Initial Treatment Protocol for AIDS
The recommended initial treatment protocol for AIDS is to initiate antiretroviral therapy (ART) as soon as possible after HIV diagnosis, ideally within 7 days, including on the same day as diagnosis if the patient is ready and there is no suspicion of a concomitant opportunistic infection. 1
Timing of ART Initiation
- ART should be initiated immediately after HIV diagnosis, including at the first clinic visit, if the patient is ready to commit to treatment 1
- Structural barriers that delay receipt of ART should be removed to allow newly diagnosed persons to receive ART at the first clinic visit after diagnosis 1
- Immediate initiation (same-day start) has been shown to improve viral suppression rates and retention in care 2, 3
- For patients with acute HIV infection, immediate ART initiation is strongly recommended 1
Recommended Initial Regimens
First-Line Regimens for Most Patients (in alphabetical order)
- Bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC) (evidence rating: AIa) 1
- Dolutegravir plus tenofovir (TAF or TDF)/emtricitabine or lamivudine (evidence rating: AIa) 1
- Dolutegravir/lamivudine (DTG/3TC) - only if HIV RNA level <500,000 copies/mL, no lamivudine resistance, and no HBV co-infection (evidence rating: AIa) 1
Why InSTI-Based Regimens Are Preferred
- Integrase strand transfer inhibitor (InSTI) based regimens are recommended due to 4, 2:
- Higher rates of virologic suppression
- Excellent tolerability
- Infrequent toxicity
- Limited drug-drug interactions
- High barrier to resistance
- Low pill burden
Special Considerations for ART Initiation
Opportunistic Infections
- For most opportunistic infections, initiate ART within 2 weeks of starting treatment for the opportunistic infection 1
- For tuberculosis with CD4 counts ≥50/μL, initiate ART within 2-8 weeks of starting TB treatment 1
- For cryptococcal meningitis, initiate ART 2-4 weeks after starting antifungal therapy 1
- For patients with TB meningitis, high-dose corticosteroids and TB treatment should be initiated immediately, with ART started when TB meningitis is under control (2-4 weeks later) 1
Cancer
- For patients with a new cancer diagnosis, initiate ART immediately with attention to drug-drug interactions 1
Pregnancy
- Recommended regimens during pregnancy include 1:
- Dolutegravir plus TAF/FTC or TDF/FTC (evidence rating: AIb)
- Atazanavir/ritonavir plus TAF/FTC or TDF/FTC (evidence rating: AIIa)
- Darunavir/ritonavir plus TAF/FTC or TDF/FTC (evidence rating: AIIa)
- Raltegravir plus TAF/FTC or TDF/FTC (evidence rating: AIIa)
Baseline Laboratory Testing
- Before initiating ART, the following tests should be performed 4, 2:
- CD4+ cell count
- HIV RNA level (viral load)
- HIV genotype resistance testing
- HLA-B*5701 testing if considering abacavir
- Hepatitis B and C serology
- Basic chemistry panel and liver function tests
- Urinalysis
Monitoring After ART Initiation
- Measure viral load 4-6 weeks after starting ART to assess initial response 2
- Once viral suppression is achieved, monitor every 3 months until suppression is maintained for at least 1 year 2
- After 1 year of viral suppression, monitoring can be reduced to every 6 months 2
- Monitor for drug-specific toxicities, particularly during the first few months of therapy 4
Common Pitfalls to Avoid
- Delaying ART initiation can lead to poorer outcomes and increased risk of HIV transmission 1, 5
- Not testing for HLA-B*5701 before prescribing abacavir-containing regimens can lead to potentially life-threatening hypersensitivity reactions 4
- Overlooking drug interactions, particularly with cobicistat-boosted or ritonavir-boosted regimens 2, 6
- Not monitoring for renal toxicity in patients receiving tenofovir disoproxil fumarate 7
- Using monotherapy is not recommended as it can lead to resistance and treatment failure 2