SAN FRANCISCO — The debate continues to rage on when to initiate highly active antiretroviral therapy in HIV disease.
At a meeting on HIV management sponsored by the University of California, San Francisco, Paul A. Volberding, M.D., joked that the answer is obvious: before it's too late, but after it's too early.
But whatever the clinician decides, there is a series of steps that must be taken before antiretroviral therapy begins, said Dr. Volberding of the Veterans Affairs Medical Center in San Francisco:
▸ Confirm the HIV results. “We [recently] had in the Bay Area yet another case of a person who had been followed for HIV infection without anyone noticing that his HIV test was negative,” he said.
▸ Take a history and conduct a thorough physical exam.
▸ Get a CBC and a chemistry profile.
▸ Order a CD4 cell count and a plasma HIV RNA measurement.
▸ Consider resistance testing. “I think we're at the point where baseline resistance testing should be recommended in all cases,” Dr. Volberding said, but this is not yet part of official practice guidelines.
▸ Assess the patient's readiness for treatment and the likelihood that he or she will be adherent.
▸ Refer the patient for an ophthalmology exam if the CD4 count is below 100 cells/μL.
▸ Make sure female patients get a gynecologic exam with a Pap smear.
▸ Test for syphilis with a rapid plasma reagin test or a Venereal Disease Research Laboratory test.
▸ Test for tuberculin with a purified protein derivative test.
▸ Order a chest x-ray.
▸ Order hepatitis A, B, and C serology.
▸ Order a toxoplasma IgG test.
▸ Order a fasting glucose and a lipid panel.