1. 1 Monitoring The Patient on ARV Treatment HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. 2 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

3. 3 Routine Monitoring Prior to starting ART, establish baseline information by evaluating patient regarding: Clinical staging OI Prophylaxis ARV treatment

4. 4 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

5. 5 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

6. 6 Monitoring Patients on ART

7. 7 Why is Monitoring Important? What are Some Goals of Monitoring?

8. 8 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

9. 9 Monitoring: How Often? Month 1Month 2Month 3+ Once per weekevery 2 weeks Once per month or every 2 months If the clinical situation is stable:

10. 10 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

11. 11 What to Monitor? (2) Laboratory Monitoring: TestFrequency CBCEvery 6 months Also after 1st month if on AZT ALTEvery 6 months Also after 1st month if on NVP CD4Every 6 months Lipids and Glucose Every year CreatinineEvery 6 months if on TDF

12. 12 Physical Exam at Every Visit Eye Mouth Skin Lymph Nodes Heart Lungs Abdomen Genital Exam Neurologic

13. 13 Case Studies

14. 14 How Do you Evaluate Treatment Success?

15. 15 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

16. 16 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

17. 17 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

18. 18 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

19. 19 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

20. 20 Thank you! Questions?