What are the current guidelines for managing HIV?

Current Guidelines for HIV Management

Antiretroviral therapy (ART) is recommended for all HIV-infected individuals regardless of CD4 count, not only for individual health benefits but also because of the reduced infectiousness of individuals achieving virologic suppression. 1

Initial Evaluation and Testing

• A comprehensive medical history, physical examination, and review of systems should be obtained for all patients upon HIV diagnosis 1
• HIV serologic testing should be performed for patients without documentation of their HIV status 1
• CD4 cell count with percentage should be obtained at initial evaluation 1
• HIV RNA (viral load) level should be measured at baseline 1
• Genotypic resistance testing should be performed before initiating ART to guide regimen selection 1
• HLA-B*5701 testing is required before using abacavir to prevent hypersensitivity reactions 1
• Tropism testing is recommended when considering CCR5 inhibitors 1

When to Start ART

• ART should be initiated immediately upon diagnosis, regardless of CD4 count 1
• Early initiation of ART reduces mortality by 74% compared to delayed initiation 2
• Rapid intervention following HIV diagnosis improves linkage to care and viral suppression 1
• Brief, strengths-based case management is recommended after HIV diagnosis to facilitate linkage to care 1

Recommended Initial ART Regimens

• Preferred regimens include an integrase strand transfer inhibitor (InSTI) plus two nucleoside reverse transcriptase inhibitors (NRTIs) 1
• Specifically recommended combinations include:
  • Dolutegravir (DTG) plus tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) or tenofovir alafenamide (TAF)/FTC 3
  • Bictegravir plus TAF/FTC 4
  • Dolutegravir plus abacavir/lamivudine (for HLA-B*5701 negative patients) 1
  • Dolutegravir plus lamivudine (as a two-drug regimen) 4
• Once-daily regimens are recommended for treatment-naive patients when possible 1
• Fixed-dose combinations are recommended to decrease pill burden 1

Monitoring of Treatment Response

• Viral load should be measured 4-6 weeks after starting ART 1
• After initial suppression, viral load monitoring is recommended every 3 months until suppressed for at least a year, then every 6 months if adherence is consistent 1
• CD4 cell counts should be monitored every 6 months until counts are above 250/μL for at least 1 year with viral suppression 1
• If viral load is above 50 copies/mL after previous suppression, measurement should be repeated within 4 weeks, and adherence should be reassessed 1
• Age- and risk-appropriate screening for sexually transmitted infections, tuberculosis, and medication toxicity is recommended 1

Adherence Support

• Systematic monitoring of ART adherence is essential for successful treatment 1
• Self-reported adherence should be obtained routinely from all patients 1
• Pharmacy refill data are recommended for adherence monitoring 1
• Personal telephone and interactive text reminders before scheduled appointments and shortly after missed appointments (24-48 hours) improve adherence 1
• Individual one-on-one ART education and adherence counseling are recommended 1
• Opioid substitution therapy is recommended for opioid-dependent patients 1
• Routine screening and treatment for depression is recommended 1

Management of Treatment Failure

• If viral load has not declined after starting ART, adherence and medication tolerability should be discussed 1
• If adherence appears sufficient but viral suppression is not achieved, genotypic resistance testing is recommended 1
• For patients with persistent quantifiable HIV RNA between 50 and 200 copies/mL, reassessment for causes of virologic failure and close monitoring are recommended 1
• Tropism testing is recommended at the time of virologic failure of a CCR5 inhibitor 1

HIV Prevention Strategies

• ART is a key component of HIV prevention as virally suppressed individuals have virtually no risk of transmitting HIV sexually 4
• Pre-exposure prophylaxis (PrEP) should be considered for HIV-negative individuals at high risk 1
• Daily TDF/FTC is the recommended PrEP regimen 1
• TDF-based PrEP is not recommended for individuals with osteopenia, osteoporosis, or creatinine clearance less than 60 mL/min 1

Special Considerations

• For patients with tuberculosis co-infection, timing of ART initiation should be carefully considered, as early ART has been shown to increase mortality in cryptococcal meningitis 1
• For patients with substance use disorders, integration of directly observed ART in treatment programs and opioid substitution therapy are recommended 1
• Screening for and addressing housing instability, food insecurity, psychiatric disorders, and medication adverse effects improves outcomes 1