: TST or IGRA at HIV dx. * Tx Latent TB and close contacts of known TB case * Atypical Presentation when CD4 < 350 * Rx. same as non-HIV * **Bacteria** * Streptococcus Pneumoniae * Community acquired pneumonia * Rx: Same as non-HIV * **Pneumocystis jiroveci (PJP)** * Unicellular Fungus * Causes disease almost exclusively in lungs * Symptoms are slow and insidious-subacute presentation common in Ol's * Fever * Progressive dyspnea * Non-productive cough * Wheeze * Hypoxia * CXR: Diffuse, bilateral interstitial (or alveolar) infiltrates * Dx: Sputum induction, BAL (w/silver staining) * Most common in Ol in N. America * Primary ppx occurs when CD4 < 200 -> CD4 < 100 * **HSV** * Herpes Simplex Virus * Orolabial and genital infections * Episodic Tx should be initiated at first tingle * Valacyclovir, Famicclovir, acyclovir * Suppressive Tx. indicated for frequent recurrences * **Candida Esophagitis** * Candida albicans * May be quite painful to swallow, anorexia * Requires Systemic therapy * Rx: Fluconazole -> CD4 < 50 * **Toxoplasmosis** * Protozoa * Causes Encephalitis * Causes characteristic “ring” lesions on brain * Primary ppx indicated for CD4 < 100 + serum toxo IgG pos. * Rx: High dose Sulfamethoxazole/Trimethoprim * **Disseminated MAC** * Mycobacterium complex * Causes fever, wl, night sweats, GI symptoms * Blood culture or LN biopsy, liver or bone marrow * Rx. Azithro, ethambutol +/- rifabutin * Tx. for minimum of 12 m/o * Primary prevention not indicated when CD4 < 50 and not on ARV's * **CMV** * Cytomegalovirus * Causes retinitis, esophagitis, colitis, neurologic disease * Retinitis Tx. consists of induction followed by maintenance therapy * Ganciclovir or Valganclovir * Intravitreal injections of ganciclovir may be used * **Cryptococcal meningitis** * Cryptococcus neoformans * Yeast * Cryptococcal Antigens (CSF), india link * Rx: 3 phases * Induction (Ampho B + Flucytosine) * Consolidation * Fluconazole High dose * Maintenance * Fluconazole low dose * Tx. for at least 1 year * Delay ARV start if ARV-naive # Primary Prevention | Disease | When to start prophylaxis | Preferred regiment(s) | |---|---|---| | P. Jiroveci pneumonia (PJP) | CD4 <200 or <14% | Cotrimoxazole i DS tab daily or 3x/week | | T. gondii | CD4 <100 and positive serology (toxo IgG) | Cotrimoxazole i single strength tab daily | | Disseminated M. avium complex (MAC) | Only if patient is not on fully suppressive ART AND CD4<50 | Azithromycin 1200 mg once weekly OR 600 mg twice weekly Clarithromycin 500 mg BID |