From the Guidelines
For a patient with HIV and an unknown infection with a CD4 count of 99, immediate antiretroviral therapy (ART) with an integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs) is recommended, as soon as possible after HIV diagnosis, as stated in the 2018 recommendations of the international antiviral society-usa panel 1.
Treatment Approach
The treatment approach should include:
- An integrase strand transfer inhibitor (InSTI) such as dolutegravir, plus
- 2 nucleoside reverse transcriptase inhibitors (NRTIs) such as tenofovir disoproxil fumarate/emtricitabine, as the initial therapy, considering unique patient circumstances, such as concomitant diseases and conditions, potential for pregnancy, and cost 1.
Prophylaxis and Monitoring
In addition to ART, the patient should receive:
- Prophylaxis against opportunistic infections, such as Pneumocystis pneumonia, with trimethoprim-sulfamethoxazole
- Mycobacterium avium complex prevention with azithromycin
- Baseline laboratory tests, including HIV viral load, resistance testing, complete blood count, comprehensive metabolic panel, and screening for hepatitis B and C, should be performed before starting ART 1.
Rationale
This approach is critical because a CD4 count below 100 indicates severe immunosuppression, putting the patient at high risk for life-threatening opportunistic infections. ART will help restore immune function by suppressing viral replication, while prophylactic medications provide protection during immune recovery. The 2018 recommendations of the international antiviral society-usa panel 1 emphasize the importance of immediate ART initiation and careful selection of medical therapy, considering the patient's unique circumstances.
From the FDA Drug Label
Efavirenz tablets is a prescription HIV-1 (Human Immunodeficiency Virus type 1) medicine used with other antiretroviral medicines to treat HIV-1 infection in adults and in children who are at least 3 months old and who weigh at least 7 pounds 12 ounces(3. 5 kg). When used with other antiretroviral medicines to treat HIV-1 infection, efavirenz tablets may help: •reduce the amount of HIV-1 in your blood. This is called viral load. •increase the number of CD4+ (T) cells in your blood that help fight off otherinfections.
The medications used to treat HIV with an unknown infection in a patient with a CD4 count of 99 include efavirenz 2.
- Efavirenz is used in combination with other antiretroviral medicines to treat HIV-1 infection.
- It may help reduce the amount of HIV-1 in the blood and increase the number of CD4+ cells. Note that the provided information does not specify the exact treatment regimen for a patient with a CD4 count of 99, but efavirenz is one of the medications used to treat HIV-1 infection.
From the Research
Treatment Options for HIV Infection
The treatment of HIV infection typically involves antiretroviral therapy (ART) [ 3 ].
- Recommended initial regimens include:
- 2 nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine)
- plus a nonnucleoside reverse transcriptase inhibitor (efavirenz),
- a ritonavir-boosted protease inhibitor (atazanavir or darunavir),
- or an integrase strand transfer inhibitor (raltegravir) [ 3 ].
- Alternatives in each class are recommended for patients with or at risk of certain concurrent conditions [ 3 ].
CD4 Count and Treatment
A CD4 count of 99 is considered low, and treatment is recommended for all adults with HIV infection, with the strength of the recommendation and the quality of the evidence increasing with decreasing CD4 cell count [ 3 ].
Monitoring and Regimen Switching
CD4 cell count and HIV-1 RNA level should be monitored, as should engagement in care, ART adherence, HIV drug resistance, and quality-of-care indicators [ 3 ]. Reasons for regimen switching include virologic, immunologic, or clinical failure and drug toxicity or intolerance [ 3 ].
Specific Treatment Regimens
Some specific treatment regimens that have been studied include: