Most people with HIV who are stable on suppressive ART need less frequent specialised monitoring than in the past. Every visit should still include BP, weight/waist circumference, an adherence and side-effect check, mental health screening and an STI risk discussion — the structured CD4/viral load schedule below sits on top of this routine review.
CD4 & viral load monitoring
- Newly starting ART: viral load every 4–8 weeks until suppressed; CD4 at baseline and again at 3 months.
- First 2 years of suppressive ART: CD4 every 3–4 months if CD4 <300, or every 6 months if CD4 ≥300. Viral load every 3–4 months.
- After 2 years, suppressed: CD4 every 6 months if still <300, every 12 months if 300–500, and optional once consistently >500. Viral load can extend to 6-monthly if adherent and stable for over a year.
- Viral load not suppressed: CD4 every 3–6 months until resuppression is achieved.
Viral load thresholds. Suppressed/undetectable is below the laboratory's detection limit — commonly <20–50 copies/mL depending on the assay. A result >200 copies/mL is more likely to reflect a true rise; repeat in 2–4 weeks (no later than 8) before acting — a single missed dose can cause a transient blip. >500 copies/mL carries a higher risk of genuine virologic failure with resistance.
Other routine investigations
- Renal function & urinalysis: baseline, 3 and 6 months after starting tenofovir disoproxil (TDF), then 6-monthly while on TDF; annually on lower-risk regimens.
- LFTs & fasting lipids: baseline and 3 months after starting or changing ART, then annually once stable.
- STI screening: annually at minimum, 3-monthly if MSM or on PrEP — see companion sheet ID-03 for full detail.
- Annual review bloods: FBC, EUC, LFTs, fasting lipids, glucose/HbA1c and a cardiovascular risk score, alongside the HIV-specific tests above.
If viral load becomes detectable
On two consecutive detectable results, investigate before changing therapy — do not adjust ART in primary care. Confirm with a repeat viral load in 4 weeks and review adherence honestly; check for new drug interactions or absorption issues (recent antibiotics, antacids, OTC supplements, St John's Wort); then arrange HIV resistance genotype testing and refer back to the HIV physician for regimen review.
Safety
- Don't change ART in primary care for a single detectable result — confirm with a repeat test in 4 weeks first.
- A transient blip (an isolated low-level detectable result that resuppresses) is common and not usually a sign of treatment failure.
- Virologic failure is generally defined as a confirmed viral load ≥200 copies/mL on treatment — this needs resistance testing, not a same-day regimen change.
Red flags / refer
- Confirmed (two consecutive) detectable viral load.
- CD4 falling on trend, or a new value <200.
- New HIV-related symptoms, or any suspected opportunistic infection.
- Pregnancy — confirmed or planned.
ID-06A v1.0 · Reviewed Jun 2026 · Review Jun 2027
Companion sheet: ID-06B (Prevention, comorbidities & referral). See also ID-01/02 (diagnosis & ART), ID-03 (STI screening) and ID-04 (OI prophylaxis). Verify against ASHM hiv.guidelines.org.au and current local pathology reference ranges before applying monitoring frequencies.
