2. Defining Treatment Success
• Mild or no reported side effects
• Excellent adherence
• Improved clinical status in 6 months
– Improved growth
– Improvement in neurological symptoms and
development
– No new AIDS defining ( WHO III OR IV) illness
– Fewer intercurrent illnesses/no hospitalizations
• Improved or stabilized immune status in 6
months ( increased/increasing CD4 count,
decreasing Viral load)
3. Monitoring the First-Line Regimen
• If taken consistently and correctly, ART will help
patients to feel better and live longer
• The majority of patients who initiate ART have
no problems or side effects.
• As with any medicines, however, a subset of
patients will develop side effects and/or drug
toxicities requiring a change in ARVs.
• A systematic approach to monitoring allows us
to identify these patients promptly and to
respond effectively
4. Formulating the Patient Care Plan
• Obtain baseline information
– Medical history, physical examination, WHO staging,
laboratory tests as above
– Psychosocial assessment
• Determine next steps for patient using SOPs
– These are step-by-step guidelines for patient care that
are consistent with South Sudan’s national norms and
ART guidelines
5. Formulating the Patient Care Plan
• Is additional information required?
• Are additional referrals required?
• Is the patient eligible for OI prophylaxis?
• Is the patient eligible for antiretroviral
therapy?
• When should s/he return to clinic?
6. Formulating the Patient Care Plan
• Guidelines for follow-up visits are based on HIV
disease stage, patient needs (psychosocial, clinical)
and the need to provide quality HIV services.
• Information gathered during baseline assessment
will dictate frequency and intensity of clinical
follow up visits
• Information obtained from clinical, laboratory,
health history and physical exam will stratify
patients into one of three categories
9. CD4 and viral load monitoring
9
Source: Swaziland integrated HIV management guidelines, 2015
10. Frequency of follow up
• Asymptomatic children over 5 years of age in pre-ART care should
have scheduled 3-monthly follow-up visits with CD4 testing at
baseline, 6 & 12 months, then Viral load at 6 months, 12 months
and annually.
• Visits may be more frequent with concurrent medical conditions
or borderline CD4 or increasing VL.
• All children below 5 years are eligible for ART and will require 6
monthly VL assay (same for preg women).
• Children should be seen Monthly for follow up visits and more
frequently if they are ill
11. Follow-up Visits (stable clients stages 1/2)
At Every Visit:
Medical history, symptom checklist and targeted (not comprehensive) physical exam
CD4/ VL count as recommended
Patient education & Supportive services
Reassessment of the care plan after each visit
Weight, height, head circumference and measurements of growth
Developmental status & Nutritional status, Immunization status
Screening for TB and other active opportunistic infections and co-infections
Eligibility interventions such as Cotrimoxazole prophylaxis (CPT) and INH preventive
therapy (IPT)- about to be implemented in South Sudan
12. Follow-up Visits: Severely ill clients (stages 3/4)
Repeat visits at every month:
Medical history, symptom checklist and targeted physical exam,
clinical stage of HIV disease
CD4/ VL count every as recommended
Patient education & Supportive services
Reassessment of the care plan after each visit
Weight, height, head circumference and measurements of growth
Developmental status & Nutritional status, Immunization status
Screening for TB and other active opportunistic infections and co-
infections
Eligibility interventions such as Cotrimoxazole prophylaxis (CPT) and
INH preventive therapy (IPT)
13. At All Visits
• Make sure the patient understands about HIV
disease and the nature of the treatment they are
receiving
• Assess psychosocial needs and encourage
participation in support groups
• Stress the importance of adherence with visits and
of informing you of new symptoms and signs
• Provide support and encouragement
14. Summary
• HIV infection compromises the immune system and
increases vulnerability to infection
• Initial assessment must be thorough and
comprehensive
• Follow-up visits are essential to disease
management, even when patients have no
symptoms and/or are not taking ART
• A multidisciplinary team approach is essential to
patient adherence and favorable patient outcomes
