Recommended HIV-Monitoring Approach for Stable Patients

Segment Description: Recommendations for monitoring techniques for patients with HIV.

Joseph Eron, MD: Ian, let’s talk a little bit about once people are on therapy and they’re undetectable, and they’re U=U [undetectable = untransmittable]. How do we monitor people now? I mean, we used to get all kinds of blood tests. What are you doing in your practice, and what’s recommended in terms of following people on treatment?

Ian Frank, MD: The frequency at which I monitor people probably depends more on comorbidities than their HIV disease. If people have undetectable viral loads and their CD4 counts are high, I usually don’t see people more frequently than every 6 months. Sometimes I make appointments every 4 months, so if people miss a visit, I know I can catch them in a 6-month interval. I don’t want it to go too long before I see people. So it’s generally every 4 to 6 months that I’m seeing people. And I’m checking viral loads that frequently. I’m still in the habit of doing CD4 counts. I’m guilty—you know, I’ll acknowledge it, although there really isn’t much of a reason to do it.

Paul Sax, MD: Keep the flow cytometers running.

Ian Frank, MD: It’s hard. Unfortunately, it’s just hard to convince my long-term patients that they don’t need to pay attention to their CD4 count. But there’s clearly no need to do that. There’s absolutely no risk of CD4 counts falling, and it always takes a long time to explain the reason why the CD4 count has declined from 1000 to 700.

Paul Sax, MD: Then it’s 1200 the next time.

Ian Frank, MD: Because of the variability of the test. So we don’t really need to do CD4 counts as frequently. And I usually monitor renal function and liver function tests. Probably the most important monitoring I do is for sexually transmitted infections [STIs].

Joseph Eron, MD: Including hepatitis C.

Ian Frank, MD: Yes. Yearly hepatitis C testing should be done in individuals who are antibody negative. And if somebody has been treated and cured of their hepatitis C, you need to do hepatitis C RNA level on a yearly basis. We have some metrics that we’re supposed to follow because of Ryan White & Global HIV/AIDS Program reporting. And in our practice, people aren’t following lipids as closely as they should. The recommendation is to do annual lipid testing. A lot of my patients are older now, so I’m usually doing that at least on an annual basis. And keep in mind that with a number of the drugs we’ve been talking about, the next-generation integrase inhibitors and some other regimens, these drugs have an impact on the distal renal tubular secretion of creatinine. So as our patients age, we’re seeing the creatinine levels go up. And with using dolutegravir and bictegravir, we’ll sometimes see a 0.1, 0.2 mg/dL increase in creatinine. That’s this distal tubular renal secretion of creatinine that’s being inhibited, and it’s not a nephrotoxicity. But I’m looking at urinalyses to make sure that there isn’t protein or glucose in the urine, which would be a sign of renal tubular damage.

Joseph Eron, MD: I’ve actually given up on that. Does anybody see people once a year?

W. David Hardy, MD: No.

Paul Sax, MD: Yeah, I do.

Eric S. Daar, MD: The patients figure this out long before the guidelines.

Paul Sax, MD: They’ve earned it.

Joseph Eron, MD: Like, “Why am I here?”

Eric S. Daar, MD: They just stop coming. They cancel appointments.

Joseph Eron, MD: “What are you doing here again? I just saw you.”

Paul Sax, MD: I kind of provocatively wrote about this on my blog. Why are we doing such frequent testing? I’d like to set up a randomized study of the guidelines-recommended frequency of testing versus just age and comorbidity-related frequency of testing and annual viral load. So if you have someone without comorbidities, without maybe high risk of any of the end-organ diseases, without high risk of STIs, you could just check a viral load annually and just compare outcomes in those 2 strategies. Or if they have comorbidities, do it more frequently. Do it as it would be appropriate in a general medicine population, and I bet there wouldn’t be a difference in outcome. So I have a lot of people who’ve earned a yearly visit because they’re so stable.

W. David Hardy, MD: But I think what we’re talking about is whether or not physicians and care providers do primary care and HIV or just do HIV. And it’s true, if you’re just doing HIV, the only thing you have to probably do is the CD4 count once a year, a viral load maybe twice a year. Part of the time you do it is because the patient wants to know it, because it does provide positive reinforcement to them—that their pill that they’re taking every day is doing something still. And I think that’s something that shouldn’t be discounted, because it’s not that expensive. But more and more, I think more primary care doctors are doing HIV also, so you are seeing the patient. It doesn’t mean every time you see the patient you have to check their HIV, though. That can be done less often.

Paul Sax, MD: One thing I think also is that if we’re going to check less frequently in our patients who have long-term virological suppression, I think we should check more frequently for people who just started therapy.

Joseph Eron, MD: Oh, yeah.

Paul Sax, MD: So those people get followed very closely until they’re virologically suppressed.

Joseph Eron, MD: Yeah. So what is your timing for when you start someone?

Paul Sax, MD: Oh, we have them back a couple of weeks later, and then we see them every 2 to 4 weeks until they’re suppressed.

Joseph Eron, MD: Oh, really?

Paul Sax, MD: But now that happens so quickly, so it’s often just 3 visits or 4 visits, and they’re suppressed.

Joseph Eron, MD: Sure, that makes sense.