HIV Treatment Recommendations
Antiretroviral therapy (ART) should be initiated as soon as possible after HIV diagnosis, ideally within 7 days, including on the same day as diagnosis if the patient is ready and there are no contraindications such as suspected opportunistic infections. 1
Initial ART Regimen Selection
Preferred First-Line Regimens
Integrase strand transfer inhibitor (InSTI)-based regimens are recommended as initial therapy for most people with HIV due to high viral suppression rates, excellent tolerability, and high barrier to resistance:
- Bictegravir/tenofovir alafenamide/emtricitabine (evidence rating: AIa) 2
- Dolutegravir/abacavir/lamivudine (evidence rating: AIa) 1, 2
- Dolutegravir plus tenofovir alafenamide/emtricitabine (evidence rating: AIa) 1, 2
Important Considerations
- HLA-B*5701 testing must be performed before using abacavir; patients who test positive should not receive abacavir (evidence rating: AIa) 1
- Tenofovir alafenamide (TAF) is preferred over tenofovir disoproxil fumarate (TDF) for patients with or at risk for kidney or bone disease 2
- NNRTIs and abacavir should not be used for rapid ART initiation without appropriate testing 2
Special Clinical Scenarios
Tuberculosis Co-infection
- For patients with tuberculosis without meningitis: Start ART within 2-8 weeks after TB treatment initiation, with earlier timing (within 2 weeks) for those with CD4 counts <50/μL (evidence rating: AIa) 1
- Recommended regimens for TB co-infection:
Cryptococcal Meningitis
- Initiate ART 2-4 weeks after starting antifungal therapy (evidence rating: BIa) 1
- Earlier initiation (at 2 weeks) for those with clinical improvement and controlled intracranial pressure 1
Pregnancy
Recommended regimens during pregnancy (combined with appropriate NRTIs):
- Dolutegravir (evidence rating: AIb) 1
- Atazanavir/ritonavir (evidence rating: AIIa) 1
- Darunavir/ritonavir (evidence rating: AIIa) 1
- Raltegravir (evidence rating: AIIa) 1
- Efavirenz (evidence rating: BIa) 1
Monitoring and Follow-up
- Check HIV viral load 1 month after starting treatment 2
- Continue monitoring every 3-4 months until viral suppression is achieved 2
- For stable patients with sustained viral suppression, monitoring can be extended to every 6 months 2
Benefits of Early ART Initiation
Early ART initiation provides significant benefits:
- Reduces overall mortality by up to 63% even in patients with CD4 counts >500 cells/μL 3
- Faster viral suppression with integrase inhibitor-based regimens compared to protease inhibitor-based regimens 4
- Provides emotional relief by offsetting fears of disease progression and giving patients agency over their health 5
Implementation Considerations
Essential elements for successful rapid ART implementation include:
- Expedited access to ART medications 6
- Expertise in benefits, linkage, and care navigation 6
- Patient-centered approach 6
- Strong communication methods and culture 6
Common Pitfalls to Avoid
- Delaying ART initiation: Structural barriers that delay ART should be removed to allow newly diagnosed persons to receive treatment at the first clinic visit after diagnosis if appropriate 1
- Ignoring drug interactions: Pay careful attention to drug-drug interactions, especially with tuberculosis medications or in patients with newly diagnosed cancer 1
- Inadequate monitoring: Failure to monitor viral load regularly can lead to delayed detection of treatment failure and development of resistance 2
- Overlooking adherence support: Patients need comprehensive adherence support, especially during the initial adjustment period after diagnosis 5
By following these evidence-based recommendations, clinicians can optimize outcomes for patients with HIV, reducing morbidity and mortality while improving quality of life.