US DHHS Guidelines with Australian commentary
Plasma HIV-1 RNA (Viral Load) and CD4 Count Monitoring
Last Updated: October 25, 2018
Recommendations on the Indications and Frequency of Viral Load and
CD4 Count Monitoring
|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.