HIV Treatment Regimen: Current 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 is no suspicion of opportunistic infection. 1
Initial ART Regimen Selection
First-Line Recommended Regimens
Integrase strand transfer inhibitor (InSTI)-based regimens are preferred for initial therapy due to their high efficacy, excellent tolerability, and high barrier to resistance:
- Bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC) 2
- Dolutegravir plus tenofovir alafenamide/emtricitabine (DTG plus TAF/FTC) 1, 2
- Dolutegravir/lamivudine (DTG/3TC) - only if HIV RNA <500,000 copies/mL, no lamivudine resistance, and no HBV co-infection 2
Alternative Regimens
When InSTI-based regimens are not an option:
- Darunavir/cobicistat plus TAF (or TDF)/emtricitabine
- Darunavir/ritonavir plus TAF (or TDF)/emtricitabine
- Efavirenz/TDF/emtricitabine
- Rilpivirine/TAF (or TDF)/emtricitabine (if HIV RNA <100,000 copies/mL and CD4 >200/μL) 1, 2
Special Clinical Scenarios
Opportunistic Infections
- Most opportunistic infections: Start ART within 2 weeks of OI treatment 1
- Tuberculosis without meningitis: Start ART within 2 weeks of TB treatment, especially if CD4 <50/μL 1
- Tuberculous meningitis: Start TB treatment and corticosteroids immediately, then ART within 2-4 weeks 1, 2
- Cryptococcal meningitis: Start ART 2-4 weeks after antifungal therapy 1, 2
- Cancer diagnosis: Start ART immediately with attention to drug-drug interactions 1, 2
Pregnancy
Recommended regimens during pregnancy:
- Atazanavir/ritonavir + TDF/FTC or TDF/3TC
- Darunavir/ritonavir + TDF/FTC or TDF/3TC
- Dolutegravir + TDF/FTC or TDF/3TC
- Efavirenz + TDF/FTC or TDF/3TC
- Raltegravir + TDF/FTC or TDF/3TC
- Rilpivirine + TDF/FTC or TDF/3TC 1
TB Co-infection
For patients on rifamycin-based TB treatment:
- Dolutegravir (50 mg twice daily) + 2 NRTIs
- Efavirenz (600 mg/d) + 2 NRTIs
- Raltegravir (800 mg twice daily) + 2 NRTIs 1
Note: Bictegravir with rifampin is not recommended due to drug-drug interactions 1
Benefits of Immediate ART Initiation
Immediate ART initiation offers significant benefits:
- 63% reduction in overall mortality, even in patients with CD4 counts >500 cells/μL 3
- Faster viral suppression compared to standard of care 4
- Improved retention in care 4
- Provides emotional relief by offsetting fears and providing agency over one's health 5
Pre-ART Laboratory Testing
Before starting ART, perform:
- HIV-1 RNA level
- CD4 cell count
- HIV genotype for NRTI, NNRTI, and PI resistance
- Laboratory tests to exclude active viral hepatitis
- Chemistry panel
- HLA-B*5701 testing if abacavir-containing regimen is planned 2
Monitoring After ART Initiation
- HIV viral load at 4-8 weeks, then every 3 months
- CD4 cell count every 3-6 months
- Complete blood count
- Liver and kidney function tests
- Assessment for immune reconstitution inflammatory syndrome (IRIS) 2
Important Considerations and Caveats
- Renal function: TDF is not recommended for patients with creatinine clearance <60 mL/min or those with or at risk for kidney disease 1, 2
- TAF limitations: Not recommended in patients with creatinine clearance <30 mL/min 1
- Abacavir use: HLA-B*5701 testing required before use; those who test positive should not receive abacavir 1
- Hepatitis B co-infection: Use TDF or TAF plus lamivudine or emtricitabine in regimen 1, 2
- Hepatitis C co-infection: Select ART regimen without significant drug interactions with HCV therapies 1
Early ART initiation is crucial for reducing HIV transmission, morbidity, and mortality. Structural barriers that delay ART should be addressed to ensure timely treatment and optimal outcomes.