What is the comprehensive management of HIV?

Comprehensive Management of HIV

Antiretroviral therapy (ART) is recommended for virtually all HIV-infected individuals as soon as possible after HIV diagnosis to reduce morbidity, mortality, and improve quality of life. 1 An integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs) is generally the preferred initial regimen due to superior efficacy and tolerability.

Initial Diagnosis and Evaluation

HIV Testing and Confirmation

• Routine opt-out HIV screening is recommended in primary care settings, emergency departments, and for all pregnant women 1
• Patients without documentation of HIV status should have an HIV serologic test performed upon initiation of care 1
• Rapid HIV test algorithms may be used to confirm preliminary positive results, allowing for same-day referral to treatment 1

Baseline Assessment

1. Medical History and Physical Examination

   • Comprehensive present and past medical history, physical examination, medication/social/family history 1
   • Screen for depression, substance use disorders, and other psychosocial factors 1

2. Laboratory Testing

   • CD4 cell count with percentage 1
   • HIV RNA viral load 1
   • HIV genotypic resistance testing at entry into care 1
   • HLA-B*5701 testing before using abacavir 1
   • Complete blood count, chemistry panel, urinalysis
   • Screening for sexually transmitted infections, tuberculosis, hepatitis B and C

Antiretroviral Therapy (ART)

When to Start

• Immediate initiation (rapid start) of ART is recommended for virtually all HIV-infected individuals, regardless of CD4 count 1
• Immediate ART initiation requires adequate staffing, specialized services, and careful selection of therapy 1
• Studies show immediate ART reduces all-cause mortality by approximately 19% compared to delayed treatment 2
• Rapid ART initiation has been shown to be acceptable to patients and provides emotional relief by offsetting fears and providing agency over one's health 3

Recommended Initial Regimens

• First-line therapy: InSTI (dolutegravir, bictegravir, or raltegravir) plus 2 NRTIs 1, 4
• Common NRTI combinations include tenofovir/emtricitabine 1, 4
• Once-daily regimens are recommended for treatment-naive patients 1
• Fixed-dose combinations are preferred to decrease pill burden 1

Monitoring and Follow-up

Laboratory Monitoring

• HIV RNA viral load at 4-6 weeks after starting ART 1
• Once HIV RNA is below 50 copies/mL, monitoring every 3 months until virus is suppressed for at least a year 1
• After 1 year of viral suppression, monitoring can be reduced to every 6 months 1
• CD4 cell counts every 6 months until above 250/μL for at least 1 year with viral suppression 1
• When virus has been suppressed for at least 2 years and CD4 count is persistently above 500/μL, routine CD4 monitoring is not recommended unless virologic failure occurs 1

Virologic Failure Management

• If viral load above 50 copies/mL is detected, repeat measurement within 4 weeks 1
• Assess medication adherence and tolerability 1
• If adherence appears sufficient but viral load has not declined, genotypic resistance testing is recommended 1
• For patients failing InSTI-based regimens, genotypic testing for InSTI resistance should be ordered 1

Retention in Care and Adherence

Strategies to Improve Retention

• Systematic monitoring of care linkage after diagnosis, retention in care, and viral suppression 1
• Brief, strengths-based case management after HIV diagnosis 1
• Personal telephone and interactive text reminders before appointments and after missed appointments 1
• Rapid intervention following missed clinic visits 1

Adherence Support

• Individual one-on-one ART education 1
• Self-reported adherence monitoring using validated instruments and pharmacy refill data 1
• Opioid substitution therapy for opioid-dependent patients 1
• Integration of directly observed ART in methadone maintenance programs and for persons with substance use disorders 1
• Screening for and addressing housing instability, food insecurity, ongoing substance use, and medication adverse effects 1

Prevention of HIV Transmission

• Condoms are required to prevent acquisition of non-HIV STIs 1
• Quarterly screening for asymptomatic STIs for populations with high rates of bacterial STIs 1
• Pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine for HIV-negative individuals at risk 1
• Daily (rather than intermittent) PrEP is recommended 1

Common Pitfalls and Caveats

1. Delayed ART initiation: Waiting for additional test results or referrals before starting ART can lead to missed opportunities for treatment and increased mortality 5, 2

2. Inadequate resistance testing: Failure to perform baseline resistance testing can result in selection of suboptimal regimens 1

3. Poor adherence monitoring: Failing to systematically assess adherence can lead to undetected treatment failure 1

4. Insufficient attention to comorbidities: HIV-infected individuals require comprehensive screening for mental health issues, substance use disorders, and other medical conditions that can impact HIV outcomes 1

5. Overlooking drug interactions: Many antiretrovirals have significant interactions with commonly prescribed medications 4

By following these comprehensive management strategies, clinicians can optimize outcomes for people living with HIV, reducing morbidity and mortality while improving quality of life.