What are the next steps after a positive Human Immunodeficiency Virus (HIV) test result?

Next Steps After a Positive HIV Test

After a positive HIV test, immediate initiation of antiretroviral therapy (ART) is recommended regardless of CD4 count, along with comprehensive laboratory monitoring to characterize HIV stage, general health, and co-infections. 1

Immediate Steps

Confirmation of Diagnosis

• A positive rapid HIV test should be confirmed with Western blot or indirect immunofluorescence assay 1
• While awaiting confirmation, proceed with the following steps without delay 1

Laboratory Evaluation

Before starting ART, obtain the following tests 1:

1. HIV Stage Assessment:

   • HIV RNA level (viral load)
   • CD4 cell count

2. General Health Assessment:

   • Kidney function (creatinine)
   • Liver function tests
   • Lipid levels
   • Complete blood count
   • Blood glucose level
   • Pregnancy test (if applicable)

3. Co-infection Screening:

   • Hepatitis A, B, and C
   • Tuberculosis
   • Sexually transmitted infections (STIs)
   • Serum cryptococcal antigen (if CD4 < 100/μL) 1

4. Resistance Testing:

   • Baseline reverse transcriptase-protease resistance genotype testing 1

Antiretroviral Therapy (ART)

Timing of ART Initiation

• Start ART as soon as possible after diagnosis - ideally same-day or within 7 days 2, 3, 4
• Do not delay ART initiation while waiting for laboratory results unless there is:
  • Preexisting kidney or liver damage
  • High likelihood of transmitted drug resistance 1

Benefits of Rapid ART Initiation

• Faster viral suppression (48 vs 77 days) 5
• Lower cumulative viral burden 5
• Reduced risk of transmission to others 4

Recommended Initial ART Regimens

• Integrase strand transfer inhibitor (InSTI)-based regimens are preferred:
  • Bictegravir plus tenofovir alafenamide/emtricitabine
  • Dolutegravir plus tenofovir disoproxil fumarate/emtricitabine
  • Dolutegravir plus abacavir/lamivudine 2

Follow-up Monitoring

Early Monitoring

• Assess adherence and medication tolerability within 6 weeks of starting ART 1
• Measure HIV RNA level at this visit 1
• If HIV RNA has not declined considerably within 4-6 weeks despite good adherence, perform genotypic resistance testing 1

Long-term Monitoring

• Monitor HIV RNA every 3 months until viral suppression for at least 1 year 1
• After sustained viral suppression, monitor every 6 months 1

Patient Education and Support

• Explain that HIV is now a manageable chronic disease with near-normal life expectancy when treated 6
• Emphasize the importance of medication adherence
• Discuss that maintaining undetectable viral load means no risk of sexual transmission (U=U: Undetectable = Untransmittable) 2
• Address potential barriers to care (transportation, insurance, housing, stigma) 1
• Consider technology support for medication adherence (alarms, pill boxes, electronic reminders, text messaging) 1

Partner Notification and Prevention

• Discuss disclosure to sexual partners and needle-sharing partners
• Offer PrEP (pre-exposure prophylaxis) to HIV-negative partners 1
• Recommend condoms for all penetrative sexual acts 1

Common Pitfalls to Avoid

1. Delaying ART initiation - Starting treatment immediately improves outcomes and reduces transmission risk 4

2. Missing co-infections - Comprehensive screening for hepatitis, tuberculosis, and STIs is essential 1

3. Inadequate follow-up - Early monitoring of viral load and adherence is critical for successful treatment 1

4. Overlooking psychosocial support - Address mental health, substance use, and social determinants of health 1

5. Neglecting resistance testing - Baseline genotype testing is important due to high rates of transmitted drug resistance 1

By following these steps, you can ensure optimal care for patients newly diagnosed with HIV, leading to improved health outcomes and reduced transmission risk.