| SCREENING FOR NON-INFECTIOUS CO-MORBIDITIES |
|
Assessment |
At HIV diag-
nosis |
Prior to starting cART |
Follow up frequency |
Comment |
See page |
with cART
|
without cART |
| History |
• Past and current co-morbidities
|
+
|
+
|
|
|
On transfer of care repeat assessment |
|
| • Family history (eg premature CVD, diabetes, hypertension, CKD) |
+ |
+ |
|
|
Premature CVD: Cardiovascular events in a first degree relative:
male <55, female <65 years |
42 |
| • Concomitant medications i |
+ |
+ |
every visit |
every visit |
|
|
| • Current lifestyle (alcohol use, smoking, diet, aerobic exercise) |
+ |
+ |
6-12 m |
annual |
Adverse lifestyle habits should be addressed more frequently |
40 |
| Body composition |
• Body-mass index
|
+
|
+
|
annual
|
annual |
|
59 |
| • Clinical lipodystrophy assessment |
+ |
+ |
annual |
| Cardiovascular disease |
• Risk assessment (Framingham score ii) |
+
|
+ |
annual |
annual |
Should be performed in every older patient without CVD
(Men > 40 years; Women >50 years) |
42 |
| • ECG |
+ |
|
|
|
| Hypertension |
• Blood pressure |
+ |
+ |
annual |
annual |
|
44 |
| Dyslipidaemia |
• TC, HDL-c, LDL-c, TG iii |
+ |
+ |
annual |
|
Repeat in fasting state if used for medical intervention
(i.e. ≥ 8h without caloric intake) |
49 |
| Diabetes mellitus |
• Serum glucose |
+ |
+ |
6-12 m |
|
Consider oral glucose tolerance test if repeated
fasting glucose levels of
6.1-6.9 mmol/L (110-125 mg/dL)
|
47 |
| Liver disease |
• Risk assessment iv
|
+
|
+
|
annual
|
annual
|
More frequent monitoring prior to starting and on treatment with hepatotoxic drugs |
60 |
| • ALT/AST, ALP |
+ |
+ |
3-6 m |
6-12 m |
| Renal disease |
• Risk assessment v |
+ |
+ |
annual |
annual |
|
57 |
| • eGFR (aMDRD) vi |
+ |
+ |
3-6 m |
6-12 m |
More frequent monitoring if CKD risk factors present and/or prior to starting and on treatment with nephrotoxic
drugs viii |
| • Urine Dipstick
analysis vii |
+ |
+ |
annual |
annual |
Every 6 months if eGFR <60 ml/min;
If proteinuria ≥ 1+ and/or eGFR<60 ml/min perform UP/C or UA/C vii |
| Bone disease |
• Risk assessment ix FRAX® x in patients >40 years)
|
+ |
+ |
2 yrs |
2 yrs |
If not using FRAX®, consider DXA of spine and hip in specific patients
|
50 |
| • 25-OH vitamin D |
+ |
|
|
|
Repeat according to risk factors |
| Neurocognitive impairment |
• Questionnaire |
+ |
+ |
1-2 yrs |
1-2 yrs |
Screen risk patients |
62 |
| Depression |
• Questionnaire |
+ |
+ |
1-2 yrs |
1-2 yrs |
Screen risk patients |
54 |
| Cancer |
• Mammography |
|
|
1-3 yrs
|
1-3 yrs
|
Women 50-70 years
|
35 |
| • Cervical PAP |
|
|
1-3 yrs |
1-3 yrs |
Sexually active women, frequency depending on CD4 |
| • Others |
|
|
|
|
Controversial |
|
| i |
Review all concomitant medications that increase the risk of co-morbidities: eg diabetes: neuroleptic drugs including clozapine, olanzapine; pentamidine, glucocorticoids, IFN-a, thiazide diuretics, furosemide, phenytoin, diazoxide, beta-blockers and others; renal disease: NSAIDs |
| ii |
A risk equation developed from HIV populations is under development (see: www.cphiv.dk/tools.aspx). Of note, if individual patients receive medication to control dyslipidaemia and/or hypertension, any risk estimation should be interpreted with caution. |
| iii |
Calculator for LDL-cholesterol in cases where TG is not high can be found at www.cphiv.dk/tools.aspx. |
| iv |
Risk factors for chronic liver disease include: alcohol, viral hepatitis, obesity, diabetes, insulin resistance, hyperlipidaemia, hepatotoxic drugs |
| v |
Risk factors for chronic kidney disease (CKD): hypertension, diabetes, CVD, family history, black African ethnicity, viral hepatitis, concomitant nephrotoxic drugs. |
| vi |
eGFR: use aMDRD based on serum creatinine, gender, age and ethnicity (see: www.cphiv.dk/tools.aspx). |
| vii |
Some experts recommend UA/C or UP/C as screening test for proteinuria in all patients. UA/C: urinary albumin creatine ratio (mg/mmol) predominantly detects glomerular disease. Use in patients with diabetes mellitus. UP/C: urinary total protein creatinine ratio (mg/mmol) detects total protein secondary to glomerular and tubular disease |
| viii |
Additional screening is required for patients receiving tenofovir (see p. 58) |
| ix |
Classic risk factors: older age, female gender, hypogonadism, family history of hip fracture, low BMI (≤ 19 kg/m2), vitamin D deficiency, smoking, physical inactivity, history of low impact fracture, alcohol excess (>3 units/day), steroid exposure (minimum prednisone 5mg or equivalent for >3 months) |
| x |
See: www.shef.ac.uk/FRAX |
|
|
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