Recommended Treatment for HIV Control
Antiretroviral therapy (ART) should be initiated as soon as possible after HIV diagnosis for all patients, with the recommended initial regimen consisting of an integrase strand transfer inhibitor (InSTI) plus two nucleoside reverse transcriptase inhibitors (NRTIs). 1
When to Start ART
- ART should be initiated immediately after diagnosis if the patient is ready to commit to treatment 1
- Structural barriers that delay ART initiation should be removed to allow newly diagnosed persons to receive ART at their first clinic visit 1
- Rapid ART initiation leads to faster viral suppression, reducing mortality by up to 63% even in patients with CD4 counts >500 cells/μL 2
Recommended Initial Regimens
First-line Options (in alphabetical order by InSTI component):
- Bictegravir/tenofovir alafenamide/emtricitabine 3
- Dolutegravir/abacavir/lamivudine (requires negative HLA-B*5701 testing) 1, 3
- Dolutegravir plus tenofovir alafenamide/emtricitabine 1, 3
- Elvitegravir/cobicistat/tenofovir alafenamide/emtricitabine 1
- Raltegravir plus tenofovir alafenamide/emtricitabine 1
Alternative Options (when InSTI is not suitable):
- Darunavir (boosted) plus tenofovir alafenamide/emtricitabine or abacavir/lamivudine 1
- Efavirenz/tenofovir disoproxil fumarate/emtricitabine 1, 4
- Rilpivirine/tenofovir alafenamide/emtricitabine 1
Special Considerations
Opportunistic Infections
- For most opportunistic infections: Start ART within 2 weeks of OI treatment 1
- For tuberculosis with CD4 ≥50/μL: Start ART within 2-8 weeks of TB treatment 1
- For cryptococcal meningitis: Start ART 4-6 weeks after antifungal therapy 1
- For TB treatment with rifamycin: Use dolutegravir (50mg twice daily), efavirenz (600mg/day), or raltegravir (800mg twice daily) plus 2 NRTIs 1
Pregnancy
Recommended regimens during pregnancy 1:
- Atazanavir/ritonavir
- Darunavir/ritonavir
- Dolutegravir
- Efavirenz
- Raltegravir
Hepatitis B Co-infection
- Use regimens containing tenofovir disoproxil fumarate or tenofovir alafenamide plus lamivudine or emtricitabine 1, 5
- Monitor hepatic function closely if discontinuing these medications 5
Monitoring Protocol
- Before starting ART: Obtain HIV-1 RNA level, CD4 count, HIV genotype for resistance, HLA-B*5701 testing, viral hepatitis screening, and basic chemistry panel 3
- Check HIV viral load 1 month after starting treatment 3
- Continue monitoring every 3-4 months until viral suppression 3
- For stable patients with sustained suppression, monitoring can be extended to every 6 months 3
Clinical Pearls and Pitfalls
- InSTI-based regimens achieve faster viral suppression than protease inhibitor-based regimens 6
- HLA-B*5701 testing must be performed before using abacavir; positive results contraindicate abacavir use 1, 3
- Avoid tenofovir disoproxil fumarate in patients with or at risk for kidney disease or osteoporosis; use tenofovir alafenamide instead 1, 5
- Avoid bictegravir with rifampin due to drug interactions 1
- Don't delay ART initiation while waiting for all baseline test results; treatment can be started before all results are available 3
- Two-drug regimens are recommended only in rare situations when patients cannot take abacavir, tenofovir alafenamide, or tenofovir disoproxil fumarate 1
The evidence strongly supports that immediate ART initiation significantly reduces morbidity and mortality across all CD4 count levels, with the most recent guidelines emphasizing rapid initiation with InSTI-based regimens as the cornerstone of effective HIV control.