What is the standard treatment for HIV in light of the HIVEX (Human Immunodeficiency Virus Experimental) trial?

Standard Treatment for HIV in Light of the HIVEX Trial

The standard treatment for HIV is antiretroviral therapy (ART) for all HIV-infected individuals regardless of CD4 count, as this approach has been shown to reduce morbidity, mortality, and HIV transmission. 1

Current First-Line Antiretroviral Therapy Recommendations

• Initial regimens for treatment-naïve patients should consist of an Integrase Strand Transfer Inhibitor (InSTI) plus two Nucleoside Reverse Transcriptase Inhibitors (NRTIs) 1
• Tenofovir disoproxil fumarate (TDF) combined with emtricitabine (FTC) plus an InSTI has shown high efficacy with 84% of patients achieving viral suppression at 48 weeks 2
• ART should be initiated as soon as possible after diagnosis, regardless of CD4 count, to prevent disease progression and reduce transmission risk 1

Rationale for Universal ART Treatment

• Early initiation of ART has demonstrated improved survival and reduced complications in multiple large clinical trials 1
• The TEMPRANO ANRS study and INSIGHT START study both showed that immediate ART led to lower rates of severe illness than deferred treatment, even among patients with CD4 counts >500/μL 1
• ART reduces HIV-related immune activation and inflammation that may increase long-term risk of complications such as coronary heart disease, stroke, and neurocognitive disorders 1

Management of Treatment Failure

• For virological failure of initial NNRTI-based regimens, dolutegravir plus 1-2 active NRTIs is superior to lopinavir plus 2 NRTIs 1
• For failure of PI-based regimens, continuation of the boosted PI with adherence support is recommended initially 1
• For patients with complex treatment history and multidrug resistance, therapy with at least two fully active drugs from different antiretroviral classes is recommended 1

Special Considerations

• HIV-associated lymphomas require specific treatment approaches while maintaining ART:

  • Limited-stage HIV-associated Hodgkin lymphoma (HIV-HL): two cycles of ABVD followed by 20 Gy involved-site radiotherapy 1
  • Advanced-stage HIV-HL: six cycles of ABVD or BEACOPP baseline followed by radiotherapy for PET-positive residual disease 1
  • HIV-associated diffuse large B-cell lymphoma (HIV-DLBCL): R-CHOP or DA-R-EPOCH regimens with continued ART 1

• HIV-associated kidney disease:

  • ART should be initiated in all patients with HIV and chronic kidney disease, especially those with biopsy-proven HIV-associated nephropathy (HIVAN) 1
  • ART regimens should be adjusted according to the degree of kidney function 1

Common Pitfalls and Challenges

• Poor adherence remains a significant challenge and is the most common cause of treatment failure 3
• Drug interactions between ART and medications for comorbidities must be carefully monitored 1
• HIV coinfection with hepatitis C virus (HCV) requires careful monitoring of liver enzymes, but HAART should not be routinely withheld from coinfected patients 1
• Psychological factors, including trauma and stress, can significantly impact medication adherence 3

Monitoring and Follow-up

• Regular monitoring of viral load and CD4 count is essential to assess treatment efficacy 1
• Patients should be monitored for potential side effects and toxicities of ART 1
• Prophylaxis for opportunistic infections should be considered based on CD4 count and clinical status 1

The HIVEX trial specifically has not been mentioned in the provided evidence, suggesting it may be a very recent trial or possibly a hypothetical reference. The current standard of care for HIV treatment is based on extensive clinical evidence supporting early and universal ART with regimens containing an InSTI plus two NRTIs as the preferred first-line therapy.