Monitoring of patients on ART is based on clinical and laboratory parameters.
Clinical Monitoring:
In most cases, treatment will be associated with weight gain and reduced morbidity from opportunistic infections and improvement in the quality of life. At each clinic visit, thorough history and physical examination should be done and recorded in the patient file.
Laboratory Monitoring:
- Initiation of ART is done irrespective of CD4 cell count. Baseline CD4 cell count should nevertheless be determined to monitor immunological response. For patients with CD4 cell count less than 350 cell/mm3, the CD4+ T-lymphocyte count should be repeated after 6 months, until patient is stable CD4+ Tlymphocyte count more than 350cell/mm3 and two consecutive viral load less than 50copies/ml). However, in cases of suspected IRIS, CD4 can be tested at intervals less than six months. IRIS is diagnosed if CD4 cell count shows rising trends.
- Viral load (VL) testing is recommended as the preferred monitoring approach to diagnose and confirm treatment failure compared to immunological and clinical monitoring.
Table 6.8 Clinical and laboratory monitoring of patients on first line drug regimen
| Regimens | Monitoring Tests | Frequency | Rationale |
| TDF/3TC or FTC/EFV
|
CD4 | Baseline, 6-monthly where there is no HVL
Baseline, 6-monthly if CD4 <350 where HVL is available |
ART monitoring
Screening for early renal toxicity |
| Serum
creatinine |
Baseline, and after every 6 months. | ||
| AZT/3TC+EFV and
AZT/3TC/NVP TDF/FTC+DTG AZT/3TC+DTG ABC/3TC+DTG
|
CD4 | Baseline, after every 6months where there is no
HVL Baseline, after every 6months if CD4 <350 where HVL is available |
ART monitoring |
| FBC/Hb
(For patients on AZT) |
Baseline, week 4, thereafter 6 monthly | Anemia | |
| ALT (For patients on NVP) | Baseline, after every 6 months and whenever symptomatic | Liver toxicity | |
| ALT (For patients on DTG) | Baseline, after every 6 months and whenever symptomatic | Liver toxicity |
NOTE: Clinical evaluation will determine more frequent laboratory tests if required.
Laboratory monitoring of patients on second line drugs
The following laboratory tests are recommended for Monitoring of patients on second line drugs:
- CD4, baseline, if less than 350 cells/ml after every 6 months until more than 350cells/ml
- FBC, baseline, then monthly for 3 months, then after every 6 months (with CD4 and viral load)
- Fasting cholesterol and triglyceride, baseline, 6 months and thereafter every 12 months
- Liver function tests, (ALT) 6 monthly
- Fasting glucose, every 12 months
- Urinalysis at baseline and after every 3 months
- Serum creatinine at baseline and once a year.
When changing treatment, the following should be observed:
- Never change a single drug in the combination if the reason for changing is treatment failure. Change at least two drugs, preferably change all three drugs
- If changing due to toxicity, change only the drug suspected to be causing the problem.
- Never change to monotherapy (i.e. single drug)
- When selecting drugs, choose drugs that have not been used before, drugs which do not have cross-resistance/or no overlapping toxicities or drug-drug interactions.
- Lamivudine has advantage of decreasing viral fitness therefore it may be retained when changing the failing regimen
