Recommended HIV Treatment Regimens
The recommended first-line antiretroviral therapy (ART) regimen for HIV treatment is an integrase strand transfer inhibitor (InSTI) plus two nucleoside reverse transcriptase inhibitors (NRTIs), specifically dolutegravir plus tenofovir alafenamide/emtricitabine or abacavir/lamivudine. 1
Initial Treatment Recommendations
Preferred Regimens
The following regimens are recommended as first-line therapy (listed alphabetically by InSTI component):
- Dolutegravir/abacavir/lamivudine (evidence rating AIa) 2
- Dolutegravir plus TAF/emtricitabine (evidence rating AIa) 2
- Elvitegravir/cobicistat/TAF/emtricitabine (evidence rating AIa) 2
- Raltegravir plus TAF/emtricitabine (evidence rating AIII) 2
Alternative Regimens
When an InSTI-based regimen is not an option, the following alternatives are recommended:
- Darunavir (boosted) plus TAF (or TDF)/emtricitabine or abacavir/lamivudine (evidence rating AIa) 2
- Efavirenz/TDF/emtricitabine (evidence rating AIa) 2
- Rilpivirine/TAF (or TDF)/emtricitabine (evidence rating AIa) 2
When to Start Treatment
- ART is recommended for all HIV-infected individuals with detectable plasma virus, regardless of CD4 cell count (evidence rating AIa) 2
- Immediate initiation is recommended as soon as possible after diagnosis, including immediately after diagnosis if the patient is ready (evidence rating BIII) 1
- Early ART initiation is recommended in the setting of acute HIV infection (evidence rating BIII) 2
Special Populations and Considerations
Renal Impairment
- TDF should be avoided in patients with or at risk of kidney disease 1
- TAF is preferred over TDF for individuals with or at risk of kidney dysfunction 1
Bone Health
- TAF is preferred over TDF for individuals with or at risk of osteopenia or osteoporosis 1
HIV/HBV Co-infection
- Patients co-infected with HIV and HBV should receive a regimen containing TDF or TAF plus lamivudine or emtricitabine (evidence rating AIa) 1
- Discontinuing treatment in patients with HBV co-infection without alternative HBV suppressive therapy is not recommended 1
HIV/HCV Co-infection
- HIV-infected patients with HCV co-infection should start an ART regimen with drugs that do not have significant drug interactions with HCV therapies (evidence rating AIIa) 2
Monitoring and Follow-up
- HIV viral load should be checked 1 month after starting or switching regimens, and regularly thereafter 1
- CD4 cell count, HIV RNA level, renal function, and hepatic function tests should be monitored regularly 1
- Follow-up visits should be scheduled at intervals of no longer than every 3 months 1
- Renal function should be assessed at least every 6 months 1
Management of Treatment Failure
- Resistance testing is recommended while the patient is taking the failing regimen (evidence rating AIa) 1
- After NNRTI failure, dolutegravir plus 2 NRTIs (with ≥1 active drug determined by genotypic testing) is recommended (evidence rating AIa) 1
- After InSTI failure, a boosted PI plus 2 NRTIs (with ≥1 active NRTI) is recommended (evidence rating AIII) 1
- Adding a single active agent to a failing regimen is not recommended (evidence rating AIa) 1
Optimizing Adherence
- Use of fixed-dose combinations can improve adherence by reducing pill burden 1
- Once-daily dosing, fixed-dose combinations, and medication timing with daily activities can improve adherence 1
- Suboptimal adherence support can lead to virologic failure 1
Important Cautions
- Initial 2-drug regimens are recommended only in rare situations in which a patient cannot take abacavir, TAF, or TDF (evidence rating BIa) 2
- Monotherapy with PIs or InSTIs should be avoided as it leads to resistance 1
- Drug-drug interactions, especially with PIs and NNRTIs, should always be checked 1
- NRTI-sparing regimens have shown higher rates of drug resistance than NRTI-based regimens 3
The current standard of care for HIV treatment has evolved to prioritize regimens that maximize efficacy while minimizing toxicity. InSTI-based regimens have become the preferred choice due to their high efficacy, favorable side effect profile, and high barrier to resistance. When selecting a regimen, considerations should include potential side effects, pill burden, dosing frequency, drug interactions, and any comorbid conditions to optimize treatment outcomes and patient quality of life.