When to Start ART in Newly Diagnosed HIV Patients
Antiretroviral therapy (ART) should be initiated as soon as possible after HIV diagnosis, including immediately at the time of diagnosis (same-day start), unless the patient is not ready to commit to starting therapy. 1
General Timing Recommendations
Start ART immediately upon diagnosis for all newly diagnosed HIV patients who are ready to commit to treatment, regardless of CD4 count or viral load 1
Same-day or rapid start (within 7-14 days) is strongly recommended based on evidence showing:
Structural barriers must be removed to allow ART initiation at the first clinic visit if the patient and clinician determine this is appropriate 1
Pre-Treatment Laboratory Testing
Draw baseline labs before starting ART, but do NOT delay treatment while waiting for results (with one important exception): 1
- HIV-1 RNA level
- CD4 cell count
- HIV genotype for resistance testing (NRTI, NNRTI, PI)
- Hepatitis B and C screening
- Basic chemistries
- HLA-B*5701 testing MUST be available before starting abacavir-containing regimens 1
Regimen Selection for Rapid Start
Avoid NNRTIs and abacavir for rapid ART start (since baseline labs may not be available) 1
Preferred regimens for rapid start include: 1
- Bictegravir/TAF/emtricitabine
- Dolutegravir plus TAF/emtricitabine
- Raltegravir plus TAF (or TDF)/emtricitabine
Do NOT use for rapid start: 1
- Dolutegravir/abacavir/lamivudine (requires HLA-B*5701 results first)
- Rilpivirine-based regimens (requires baseline viral load <100,000 copies/mL and CD4 >200/μL) 3
Special Circumstances: Opportunistic Infections
Most Opportunistic Infections
Start ART within 2 weeks of OI diagnosis for most opportunistic infections 1
Tuberculosis
- CD4 <50 cells/μL: Start ART within 2 weeks of TB treatment initiation 1
- CD4 ≥50 cells/μL: Start ART within 2-8 weeks of TB treatment initiation 1
- Use rifampin-compatible regimens: Dolutegravir 50 mg twice daily, efavirenz, or raltegravir 800 mg twice daily (avoid bictegravir with rifampin) 1
Cryptococcal Meningitis
This is the major exception to early ART initiation: 1, 4
- Delay ART for 4-6 weeks after starting antifungal therapy in most cases 1
- May start at 2 weeks only if patient has clinically improved, has controlled intracranial pressure, has negative CSF cultures, and can be closely monitored 4
- Rationale: Delaying ART allows time for control of intracranial pressure and reduces risk of immune reconstitution inflammatory syndrome (IRIS) 4
- In 2018 guidelines for high-resource settings, ART could begin within 2 weeks with optimal antifungal therapy and aggressive intracranial pressure management, but the 2020 guidelines and current evidence favor the more conservative 4-6 week delay 1
Malignancy
Start ART immediately when HIV and malignancy are diagnosed concurrently, with attention to drug-drug interactions 1
Prophylaxis Considerations
- Pneumocystis pneumonia prophylaxis: Initiate for CD4 <200 cells/μL 1
- MAC prophylaxis: No longer recommended if effective ART is initiated 1
- Cryptococcal prophylaxis: Not recommended in high-resource settings with low disease prevalence 1
Pregnancy
Pregnant individuals should initiate ART immediately for their own health and to reduce vertical transmission risk 1
Common Pitfalls to Avoid
- Do not delay ART waiting for complete laboratory results (except HLA-B*5701 if using abacavir) 1
- Do not use abacavir or NNRTIs for same-day start due to need for baseline testing 1
- Do not start ART early in cryptococcal meningitis without meeting strict clinical criteria 1, 4
- Ensure patient readiness: The only acceptable reason to delay ART is if the patient is not ready to commit to therapy 1