BHIVA guidelines for the routine investigation and monitoring of adult HIV (2011)

New guidelines for routine management of HIV are now posted to the BHIVA website and are published in the January 2012 edition of HIV Medicine (with free access). [1]

The comprehensive 40-page document includes a detailed review of the most important routine monitoring. It is an essential reference for understanding the current recommended minimum standard of care.

These guidelines include suggestions for audited targets and cover each stage of the treatment pathway from initial diagnosis, through to naïve and experienced management, and includes the case of transferred care.

It is also important for highlighting simple and inexpensive aspects of care that are important but if overlooked have the potential to greatly impact on patient quality of life. These include full patient history, psychological assessment (including depression, anxiety and social support), sexual history (including sexual health), support for evaluating adherence, baseline evaluations (including physical examination, waist circumference, blood pressure and BMI). Mental health has a separate consideration.

Recommendations for CD4 and viral load monitoring are similar to earlier guidelines. In naïve patients, as long as CD4 count remains 100 cells higher than the threshold for starting treatment (currently this would be 450), CD4 monitoring should be every 4-6 months, and 3-4 monthly if it falls below this. CD4 count should still be monitored four weeks after starting therapy (with viral load). In people who maintain an undetectable viral load for more than one year and whose CD4 count is greater than 200, CD4 monitoring can be reduced to six-monthly.

Viral load should still be a factor when deciding to initiate HAART, needing at least two results for patients in chronic infection to establish a reliable set point, six monthly thereafter and repeated within one month prior to treatment. Short term efficacy needs to be confirmed by a drop of at least I log, four weeks after starting treatment, and further tests at 3 and 6 months. Undetectable (<40 or <50 copies/mL) should be achieved by 4-6 months. Subsequent monitoring should be 3-4 monthly, and six-monthly viral load can be considered in a strictly adherent patients on stable treatment. Viral rebound to >50 copies/mL needs to be conformed with a new sample.

The cut-off for switching treatment is only briefly mentioned but blips are described as transient increases to between 50 and 1000 copies/mL (subsequent test being < 50 copies/mL) and multiple blips a signal to review drug potency, adherence, tolerability, resistance and potential modifications to the combination.

Resistance testing is still strongly recommended for all newly diagnosed patients and again prior to starting treatment if reinfection is possible, or in patients without results from first diagnosis, at week four of treatment if viral suppression is less than 1 log copies/mL, in all patients with confirmed viraemia (while on the failing combination) recognising that specialised labs are able to work with samples where viral load is ‘just over’ 50 copies/mL.

The guidelines also address laboratory monitoring for renal, hepatic, cardiovascular, bone and biomarkers, other infections including sexual health and for specific patient groups (women, older patients, injecting drug users and late presenters.

British HIV Association guidelines for the routine investigation and monitoring of adult HIV-1-infected individuals 2011