Duration of Antiretroviral Therapy for HIV Patients

HIV patients should take antiretroviral therapy (ART) lifelong, as there is currently no cure for HIV infection. 1

Rationale for Lifelong ART

ART suppresses HIV replication but does not eliminate viral reservoirs, which persist primarily through cell longevity and proliferation, requiring continuous treatment to maintain viral suppression 2
Discontinuation of ART leads to viral rebound, increased risk of AIDS-related events, non-AIDS-related events, and increased all-cause mortality 1
Planned discontinuation of ART, even when started early during acute infection, is not recommended outside research settings as the benefits do not persist and viral rebound occurs 1
Lifelong ART has transformed HIV from a fatal disease to a chronic, manageable condition, with persons with HIV now living near-normal lifespans 1

ART should be initiated as soon as possible after HIV diagnosis for all individuals with detectable viremia, regardless of CD4 cell count 1
Rapid ART initiation (within 7-14 days of diagnosis) is recommended to improve viral suppression and retention in care 1
For patients with opportunistic infections, timing of ART initiation varies:
- For most opportunistic infections: start ART within the first 2 weeks after diagnosis 1
- For tuberculosis with CD4 <50/μL: start ART within 2 weeks of TB treatment 1
- For tuberculosis with CD4 ≥50/μL: start ART within 2-8 weeks of TB treatment 1
- For cryptococcal meningitis: start ART 2-4 weeks after antifungal therapy initiation 3

Initial monitoring: Within 6 weeks of starting ART, assess adherence, tolerability, and HIV RNA level 1
Regular monitoring schedule:
- HIV RNA levels: Every 3 months until suppressed for at least 1 year, then every 6 months if adherence is maintained 1
- CD4 cell counts: Every 6 months until above 250/μL for at least 1 year with viral suppression, then no further monitoring needed unless ART fails or patient has an immunosuppressive condition 1
- Regular screening for STIs, tuberculosis, general health issues, and medication toxicity 1
- Annual hepatitis C screening for those with ongoing risk factors 1

High levels of adherence (≥95%) are essential for prolonged viral suppression 4
Brief adherence interventions delivered by HIV care providers during routine visits can help maintain adequate adherence to ART regimens 4
Challenges of lifelong therapy include stigma, pill burden, side effects, and the risk of viral resistance with non-compliance 5

Virologic failure is defined as HIV RNA level above 200 copies/mL on at least 2 consecutive measurements 1
When virologic failure occurs, genotypic resistance testing should be performed while the patient is still taking the failing regimen 1
New regimens should include at least 2 fully active drugs from different antiretroviral classes 1

Research continues toward potential HIV cure strategies that would eliminate the need for lifelong ART 5
Until a cure is developed, ART remains the gold standard treatment and must be continued indefinitely 5
The COVID-19 pandemic has created challenges for HIV care, but uninterrupted access to ART should be ensured, with 90-day rather than 30-day refills recommended 1