What treatment is recommended for HIV with a CD4 (Cluster of Differentiation 4) count of 793?

Treatment Recommendation for HIV-Positive Patient with CD4 Count of 793

Antiretroviral therapy (ART) should be initiated immediately, regardless of the CD4 count of 793 cells/μL, using an integrase strand transfer inhibitor (InSTI)-based regimen as first-line therapy. 1

When to Start Treatment

All HIV-infected individuals with detectable plasma virus should receive treatment, regardless of CD4 cell count. 1 This universal treatment recommendation represents a fundamental shift from earlier guidelines that used CD4 thresholds, and is now supported by the highest level of evidence (AIa rating). 1

• The recommendation to treat all viremic patients applies even at high CD4 counts like 793 cells/μL, as early ART initiation reduces severe morbidity by 44-57% compared to deferred treatment. 2
• Initiation should occur as soon as possible after diagnosis to reduce both individual morbidity/mortality and prevent HIV transmission to others. 1, 3
• With a CD4 count of 793 cells/μL, this patient has preserved immune function, making this an optimal time to start therapy before any immune deterioration occurs. 2

Recommended Initial Regimen Options

The preferred first-line regimens are InSTI-based combinations, which offer superior efficacy and tolerability: 1, 3

Primary Recommended Regimens (in alphabetic order):

• Dolutegravir/abacavir/lamivudine (evidence rating AIa) - requires HLA-B*5701 testing first 1
• Dolutegravir plus tenofovir alafenamide (TAF)/emtricitabine (evidence rating AIa) 1
• Elvitegravir/cobicistat/TAF/emtricitabine (evidence rating AIa) 1
• Raltegravir plus TAF/emtricitabine (evidence rating AIII) 1

Alternative Regimens (if InSTI not suitable):

• Darunavir (boosted) plus TAF/emtricitabine or abacavir/lamivudine (evidence rating AIa) 1
• Efavirenz/TDF/emtricitabine (evidence rating AIa) 1
• Rilpivirine/TAF/emtricitabine (evidence rating AIa) 1

Critical Pre-Treatment Testing

Before initiating therapy, the following must be obtained: 1, 3

• HLA-B*5701 testing - mandatory before prescribing any abacavir-containing regimen to prevent potentially fatal hypersensitivity reactions (evidence rating AIa) 1
• Drug resistance testing - should be performed before starting therapy to guide optimal regimen selection 3
• Hepatitis B and C screening - if HBV coinfection present, must use regimen containing TDF or TAF plus lamivudine or emtricitabine 1
• Pregnancy status - if pregnant, ART should still be initiated for maternal health and prevention of vertical transmission 1
• Renal function and bone density assessment - tenofovir disoproxil fumarate (TDF) should be avoided in patients with or at risk for kidney or bone disease 1

Expected Treatment Response and Monitoring

With adequate adherence, expect the following virologic response timeline: 4

• 2-8 weeks: 1.0 log₁₀ (10-fold) decrease in viral load 4
• 4-6 weeks: Measure HIV RNA and assess adherence/tolerability 4
• 12-24 weeks: Viral load should decrease to <200 copies/mL 4
• 4-6 months: Expect undetectable virus (<50 copies/mL) 4

Monitoring schedule once suppressed: 5

• HIV RNA viral load every 3 months until <50 copies/mL for 1 year, then every 6 months 5
• CD4 cell count every 6 months until >250/μL for 1 year, then can be discontinued if viral suppression maintained 5
• Safety testing (comprehensive metabolic panel, complete blood count) regularly to monitor for medication side effects 5

Common Pitfalls to Avoid

Do not delay treatment initiation based on the high CD4 count - the evidence clearly demonstrates benefit of immediate treatment regardless of CD4 level, and waiting allows ongoing viral replication and potential immune damage. 1, 2

Do not skip HLA-B*5701 testing if considering abacavir - this can result in life-threatening hypersensitivity reactions and is contraindicated without testing. 1

Do not assume adherence without thorough assessment - nonadherence is the most common cause of treatment failure, and adherence counseling should begin before ART initiation. 4

Do not use TDF in patients with renal impairment or osteoporosis risk - TAF is the preferred tenofovir formulation with better renal and bone safety profile. 1

Rationale for Universal Treatment at High CD4 Counts

The recommendation to treat at CD4 793 cells/μL is based on: 2

• Reduced mortality and morbidity: Early ART significantly reduces risk of AIDS, tuberculosis, invasive bacterial diseases, and Kaposi's sarcoma 2
• Prevention of transmission: Viral suppression through ART prevents HIV transmission to sexual partners 1, 2
• Preservation of immune function: Starting at high CD4 counts prevents irreversible immune damage 2
• Improved long-term outcomes: Patients who start treatment at higher CD4 counts have better long-term prognosis than those who delay 6