Current Standard of Care for HIV Treatment
The current standard of care for HIV treatment is antiretroviral therapy (ART) with an integrase strand transfer inhibitor (InSTI) plus two nucleoside reverse transcriptase inhibitors (NRTIs) for all HIV-infected individuals with detectable plasma virus, regardless of CD4 cell count. 1
When to Start ART
- ART is recommended for all HIV-infected individuals with detectable plasma virus, regardless of CD4 cell count 1
- Initiation of ART is recommended as soon as possible (rapid ART) after HIV diagnosis, ideally within 7 days 1
- Same-day ART initiation is feasible and recommended when resources permit, as it increases care retention and population-level viral suppression 1
- For patients with acute HIV infection, immediate ART is strongly recommended due to the urgent need for viral suppression 1
Recommended Initial ART Regimens
Preferred First-Line Regimens (alphabetical order):
- Dolutegravir/abacavir/lamivudine 1
- Dolutegravir plus tenofovir alafenamide (TAF)/emtricitabine 1
- Elvitegravir/cobicistat/TAF/emtricitabine 1, 2
- Raltegravir plus TAF/emtricitabine 1
Key Considerations:
- HLA-B*5701 testing must be performed before abacavir use; those who test positive should not receive abacavir 1
- InSTI-based regimens are preferred due to superior efficacy, tolerability, and higher genetic barrier to resistance compared to other drug classes 3, 4
- Once-daily regimens and fixed-dose combinations are preferred to decrease pill burden and improve adherence 4
- In patients with renal impairment, TDF should be avoided or dose-adjusted if creatinine clearance is below 60 mL/min 3
Monitoring of Treatment Response
- HIV RNA level testing is recommended within 4-6 weeks of starting ART 4
- After initial suppression, viral load monitoring should occur every 3 months until suppressed for at least a year, then every 6 months if adherence is consistent 4
- CD4 cell count monitoring is recommended every 6 months until counts are above 250/μL for at least 1 year with viral suppression 4
- Routine monitoring for drug toxicities is essential, particularly:
Adherence Support
- Systematic monitoring of ART adherence is crucial for successful treatment 4
- Self-reported adherence should be obtained routinely from all patients 4
- Pharmacy refill data should be used for adherence monitoring 4
- Personal telephone and interactive text reminders can improve adherence 4
- Integration of directly observed ART in methadone maintenance programs and as a treatment strategy for persons with substance use disorders is recommended 1
Management of Treatment Failure
- If viral load has not declined after starting ART, adherence and medication tolerability should be assessed 4
- If adherence appears sufficient but viral suppression is not achieved, genotypic resistance testing is recommended 1
- For failure of NNRTI-based regimens, DTG plus active NRTIs is superior to protease inhibitor-based regimens 3
- For failure of InSTI-based regimens, boosted protease inhibitor with active NRTIs is recommended 3
Special Considerations
- For patients with tuberculosis co-infection, timing of ART initiation should be carefully considered:
- For patients with cryptococcal meningitis, ART should be started 4-6 weeks after antifungal therapy initiation 1
- For patients with cancer, immediate ART initiation is recommended with attention to drug interactions 1
HIV Prevention Strategies
- Pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine is recommended for individuals at risk for HIV infection 1
- PrEP is recommended for populations whose annual HIV incidence is at least 2% 1
- A 1-week lead-in time with daily dosing is recommended for rectal, penile, and vaginal exposures 1
- Condoms remain essential for prevention of non-HIV sexually transmitted infections 1
With current ART regimens, survival rates among HIV-infected adults who are retained in care can approach those of uninfected adults 1. The field continues to evolve with development of new drugs focused on improving safety, resistance profiles, and treatment simplification with infrequent dosing options like long-acting injectables 5.