Patient monitoring during HIV antiretroviral therapy
- John G Bartlett, MD
John G Bartlett, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — HIV; Pulmonary Infections
- Professor Emeritus
- Johns Hopkins University School of Medicine
- Paul E Sax, MD
Paul E Sax, MD
- Clinical Director, Division of Infectious Diseases
- Brigham and Women's Hospital
- Professor of Medicine
- Harvard Medical School
Proper utilization of antiretroviral therapy (ART) requires ongoing patient monitoring to assess therapeutic response and to identify adverse events related to chronic administration of potentially toxic medications. Failure to respond to a recommended ART regimen is almost always a result of suboptimal adherence or viral resistance.
This topic will address laboratory monitoring during ART. Discussions related to the initiation and modification of ART are found elsewhere. (See "Considerations prior to initiating antiretroviral therapy" and "Selecting antiretroviral regimens for the treatment-naïve HIV-infected patient" and "When to initiate antiretroviral therapy in HIV-infected patients" and "Overview of antiretroviral agents used to treat HIV".)
At each visit, patients should be interviewed regarding medication adherence in a nonjudgmental manner. Optimal adherence (ie, taking all medication doses at the time intervals prescribed) to an antiretroviral therapy (ART) regimen is important to help patients achieve and maintain virologic suppression. Adherence can vary over time and can be impacted by factors such as depression and substance use . Strict adherence is most important when patients are initiating or changing an ART regimen.
To enhance adherence, patients should understand the link between adherence and drug resistance. In addition, it is useful to discuss medication schedules with patients to help them link pill-taking behaviors to other daily activities (eg, brushing teeth). If the patient admits to difficulties with adherence, potential barriers could involve the number and timing of doses, sizes of pills, food restrictions, and treatment-limiting side effects. The patient should also be advised to notify the provider if there is an anticipated problem with adherence, such as elective surgery, or a prolonged intercurrent illness. (See "Overview of antiretroviral agents used to treat HIV".)
Adherence can be difficult to assess. As an example, one study demonstrated that clinicians incorrectly predicted adherence in 41 percent of patients . In addition, patients often exaggerate adherence to their provider. Pharmacy records are useful to help track compliance when refills are obtained from a single pharmacy source. Clinical trials have tried to assess whether directly observed therapy may improve virologic suppression rates. One meta-analysis of 12 studies suggested that such therapy seemed to offer no benefit over self-administered treatment . However, directly observed therapy may be beneficial in patient subgroups that are at high risk for nonadherence, such as those who are homeless . Other adherence interventions (eg, assessing serum drug concentrations, monitoring pill counts, or use of electronic drug monitoring devices) are not routinely recommended .
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- Medication persistence
- VISIT FREQUENCY
- GENERAL LABORATORY MONITORING
- VIROLOGIC RESPONSE
- Virologic failure
- Viral blips
- CD4 CELL COUNTS
- FREQUENCY OF IMMUNOLOGIC AND VIROLOGIC MONITORING
- Viral load monitoring
- Recommendations of others
- CD4 cell count monitoring
- DRUG RESISTANCE TESTING
- THERAPEUTIC DRUG MONITORING
- INDICATIONS FOR CHANGING THERAPY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS