What routine laboratory tests should be ordered for an HIV‑positive male patient?

Routine Laboratory Monitoring for HIV-Positive Male Patients

For an HIV-positive male patient, obtain baseline labs including HIV RNA viral load, CD4 count, HIV genotype resistance testing, hepatitis B and C serology, STI screening, complete metabolic panel, complete blood count, fasting lipid panel, fasting glucose/HbA1c, and urinalysis with calculated creatinine clearance. 1, 2

Baseline Assessment (Initial Labs)

HIV-Specific Testing

• HIV RNA viral load to establish baseline viremia and assess prognosis 1, 2
• CD4 count with percentage as the primary marker of immune function and disease stage 1, 2
• HIV genotype resistance testing (reverse transcriptase and protease) to detect transmitted drug resistance, even if ART is deferred 1, 2
• HLA-B*5701 testing if abacavir use is being considered (only needed once in lifetime) 1, 2
• CCR5 tropism testing only if considering maraviroc 1, 2

Coinfection Screening

• Hepatitis B panel: HBsAg, HBsAb, and anti-HBc total to identify active infection and immunity status 3, 4, 2
• Hepatitis C antibody (and confirmatory RNA if positive) 3, 4, 2
• Hepatitis A serology to determine vaccination need 3
• Tuberculosis screening with either tuberculin skin test (TST) or interferon-gamma release assay (IGRA) 1, 2
• Toxoplasma IgG antibody to identify patients at risk for reactivation 2
• Syphilis serology (RPR or VDRL with confirmatory treponemal testing if positive) 1, 2

STI Screening (Critical for MSM)

• Gonorrhea and chlamydia NAAT from urine, pharynx, and rectum (based on sexual practices) 3, 2
• Repeat STI screening at least annually, or every 3 months for men who have sex with men (MSM) with ongoing risk 1

Safety and Metabolic Labs

• Complete blood count with differential to assess for cytopenias common in HIV 2
• Comprehensive metabolic panel including ALT, AST, bilirubin, alkaline phosphatase, albumin, electrolytes, BUN, and creatinine 4, 2
• Calculated creatinine clearance (especially important for Black patients and those with advanced disease) 2
• Urinalysis to screen for proteinuria and nephropathy 2
• Fasting lipid panel (total cholesterol, LDL, HDL, triglycerides) due to increased cardiovascular risk 2
• Fasting glucose or HbA1c to screen for diabetes 2
• G6PD screening if patient has African, Asian, or Mediterranean ancestry (before using oxidant drugs like dapsone) 2

Additional Baseline Testing

• Chest radiograph if tuberculosis screening is positive or if underlying lung disease is suspected 1, 2
• Morning serum testosterone if patient has decreased libido, erectile dysfunction, reduced bone mass, fractures, or nonspecific symptoms like fatigue 1

Ongoing Monitoring Schedule

HIV RNA Viral Load Monitoring

• Within 4-6 weeks after starting or changing ART to assess initial response 1, 3, 4
• Every 3 months until HIV RNA <50 copies/mL for at least 1 year 1, 3, 4
• Every 6 months after sustained suppression for ≥1 year if adherence is excellent 1, 3, 4
• If HIV RNA rises above 50 copies/mL: repeat within 2-4 weeks and assess adherence 1, 3
• Virologic failure is defined as HIV RNA >200 copies/mL on 2 consecutive tests; obtain resistance testing (including integrase genotype) while still on failing regimen 1, 3, 4

CD4 Count Monitoring

• Every 6 months until CD4 >250 cells/μL for at least 1 year with concurrent viral suppression 1, 4
• Can discontinue CD4 monitoring once consistently >250 cells/μL for ≥1 year with sustained viral suppression, unless ART fails or immunosuppressive conditions develop 1, 4
• Note: Research shows that only 4% of patients with baseline CD4 >200 cells/μL experience decline below 200 cells/μL, and most declines are transient 5

Safety Labs During ART

• Hepatic and renal function tests (ALT, AST, creatinine) every 3-6 months aligned with viral load monitoring 4
• Fasting lipids and glucose annually or more frequently if abnormal 2
• Complete blood count every 6-12 months or as clinically indicated 2

Periodic Screening

• STI screening every 3-12 months depending on risk (every 3 months for MSM with ongoing condomless sex) 1
• Hepatitis C antibody annually for MSM and persons who inject drugs 2
• Tuberculosis screening should be repeated if new exposure or symptoms develop 1

Critical Pitfalls to Avoid

• Never extend monitoring intervals beyond 6 months for viral load once suppressed, as this allows more time for resistance to emerge if treatment fails 1
• Do not stop CD4 monitoring prematurely before reaching the threshold of >250 cells/μL for ≥1 year with viral suppression 1
• Always obtain resistance testing while patient is still on the failing regimen (or within 4 weeks of stopping), as archived resistance may not be detected later 1
• For patients with hepatitis B coinfection, never abruptly discontinue tenofovir-containing regimens as this can cause severe hepatitis flares 4
• Baseline resistance testing is essential even if ART is deferred, as 25% of patients still present with advanced disease and transmitted resistance affects treatment choices 1, 5