Stratified Management


Specific management considerations in HIV-infected patients include initiation and continuation of antiretroviral therapy, prophylaxis against PCP and other opportunistic infection, and health care maintenance issues. Patients are stratified based upon their CD4 cell count.

Stratified Management

CD4 Cell Count > 350/mm³
  • initiate antiretroviral therapy if patient is symptomatic or has viral load > 55,000 copies/ml (PCR) or > 30,000 copies/ml (bDNA)
  • if the above criteria not met, either initiate therapy or monitor patient off therapy
  • attention given to health care maintenance issues and immunizations
CD4 Cell Count 350-200/mm³
  • initiate or maintain antiretroviral therapy with modification of regimen as necessary

CD4 Cell Count 200-50/mm³

  • initiate or maintain antiretroviral therapy with modification of regimen as necessary
  • initiate PCP prophylaxis +

CD4 Cell Count < 50/mm³

  • initiate or maintain antiretroviral therapy with modification of regimen as necessary
  • maintain PCP prophylaxis
  • initiate MAC prophylaxis

+ Alternative prophylaxis for toxoplasmosis should be initiated in the patient with CD4 count < 100/mm3 and positive toxoplasmosis serology who is not receiving TMP-SMX for PCP prophylaxis.

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Follow-up Visits

Medical visits should be scheduled with appropriate frequency to monitor for disease progression and complications and to monitor drug therapies. In general, patients with advanced HIV disease require more frequent visits than those with earlier stages.

Initial evaluation is generally accomplished in two visits. At the first one, a history and physical examination are performed and baseline laboratory studies are obtained. At the second, results of evaluation are reviewed, and a management plan is discussed.

If antiretroviral therapy is initiated, a follow-up visit is arranged in four weeks to assess tolerability of medical regimen and to repeat laboratory parameters used to determine its effectiveness. Once a patient is on a stable treatment regimen, follow-up visits every three months are recommended unless intercurrent problems necessitate more frequent appointments.

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Laboratory Testing

Laboratory evaluation at follow-up visits should include the following:

Patients Receiving Antiretroviral Therapy

Patients Not on Antiretroviral Therapy

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Comments about these guidelines are welcome and can be sent to the author at hlibman@caregroup.harvard.edu