Recommended Treatment for HIV Viral Suppression
Antiretroviral therapy (ART) should be initiated as soon as possible after HIV diagnosis, ideally within 7 days or even on the same day as diagnosis, using an integrase strand transfer inhibitor (InSTI)-based regimen for most patients to achieve rapid viral suppression. 1
First-Line Treatment Regimens
- InSTI-based regimens are recommended as initial treatment for most people with HIV due to high viral suppression rates, excellent tolerability, infrequent toxicity, limited drug-drug interactions, high barrier to resistance, and low pill burden (evidence rating: AIa) 1, 2
- Recommended first-line regimens include:
- Integrase inhibitor-based regimens achieve viral suppression significantly faster than protease inhibitor-based regimens 3
Timing of ART Initiation
- Immediate ART initiation (same day to 14 days after diagnosis) is now the standard of care 1
- Studies show significant improvements in viral load suppression and retention in care with rapid initiation of therapy 1
- For most acute opportunistic infections, ART should be started within the first 2 weeks after diagnosis 1
- For patients with tuberculosis and CD4 counts below 50/μL, ART should be initiated within 2 weeks of TB treatment; for those with CD4 counts above 50/μL, ART should be initiated within 2-8 weeks 1
Monitoring for Viral Suppression
- Viral load should be measured 4-6 weeks after starting ART to assess initial response 1
- Once viral suppression is achieved, monitoring can occur every 3 months until suppression is maintained for at least 1 year 1
- After 1 year of viral suppression, monitoring can be reduced to every 6 months 1
- If HIV RNA remains above detection limit by 24 weeks or rebounds above 50 copies/mL at any time, repeat testing within 4 weeks to exclude virologic failure 1
- The adherence level necessary to achieve viral suppression may be around 82% overall, with InSTI-based regimens potentially requiring lower adherence levels (75%) 4
Strategies to Improve Adherence and Viral Suppression
- Systematic monitoring of time to care linkage, retention in care, ART adherence, and viral suppression rates is recommended in all care settings 1
- Brief, strengths-based case management after HIV diagnosis facilitates linkage to care 1
- Personal telephone and text reminders for appointments improve retention 1
- Adherence monitoring using validated self-report instruments and pharmacy refill data is recommended 1
- Screening for and addressing housing instability, food insecurity, substance use, and psychiatric disorders improves outcomes 1
Same-Day ART Initiation
- Same-day ART initiation has been shown to shorten time to viral suppression significantly 5
- In one study, 79% of patients who initiated ART at their HIV care intake visit achieved viral suppression by week 12,82% by week 24, and 88% by week 48 1
- Another study showed median time to viral suppression was 1.8 months with same-day ART versus 4.3 months with standard care 5
- Same-day ART requires coordination between testing and treatment settings and access to resources 1
Common Pitfalls to Avoid
- Delaying ART initiation can lead to poorer outcomes 2
- Not testing for HLA-B*5701 before prescribing abacavir-containing regimens can lead to potentially life-threatening hypersensitivity reactions 2
- Overlooking drug interactions, particularly with cobicistat-boosted regimens 2
- Switching from a boosted protease inhibitor to a non-nucleoside reverse transcriptase inhibitor (NNRTI) or an InSTI (except dolutegravir) without considering viral resistance profile 1
- Using monotherapy with boosted PIs or dolutegravir is not recommended 1
Remember that the ultimate goal of HIV treatment is to achieve and maintain viral suppression, which not only improves individual health outcomes but also prevents HIV transmission to others 1.