What is the recommended treatment for HIV AIDS?

Recommended Treatment for HIV/AIDS

Antiretroviral therapy (ART) is recommended for all individuals with HIV infection, regardless of CD4 cell count, and should be initiated as soon as possible after diagnosis, including immediately after diagnosis if the patient is ready to commit to treatment. 1

First-Line ART Regimens

Recommended Initial Regimens

• Integrase strand transfer inhibitor (InSTI)-based regimens are the preferred first-line treatment due to high efficacy, excellent tolerability, and high barrier to resistance 1, 2:
  • Dolutegravir/abacavir/lamivudine (requires HLA-B*5701 testing prior to use) 1, 2
  • Dolutegravir plus tenofovir alafenamide (TAF)/emtricitabine 1
  • Elvitegravir/cobicistat/TAF/emtricitabine 1
  • Bictegravir/TAF/emtricitabine 2
  • Raltegravir plus TAF/emtricitabine 1

Alternative Regimens When InSTIs Are Not an Option

• Darunavir (boosted) plus TAF (or TDF)/emtricitabine or abacavir/lamivudine 1
• Efavirenz/TDF/emtricitabine 1
• Rilpivirine/TAF (or TDF)/emtricitabine 1
• Doravirine/TDF/lamivudine or doravirine plus TAF/emtricitabine 1

Timing of ART Initiation

• ART should be initiated immediately upon diagnosis when possible 1, 2
• For patients with opportunistic infections (OIs):
  • Start ART within 2 weeks of initiating treatment for most OIs 1
  • For tuberculosis with CD4 counts ≥50/μL, start ART within 2-8 weeks of TB treatment initiation 1
  • For cryptococcal meningitis, delay ART until 4-6 weeks after starting antifungal therapy 1
• For patients with newly diagnosed cancer, initiate ART immediately with attention to drug-drug interactions 1

Monitoring Treatment Response

• HIV RNA level testing is recommended within 6 weeks of starting ART 3, 2
• Continue monitoring every 3 months until viral suppression is maintained for at least 1 year 2
• After 1 year of viral suppression, monitoring can be reduced to every 6 months 2
• If HIV RNA remains detectable by 24 weeks or rebounds above 50 copies/mL at any time, repeat testing within 4 weeks to confirm virologic failure 2

Management of Treatment Failure

• Confirm virologic failure (HIV RNA >200 copies/mL) with repeat testing 1
• Perform resistance testing while the patient is still on the failing regimen or within 4 weeks of stopping 1
• Do not add a single active agent to a failing regimen 1
• For failure of NNRTI-based regimens, switch to dolutegravir plus ≥1 active NRTIs 1
• For failure of InSTI-based regimens, switch to a boosted protease inhibitor plus ≥1 active NRTIs 1
• For raltegravir or elvitegravir resistance, dolutegravir (dosed twice daily) plus at least one fully active agent is recommended 1
• For multi-class resistance, use newer agents like fostemsavir or ibalizumab with at least one additional active drug 1

Special Considerations

Renal Impairment

• Tenofovir disoproxil fumarate (TDF) requires dose adjustment based on creatinine clearance 4:
  • CrCl 30-49 mL/min: 300 mg every 48 hours
  • CrCl 10-29 mL/min: 300 mg every 72-96 hours
  • Hemodialysis: 300 mg every 7 days or after approximately 12 hours of dialysis
• Consider TAF instead of TDF for patients with or at risk for kidney dysfunction 1, 3

Pregnancy

• 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)

Tuberculosis Co-infection

• For patients with TB receiving rifamycin-based treatment 1:
  • Dolutegravir (50 mg twice daily), efavirenz (600 mg/day), or raltegravir (800 mg twice daily) plus 2 NRTIs
  • Bictegravir with rifampin is not recommended due to drug interactions
  • Boosted protease inhibitors should be used only if an InSTI or efavirenz-based regimen is not an option

Strategies to Improve Outcomes

• Systematic monitoring of time to care linkage, retention in care, ART adherence, and viral suppression rates 1
• Brief case management after HIV diagnosis 1
• Personal telephone and text reminders for appointments 1
• Adherence monitoring using validated self-report instruments and pharmacy refill data 1
• For patients who inject opioids, opioid substitution therapy is recommended 1
• Routine screening for depression 1

Common Pitfalls to Avoid

• Delaying ART initiation, which can lead to poorer outcomes 2
• Not testing for HLA-B*5701 before prescribing abacavir-containing regimens 1, 2
• Using TDF in patients with renal impairment without appropriate dose adjustment 4
• Using monotherapy with boosted PIs or dolutegravir 2
• Overlooking drug interactions, particularly with cobicistat-boosted regimens 2
• Switching from a boosted protease inhibitor to an NNRTI or an InSTI (except dolutegravir) without considering viral resistance profile 2