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Monitoring The Patient on ARV Treatment

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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Learning Objectives

By the end of this session, participants should be able to:

Describe the protocol for performing routine follow-up with ARV patients

Explain how to monitor patients for treatment success or failure based on clinical and lab indicators

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Routine Monitoring

Prior to starting ART, establish baseline information by evaluating patient regarding:

Clinical stagingOI ProphylaxisARV treatment

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Pre-ART Evaluation (1)

Clinical evaluation: Check general status, weight, height,

temperature Assess WHO Clinical Stage Look for signs of OI or HIV related

disease Screen for TB and pregnancy

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Pre-ART Evaluation (2)

Laboratory evaluation: All patients:

• CBC, ALT, HBsAg, CD4, HCV Ab, Cr TB screening:

• Sputum AFB, Chest X-Ray Female Patients

• Pregnancy test, if indicated Testing for OI

• If indicated by clinical evaluation

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Monitoring Patients on ART

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Why is Monitoring Important?

What are Some Goals of Monitoring?

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Goals of Monitoring

Follow clinical status and reassess clinical stage

Monitor adherence Monitor for drug toxicity, side effects Evaluate for new or recurrent OI Evaluate for IRIS Check possibility of pregnancy (female) Monitor for success or failure of ARV

treatment

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Monitoring: How Often?

Month 1 Month 2 Month 3+

Once per week every 2 weeksOnce per month

orevery 2 months

If the clinical situation is stable:

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What to Monitor? (1)

Adherence monitoring

Assess missed doses

Provide counseling about adherence, prevention, and healthy living

Clinical Monitoring Weight,

temperature WHO Clinical Stage ARV side effects or

toxicity Signs of IRIS

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What to Monitor? (2)

Laboratory Monitoring:

Test Frequency

CBC Every 6 monthsAlso after 1st month if on AZT

ALT Every 6 monthsAlso after 1st month if on NVP

CD4 Every 6 months

Lipids and Glucose

Every year

Creatinine Every 6 months if on TDF

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Physical Exam at Every Visit

Eye

Mouth

Skin

Lymph Nodes

Heart

Lungs

Abdomen

Genital Exam

Neurologic

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Case Studies

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How Do you Evaluate Treatment Success?

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Clinical Evaluation of ARV Treatment (1)

Treatment Success:

Weight gain Return of appetite Increased activity

Resolution of fevers, diarrhea, skin rashes, thrush…

Resolution of OIs

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Clinical Evaluation of ARV Treatment (2)

Treatment Failure: Weight Loss New or recurrent OI or malignancy after

6 months of ARV New or recurrent WHO Stage 4

conditions • wasting• chronic diarrhea, chronic fever• recurrent bacterial infection• recurrent fungal infections

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Laboratory Evaluation of ARV Treatment (1)

(When CD4 Testing Available)

Treatment Success CD4 increase: number and

percentage Average expected CD4 change:

• First 1-3 months: 50 cells/mm3• Then every 1 year: 50-100 cells/mm3

CD4 may more slowly in Viet Nam and in IDU

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Laboratory Evaluation of ARV Treatment (2)

(When CD4 Testing Available)

Treatment Failure ? ART at least 6 months and good adherence CD4 > 50% from peak or baseline Or CD4 below baseline after initial rise Or CD4 < 100 cells/mm³ after one year Exclude errors of technical protocol of CD4

test (retest CD4) Check viral load before changing to 2nd line

ARV if possible

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Key Points

Pre-ART examination sets baseline to evaluate for treatment response

All ART patients need routine clinical and laboratory monitoring

Clinical and adherence monitoring should be done at every visit

Patients on ART need monitoring for treatment success or failure

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Thank you!

Questions?