What follow-up care is recommended for a patient who has recently initiated antiretroviral therapy (ART) and been treated with benzathine penicillin G?

Follow-Up Care After Rapid ART Initiation and Syphilis Treatment

Within 4-6 weeks of ART initiation, the patient should return for HIV RNA viral load measurement, adherence assessment, and tolerability evaluation, while syphilis follow-up requires repeat RPR titers at 3,6, and 12 months to confirm adequate serologic response. 1

HIV Monitoring Timeline

Initial Follow-Up (4-6 Weeks Post-ART)

• Measure HIV RNA level to assess early virologic response 1
• Assess medication adherence and tolerability of the ART regimen 1
• Evaluate for adverse effects including any drug-related toxicity 1
• HIV RNA suppression may occur faster with integrase strand transfer inhibitor (InSTI)-based regimens but can take up to 24 weeks 1

Subsequent HIV RNA Monitoring

• Every 3 months until viral suppression below 50 copies/mL is achieved and maintained for at least 1 year 1
• Every 6 months thereafter if the patient remains virologically suppressed, clinically stable, and adherent 1
• If HIV RNA has not declined considerably by 4-6 weeks and adherence is adequate, genotypic resistance testing should be performed 1

CD4 Cell Count Monitoring

• Every 6 months until CD4 count is consistently above 250 cells/μL for at least 1 year with concurrent viral suppression 1
• After 1 year of CD4 >250 cells/μL, routine CD4 monitoring can be discontinued unless virologic failure occurs or immunosuppressive conditions develop 1

Defining Virologic Failure

• Confirmed HIV RNA >200 copies/mL on at least 2 consecutive measurements defines virologic failure 2
• If HIV RNA >50 copies/mL is detected after previous suppression, repeat measurement within 4 weeks and reassess adherence 1, 2
• Do not confuse isolated viral blips (<1000 copies/mL with subsequent return to undetectable) with true virologic failure 2

Syphilis Follow-Up

Serologic Monitoring Schedule

• RPR titers at 3,6, and 12 months after benzathine penicillin G treatment to assess serologic response 3
• Treatment success is defined as at least a fourfold decline in RPR titer at 12 months compared to baseline 3

HIV-Specific Considerations for Syphilis

• HIV-positive patients have poorer serologic responses to single-dose benzathine penicillin G compared to HIV-negative patients (73.4% vs 91.2% response rate at 12 months) 3
• Among HIV-positive patients, 12.5% fail to achieve fourfold decline in RPR titers and 14.1% experience fourfold increase (serologic failure) 3
• Higher baseline RPR titers predict better serologic response (adjusted OR 1.36 per 1-log2 increase) 3

Treatment Failure Criteria

• Lack of fourfold decline in RPR titer at 12 months 3
• Fourfold or greater increase in RPR titer during follow-up 3
• Clinical signs of persistent or progressive syphilis despite treatment 3

Additional Screening and Monitoring

Baseline and Ongoing Assessments

• Screen for other sexually transmitted infections at all exposed mucosal sites (pharyngeal, urethral, rectal as appropriate) 1
• Hepatitis C screening annually for men who have sex with men with ongoing risk 1
• Age- and risk-appropriate cancer screening including anal and cervical dysplasia screening 1
• Assess for opportunistic infections if CD4 count was initially low 1

Laboratory Safety Monitoring

• Renal function monitoring (creatinine, estimated GFR) particularly if using tenofovir-containing regimens 1
• Liver function tests at baseline and as clinically indicated 1
• Lipid panel for cardiovascular risk assessment 1
• Complete blood count to monitor for hematologic toxicity 1

Critical Pitfalls to Avoid

• Do not delay follow-up beyond 6 weeks for initial viral load assessment, as early identification of inadequate response allows for timely intervention 1
• Do not assume syphilis treatment success without serologic confirmation, especially in HIV-positive patients who have higher failure rates 3
• Do not switch ART based on single detectable viral load without confirmation—isolated blips do not constitute virologic failure 2
• Do not continue CD4 monitoring indefinitely once sustained suppression and immune reconstitution are achieved, as this adds unnecessary cost without clinical benefit 1
• Do not order resistance testing for viral loads <200 copies/mL, as amplification is unlikely to succeed and does not meet the threshold for confirmed failure 2