Recent Advances in HIV Treatment and Prevention
The most significant advances in HIV management include immediate antiretroviral therapy (ART) initiation for all HIV-infected individuals regardless of CD4 count, integrase strand transfer inhibitor (InSTI)-based regimens as first-line therapy, and daily tenofovir disoproxil fumarate/emtricitabine for pre-exposure prophylaxis (PrEP) in high-risk individuals. 1
Treatment Initiation and Recommended Regimens
- ART should be started in all HIV-infected individuals with detectable viremia as soon as possible after diagnosis, regardless of CD4 cell count, to prevent disease progression, improve clinical outcomes, and limit transmission 1
- Immediate initiation of ART (rapid start) is recommended when clinically appropriate, though this requires adequate staffing, specialized services, and careful medication selection 1
- The recommended optimal initial regimen for most patients consists of an integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs) 1
- Alternative effective regimens include non-nucleoside reverse transcriptase inhibitors (NNRTIs) or boosted protease inhibitors with 2 NRTIs 1
- When selecting a regimen, consider patient-specific factors including concomitant conditions, pregnancy potential, and cost 1
Monitoring and Laboratory Assessment
- Before initiating ART, recommended laboratory tests include CD4 cell count, HIV RNA level, genotype testing, and screening for general health and co-infections 1
- Ongoing monitoring during treatment is essential to assess response, detect adverse effects, and evaluate adherence 1
- Laboratory assessments should be performed at specified intervals to ensure continued viral suppression and to detect any complications early 1
Regimen Switching
Reasons for switching therapy may include:
When switching regimens:
HIV Prevention Strategies
- HIV testing is recommended at least once for anyone who has ever been sexually active and more frequently for individuals at ongoing risk for infection 1
- Daily tenofovir disoproxil fumarate/emtricitabine is recommended as PrEP for individuals at high risk of HIV infection 1
- When indicated, post-exposure prophylaxis (PEP) should be initiated as soon as possible after exposure 1
- PrEP requires appropriate monitoring to ensure safety and effectiveness 1
Clinical Outcomes and Benefits
- When used effectively, current ART regimens can sustain HIV suppression and prevent new HIV infections 1
- With modern treatment regimens, survival rates among HIV-infected adults who are retained in care can approach those of uninfected adults 1
- Successful treatment is associated with durable suppression of HIV viremia over years, reducing the risk of clinical progression 2
Emerging Approaches and Future Directions
- Two-drug regimens, such as dolutegravir/lamivudine, have been developed to reduce toxicities while maintaining efficacy 3
- Research continues on novel drug targets including:
- Efforts are underway to develop treatments for latent HIV infection, aiming for either complete eradication or stringent control of viral replication without ART 5
Common Pitfalls and Considerations
- Adherence to ART is crucial for treatment success; approaches to improve linkage to and retention in care should be implemented 1
- Drug interactions must be carefully evaluated when prescribing ART, particularly with medications metabolized by CYP3A and CYP2D6 6
- Special considerations are needed for specific populations such as pregnant women, where some antiretrovirals may have altered pharmacokinetics 7, 6
- Despite advances in treatment, the emergence of drug resistance remains a challenge, emphasizing the importance of adherence and appropriate regimen selection 2