Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV

The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

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Laboratory Testing

Plasma HIV-1 RNA (Viral Load) and CD4 Count Monitoring

Last Updated: May 1, 2014; Last Reviewed: May 1, 2014

Table 4. Recommendations on the Indications and Frequency of Viral Load and CD4 Count Monitoringa
Clinical Scenario Viral Load Monitoring CD4 Count Monitoring
Before initiating ART
At entry into care (AIII)

If ART initiation is deferred, repeat before initiating ART (AIII).

In patients not initiating ART, repeat testing is optional (CIII).
At entry into care (AI)

If ART is deferred, every 3 to 6 monthsb (AIII)
After initiating ART Preferably within 2 to 4 weeks (and no later than 8 weeks) after initiation of ART (AIII); thereafter, every 4 to 8 weeks until viral load is suppressed (BIII). 3 months after initiation of ART (AIII)
After modifying ART because of drug toxicities or for regimen simplification in a patient with viral suppression
4 to 8 weeks after modification of ART to confirm effectiveness of new regimen (AIII). Monitor according to prior CD4 count and duration on ART, as outlined below.
After modifying ART because of virologic failure
Preferably within 2 to 4 weeks (and no later than 8 weeks) after modification (AIII); thereafter, every 4 to 8 weeks until viral load is suppressed (BIII). If viral suppression is not possible, repeat viral load every 3 months or more frequently if indicated (AIII). Every 3 to 6 months (AI)
During the first 2 years of ART Every 3 to 4 months (AIII)
Every 3 to 6 monthsa (BII)
After 2 years of ART (VL consistently suppressed, CD4 consistently 300-500 cells/mm3) Can extend to every 6 months for patients with consistent viral suppression for ≥2 years (AIII). Every 12 months (BII)
After 2 years of ART (VL consistently suppressed, CD4 consistently >500 cells/mm3) Optional (CIII)
While on ART with detectable viremia (VL repeatedly >200 copies/mL) Every 3 months (AIII) or more frequently if clinically indicated (see Virologic Failure). Every 3 to 6 months (AIII)
Change in clinical status (e.g., new HIV clinical symptom or initiation of interferon, chronic systemic corticosteroids, or antineoplastic therapy) Every 3 months (AIII) Perform CD4 count and repeat as clinically indicatedc (AIII)
a Monitoring of lymphocyte subsets other than CD4 (e.g., CD8, CD19) has not proven clinically useful, adds to costs, and is not routinely recommended (BIII).

b Some experts may repeat CD4 count every 3 months in patients with low baseline CD4 count (<200–300 cells/mm3) before ART but every 6 months in those who initiated ART at higher CD4 cell count (e.g., >300 cells/mm3).

c The following are examples of clinically indicated scenarios: changes in a patient’s clinical status that may decrease CD4 count and thus prompt initiation of prophylaxis for opportunistic infections (OI), such as new HIV-associated symptoms, or initiation of treatment with medications which are known to reduce CD4 cell count.

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