What is the initial recommendation for managing HIV?

Initial Management of HIV Infection

Antiretroviral therapy (ART) should be initiated as soon as possible after HIV diagnosis, including immediately after diagnosis if the patient is ready to commit to treatment. 1

When to Start ART

• ART is recommended for all HIV-infected individuals with detectable viremia, regardless of CD4 cell count, to reduce morbidity and mortality 1
• Immediate initiation of ART (same-day or rapid start) is recommended when possible, as this approach improves clinical outcomes and reduces transmission risk 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
• For acute HIV infection, immediate ART initiation is strongly recommended to reduce the size of the latent HIV reservoir and reduce immune activation 1

Baseline Testing Before Starting ART

• Before initiating ART, the following tests should be obtained 1, 2:

  • HIV-1 RNA level (viral load)
  • CD4 cell count
  • HIV genotype for NRTI, NNRTI, and PI resistance
  • Laboratory tests to exclude active viral hepatitis
  • Basic chemistry panel
  • HLA-B*5701 testing if considering abacavir-containing regimens

• Treatment may be started before all laboratory results are available, except for HLA-B*5701 testing when abacavir is being considered 1, 2

Recommended Initial Regimens

First-Line Regimens (in alphabetical order by InSTI component)

• Bictegravir/tenofovir alafenamide/emtricitabine (evidence rating AIa) 1
• Dolutegravir/abacavir/lamivudine (evidence rating AIa) 1
• Dolutegravir plus tenofovir alafenamide/emtricitabine (evidence rating AIa) 1

Alternative Regimens When First-Line Options Are Not Available

• Darunavir/cobicistat plus tenofovir alafenamide (or TDF)/emtricitabine (evidence rating AIa) 1
• Darunavir boosted with ritonavir plus tenofovir alafenamide (or TDF)/emtricitabine (evidence rating AIa) 1
• Efavirenz/tenofovir disoproxil fumarate/emtricitabine (evidence rating AIa) 1
• Elvitegravir/cobicistat/tenofovir alafenamide (or TDF)/emtricitabine (evidence rating AIa) 1
• Raltegravir plus tenofovir alafenamide (or TDF)/emtricitabine (evidence rating AIa for TDF) 1
• Rilpivirine/tenofovir alafenamide (or TDF)/emtricitabine (if pretreatment HIV RNA level is <100,000 copies/mL and CD4 cell count is >200/μL) (evidence rating AIa) 1

Special Considerations

Opportunistic Infections

• ART should be started as soon as possible but within the first 2 weeks after diagnosis for most opportunistic infections (OIs) 1
• For tuberculosis with CD4 counts ≥50/μL, ART should be initiated within 2-8 weeks of starting TB treatment 1
• For cryptococcal meningitis, ART should be initiated 4-6 weeks after starting antifungal therapy 1
• Primary prophylaxis for Pneumocystis pneumonia should be initiated for patients with CD4 cell counts below 200/μL 1
• Primary MAC prophylaxis is no longer recommended if effective ART is initiated 1

Pregnancy

• Pregnant individuals with HIV infection should initiate ART for their own health and to reduce the likelihood of HIV transmission to the infant 1
• Recommended regimens during pregnancy include 1:
  • Dolutegravir (evidence rating AIb)
  • Raltegravir (evidence rating AIIa)
  • Atazanavir/ritonavir (evidence rating AIIa)
  • Darunavir/ritonavir (evidence rating AIIa)
  • Efavirenz (evidence rating BIa)

Comorbidities

• Tenofovir disoproxil fumarate (TDF) is not recommended for individuals with or at risk for kidney or bone disease (osteopenia or osteoporosis) 1
• For patients with hepatitis B virus coinfection, ART should include tenofovir (TDF or TAF) plus lamivudine or emtricitabine 1
• For patients with hepatitis C virus coinfection, ART regimens should avoid significant drug interactions with HCV therapies 1

Monitoring After ART Initiation

• HIV RNA level should be monitored within 4-6 weeks after starting ART to assess initial response 3
• Regular monitoring for drug toxicities is essential, particularly during the first few months of therapy 2
• Once viral suppression is achieved, monitoring can be done every 3 months until suppression is maintained for at least 1 year, then every 6 months 3

Common Pitfalls to Avoid

• Not testing for HLA-B*5701 before prescribing abacavir-containing regimens, which can lead to potentially life-threatening hypersensitivity reactions 1, 2
• Using NNRTIs and abacavir for rapid ART start before baseline laboratory results are available 1
• Delaying ART initiation, which can lead to poorer outcomes and increased risk of HIV transmission 3, 4
• Overlooking drug interactions, particularly with cobicistat-boosted regimens 2