Table 6. Sample Schedule for Clinical and Laboratory Monitoring of Children Before and After Initiation of Antiretroviral Therapya

Table 6. Sample Schedule for Clinical and Laboratory Monitoring of Children Before and After Initiation of Antiretroviral Therapya
Laboratory Testing Entry Into Carea,b Pre-Therapyb ART Initiationc Weeks 1–2 on Therapy Weeks 2–4 on Therapy Every 3–4 Monthsd Every 6–12 Monthse Virologic Failure (Prior to Switching ARV Regimens)
Medical History and Physical Examinationf,g  
Adherence Evaluationg    
CD4 Count      
Plasma Viral Loadh    
Resistance Testing            
CBC with Differentiald    
Lipid Panele        
Random Plasma Glucosei          
HBV Screeningk            
Pregnancy Test for Girls and Young Women of Childbearing Potentiall          

a See the texts on immunologic, virologic, general laboratory, and clinical monitoring of children with HIV for details on recommended laboratory tests to perform

b  If a child does not initiate ART after receiving an HIV diagnosis, the child’s CD4 count and plasma viral load should be monitored at least every 3 to 4 months.

c If ART is initiated within 30 to 90 days of a pre-therapy laboratory result, repeat testing may not be necessary.

d CD4 count, CBC, and chemistries can be monitored less frequently (every 6–12 months) in children and youth who are adherent to therapy, who have CD4 count values that are well above the threshold for opportunistic infection risk, and who have had sustained virologic suppression and stable clinical status for more than 2 to 3 years. Viral load testing every 3 to 4 months is generally recommended to monitor ARV adherence.

e If lipid levels have been abnormal in the past, more frequent monitoring may be needed. For patients treated with TDF, more frequent urinalysis should be considered.

f Pay special attention to changes in weight that might occur after altering an ARV regimen. Weight gain or weight loss may occur when using some ARV drugs (see Table 15h. Lipodystrophies and Weight Gain).

g Virtual visits may be appropriate at some time points, particularly for adherence assessments and for visits for established patients, see Table 4 above.

h Some experts monitor viral load more often (with each injection) in adolescents initiating injectable CAB and RPV. Viral load monitoring should be performed 4 to 8 weeks after a switch to long-acting CAB and RPV. HIV-RNA also should be checked in patients with unplanned missed visits and delayed dosing of long-acting CAB and RPV. When viremia develops during long-acting therapy, resistance testing, including integrase resistance testing, should be performed. Follow-up dosing in patients with missed doses should not be delayed while waiting for viral load and resistance test results. However, regimen changes should be prompted if resistance to CAB and/or RPV is discovered (see Optimizing Antiretroviral Therapy in the Setting of Viral Suppression in the Adult and Adolescent Antiretroviral Guidelines).

i Chemistries refer to a comprehensive metabolic panel. Some experts perform a comprehensive panel at entry and routinely test Cr, ALT, AST, with additional tests tailored to the history of the individual patient.

j Random plasma glucose is collected in a gray-top blood collection tube or other designated tube. Some experts would consider monitoring HgbA1C in children at risk for prediabetes/diabetes rather than routine blood glucose.

k This screening is only recommended for individuals who have previously demonstrated no immunity to HBV and who are initiating a regimen that contains ARV drugs with activity against HBV, specifically 3TC, FTC, TAF, or TDF.

l See the Prepregnancy Counseling and Care for Persons of Childbearing Age with HIV in the Perinatal Guidelines.

m Conduct HLA-B*5701 on entry or prior to initiating ABC if not done previously. Choose an alternative ARV drug if the patient is HLA-B*5701 positive (see the Abacavir section in Appendix A: Pediatric Antiretroviral Drug Information).

Key: 3TC = lamivudine; ABC = abacavir; ALT = alanine aminotransferase; ART = antiretroviral therapy; ARV = antiretroviral; AST = aspartate aminotransferase; CBC = complete blood count; CD4 = CD4 T lymphocyte; Cr = creatinine; FTC = emtricitabine; HBV = hepatitis B virus; HgbA1C = glycosylated hemoglobin; OI = opportunistic infection; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate