What is the next step in management and what additional labs are required for a patient with a confirmed HIV (Human Immunodeficiency Virus) diagnosis?

Next Steps After Confirmed HIV Diagnosis

Initiate antiretroviral therapy (ART) as soon as possible after confirmed HIV diagnosis—ideally on the same day or within days—while simultaneously obtaining baseline laboratory tests that should not delay treatment initiation. 1

Immediate Management Actions

Start ART Without Delay

• Begin treatment immediately or within days of confirmed diagnosis, even before all baseline laboratory results return 1
• Rapid initiation (same-day or within 7 days) improves viral suppression rates and retention in care compared to delayed initiation 2, 3
• Treatment should not be delayed waiting for baseline test results, with the exception that HIV RNA must confirm true infection (not a false positive) 1

Preferred Initial ART Regimens

The most recent 2024 guidelines recommend starting with an integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs): 1

• Bictegravir/tenofovir alafenamide/emtricitabine
• Dolutegravir plus tenofovir alafenamide (or tenofovir disoproxil fumarate)/emtricitabine
• Dolutegravir plus abacavir/lamivudine (if HLA-B*5701 negative)

Essential Baseline Laboratory Tests

HIV-Specific Tests (Obtain Before or At ART Initiation)

• HIV RNA viral load - confirms active infection and establishes baseline 1
• CD4+ cell count with percentage - assesses immune status and guides prophylaxis decisions 1
• HIV genotype resistance testing (reverse transcriptase and protease) - detects transmitted drug resistance 1
• InSTI resistance testing is NOT routinely recommended at baseline unless the patient was exposed to cabotegravir PrEP or a partner with known InSTI resistance 1

Additional Critical Baseline Tests

• HLA-B*5701 testing - must be performed before using abacavir to prevent hypersensitivity reactions 1
• Hepatitis B surface antigen, hepatitis B core antibody, and hepatitis B surface antibody - identifies coinfection and guides treatment selection 1
• Hepatitis C antibody with reflex RNA if positive - screens for coinfection 1
• Complete blood count, comprehensive metabolic panel - establishes baseline organ function 1
• Lipid panel and glucose - baseline cardiovascular risk assessment 1
• Estimated glomerular filtration rate (eGFR) and urinalysis - assesses renal function before tenofovir use 1, 4
• Pregnancy test in individuals of childbearing potential 1

Screening for Opportunistic Infections

• Tuberculosis screening with either tuberculin skin test (TST) or interferon-gamma release assay (IGRA) 1
• Cryptococcal antigen if CD4 count <100 cells/μL 1
• Toxoplasma IgG antibody - determines need for prophylaxis if CD4 <100 cells/μL 1
• Sexually transmitted infection screening including syphilis (RPR or VDRL), gonorrhea, and chlamydia at all exposed sites 1

Critical Follow-Up Timeline

First Follow-Up (4-6 Weeks After Starting ART)

• Measure HIV RNA viral load - should show significant decline 1
• Assess adherence and tolerability of the regimen 1
• Review any pending baseline laboratory results 1

Expected Virologic Response

• HIV RNA should decrease to <200 copies/mL by 12-24 weeks of therapy 1
• If viral load has not declined appropriately by 12-24 weeks despite adequate adherence, obtain resistance testing 1

Ongoing Monitoring Schedule

• HIV RNA every 3 months until suppressed for at least 1 year, then can extend to every 6 months if adherence is excellent 1
• CD4 count every 6 months until >250 cells/μL for at least 1 year with viral suppression 1

Important Clinical Caveats

Do Not Delay Treatment

The 2024 guidelines emphasize that baseline laboratory tests should be obtained but should NOT delay ART initiation 1. The only exception is confirming the HIV diagnosis with HIV RNA to rule out false-positive screening tests 1.

Rapid Start Considerations

• Rapid ART initiation requires adequate clinical staffing and support services 1
• Same-day start is safe and acceptable, with 95% of patients accepting treatment when offered 2
• No increased toxicity or loss to follow-up has been observed with rapid initiation compared to standard timing 2, 3

Special Populations

• If CD4 <200 cells/μL: Consider opportunistic infection prophylaxis (Pneumocystis, toxoplasmosis, MAC depending on CD4 level) 1
• If pregnant: Immediate ART is critical for maternal health and prevention of vertical transmission 5
• If hepatitis B coinfected: Select ART regimen that treats both HIV and HBV (tenofovir-containing regimen) 1, 4