Thursday 26 August 2021
Author: Laura Waters; reviewers: Jo Josh, Angela Bailey, Tristan Barber, John McSorley
Review date: 1 December 2021
During the national shortage of blood bottles BHIVA supports the cessation of non-essential monitoring for people with HIV, and avoidance of non-essential medication change that would require additional monitoring, where it is deemed clinically safe and appropriate to do so. Non-essential medication change would include switches for cost, or switches for pill burden/food requirement based on preference rather than need; switches for tolerability, toxicity or important drug–drug interactions should not be limited.
Many clinics, and service users, will feel confident to defer monitoring thanks to experience gained during the COVID-19 pandemic.
We suggest that the following factors should be considered when deciding which tests can be safely deferred:
1. Duration on current antiretrovirals
2. Duration of viral suppression
3. Adherence
4. Risk of drug–drug interactions
5. Comorbidities
6. Monitoring undertaken in primary and other secondary care services
7. Patient preference (e.g. anxiety related to deferred testing)
8. Symptoms
All efforts should be taken to ensure that, where people are monitored by more than one service, monitoring is simplified in a co-ordinated manner. For example, if you are able to, please access local databases to check whether a test has been done or necessary tests can be added to an existing sample.
Examples:
1. HIV viral load monitoring can be deferred for people on stable, suppressive antiretroviral therapy (ART) with high adherence; we do not recommend deferring viral load monitoring beyond 12 months. Where frequent viral load monitoring is essential, such as in pregnancy or during breastfeeding, this should continue
2. Routine safety monitoring (renal, liver, bone) can be deferred where previous tests were normal/stable and there is no clinical indication to test
3. People on tenofovir-DF-based ART with previously normal renal function and no new proteinuria or nephrotoxic medication can have renal monitoring deferred
4. Risk-based sexually transmitted infection (STI) screening and signposting to online services for STI serology where available
5. Avoidance of lipid or HbA1C measurement unless essential
6. Avoidance of CD4 monitoring unless it will alter management
Local arrangements for specimen pathways will vary (e.g. some laboratories cannot process an EDTA sample for CD4 quantification if already processed for full blood count measurement) so please liaise with your local laboratories to ensure testing and sample collection is optimised. Please use this opportunity to review your local practice against the BHIVA monitoring guidelines, for example ceasing CD4 count monitoring in virally suppressed individuals with a CD4 count >350 cells/mm3.
Please direct any enquiries to [email protected]