January 30, 2019
Interesting query from a colleague recently:
I'm a community ID doc in the trenches (the measles trenches at present) with an HIV question. Why do we still check CBCs & chem panels every 3-6 months in our HIV patients? Particularly our well-controlled, virologically-suppressed patients? This strikes me as a tremendous waste. I haven't been in practice that long, but I can count on one hand the number of times these routine labs have led to a change in ART (and even then, it was probably a patient on TDF, which I don't use much any more). Is this an evidence-based practice? Or a vestige of an earlier era of more toxic drugs?
Andrew raises an important question -- do the guidelines for laboratory monitoring still make sense when our HIV treatments have become so safe and effective?
Below I've summarized the labs recommended by the DHHS Guidelines for our stable patients -- the people who have been virally suppressed on ART for years. In italics, a bit of commentary.
When I've floated this idea by certain colleagues, they frequently cite the asymptomatic sexually transmitted infections they've picked up in their twice-yearly (or more frequent) monitoring.
I'd argue that this reflects an individual's STI risk, which is not the same in all people with HIV. By all means, continue to screen for STIs when clinically indicated, and the same goes for underlying medical problems that increasingly arise during aging.
So to test this revised strategy, let's imagine a clinical study:
Eligible: Stable on guidelines-approved ART; no history of virologic failure or treatment interruption; HIV < 200 on all measurements during the past 5 years.
Intervention: Randomized to 1) guidelines-recommended monitoring, or 2) HIV RNA once-yearly, other testing as indicated by demographics, clinical status, comorbid conditions, STI risk.
Primary endpoint: Virologic suppression at the end of the study.
Secondary endpoints: Occurrence/diagnosis of HIV or non-HIV-related comorbidities; cost (to healthcare system); cost (to patient).
And, since we're talking about a way to reduce office visits and healthcare utilization, how about this recent "appointment" in Alaska?
|The Evolution of Antiretroviral Therapy: Past, Present, and Future|
|This Week in HIV Research: How Should We Measure Success?|
|What Should We Do About Persistent Low-Level Viremia?|
|Read the Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents|
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