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3–2 | Clinical Manual for Management of the HIV-Infected Adult/2006
O: Objective
Perform the following objective tests:
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Complete physical examination (see chapter Initial
Physical Examination)
Current CD4 count and HIV viral load: preferably
2 or more separate results approximately 1 month
apart
Drug resistance test. To try to detect the presence of
transmitted ARV resistance mutations, a genotype
should be performed in all patients before initiating
ART. This should be done as early in the course of
infection as possible, because mutations may revert
to wild type. Review the results of previous resistance
testing or obtain a baseline resistance test, if this was
not done earlier. (See chapter Resistance Testing.)
Complete blood count (CBC) and platelet count,
liver function tests (LFTs), renal function tests,
fasting lipid panel (see chapter Initial and Interim
Laboratory and Other Tests) fasting glucose, rapid
plasma reagin (RPR), tuberculin skin test, hepatitis
serologies
A: Assessment
Make the following basic decisions:
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The patient is or is not likely to benefit from ART
at this time (ie, do potential benefits outweigh the
risks)? See the Adult and Adolescent ARV Guidelines
noted above, which thoroughly address the issue.
A brief summary is included in the tables in the
chapter Determining Risk of HIV Progression and in
the chapter CD4 Monitoring and Viral Load Testing.
The patient is or is not willing to start ARVs at
this time (the choice to accept or decline therapy
ultimately lies with the patient).
The patient is or is not likely to adhere to an ARV
regimen (an adherence counselor, with or without
a mental health clinician, may be able to assist
with this assessment and should be called upon
if available). No patient should be automatically
excluded from consideration of ART; the likelihood
of adherence must be discussed and determined
individually.
P: Plan
After educating the patient about the purpose and
logistics of the proposed regimen and assessing the
patient’s potential for adherence, the ART regimen can
be initiated, changed, or postponed accordingly.
The goals of therapy are to achieve maximal and durable
viral suppression, restore or preserve immune function,
improve quality of life, and reduce HIV-related
morbidity and mortality.
Considerations before Initiating ART
No “average patient” exists. Some patients will do better
during treatment and some will do worse than clinical
studies would predict. Health care providers must
work with each patient to develop a treatment strategy
that is both clinically sound and appropriate for that
individual’s needs, priorities, and circumstances of daily
life. Not all patients will be able to tolerate all drugs,
and the patients understanding, readiness to commit
to the regimen, and history of adherence to previous
regimens must be considered when choosing ARV
combinations. Major considerations are as follows:
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Willingness of the individual to begin therapy,
coupled with understanding of the purpose and the
mechanics of the planned regimen, and how it will
fit into his or her life
Degree of immunodeficiency and risk of disease
progression as reflected by the CD4 count and HIV
RNA level (see tables in the chapter Determining
Risk of HIV Progression and the chapter CD4
Monitoring and Viral Load Testing)
Potential benefits and risks of ARV drugs
Likelihood of adherence to the prescribed regimen
Resistance, if any, to ARV medications (obtain
resistance testing prior to ARV initiation in ARVnaive
patients)
The patient has the right to decline or postpone ART.
This decision should not affect any other aspect of
care, and ART should be offered again at each visit to
patients who meet the criteria for treatment. If mental
health issues, addiction, or the patient's social situation
are barriers to adherence, initiate appropriate referrals
and reassess adherence barriers at regular intervals.