What are the latest recommendations for HIV management and vaccination?

Latest in HIV Management and Vaccination

Immediate ART Initiation is the Standard of Care

Start antiretroviral therapy (ART) as soon as possible after HIV diagnosis—ideally within 7 days and even on the same day of diagnosis if the patient is ready to commit to treatment. 1, 2 This rapid-start approach has demonstrated improved viral suppression rates and retention in care without safety concerns. 1, 3, 4

Key Implementation Steps for Rapid ART Start

• Draw baseline laboratories immediately (HIV-1 RNA level, CD4 count, genotype for resistance testing, hepatitis screening, HLA-B*5701 if abacavir is considered), but do not delay treatment while waiting for results. 1

• Avoid NNRTIs and abacavir for same-day starts due to the time required for HLA-B*5701 testing and higher toxicity profiles. 1

• Use integrase strand transfer inhibitor (InSTI)-based regimens for rapid initiation, as they achieve faster viral suppression, particularly when started at the first clinic visit. 4

First-Line Treatment Regimens

Generally Recommended Initial Regimens (Listed Alphabetically)

The optimal initial regimen consists of an integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs). 1, 2, 5 The following are top-tier options:

• Bictegravir/tenofovir alafenamide (TAF)/emtricitabine 1, 2, 5

  • Single-tablet regimen with high barrier to resistance
  • No pharmacologic boosting required
  • Note: Fewer long-term safety data compared to dolutegravir 1

• Dolutegravir/abacavir/lamivudine 1, 2, 5

  • Requires HLA-B*5701 testing before use—patients who test positive must not receive abacavir 1
  • Single-tablet option with extensive efficacy data
  • Important pregnancy consideration: Early concerns about neural tube defects have been largely mitigated, but discuss with patients of childbearing potential 1

• Dolutegravir plus TAF (or TDF)/emtricitabine 1, 2, 5

  • Flexible option allowing tenofovir formulation selection based on patient factors
  • Dolutegravir has substantial long-term data supporting its use 5

The TLD Regimen: A Global Standard

Tenofovir disoproxil fumarate (TDF)/lamivudine/dolutegravir (TLD) is widely used globally, particularly in resource-limited settings, as a cost-effective single daily pill. 2

Key advantages:

• High barrier to resistance with dolutegravir 2
• Single daily pill enhancing adherence 2
• Cost-effectiveness in low- and middle-income countries 2

Critical caveats for TLD:

• Avoid TDF in patients with or at risk for kidney disease (creatinine clearance <60 mL/min requires dose adjustment or alternative) 1, 2, 5
• Avoid TDF in patients with or at risk for bone disease (osteopenia/osteoporosis) 1, 2
• Screen for hepatitis B before initiation—TDF has activity against HBV, and discontinuation can cause hepatitis flares 2

Alternative Regimens When First-Line Options Unavailable

• Darunavir/cobicistat or darunavir/ritonavir plus TAF (or TDF)/emtricitabine 1
• Raltegravir plus TAF (or TDF)/emtricitabine 1
• Rilpivirine/TAF (or TDF)/emtricitabine—only if baseline HIV RNA <100,000 copies/mL and CD4 >200/μL 1, 5

Emerging Long-Acting Options

Long-acting injectable cabotegravir (InSTI) plus rilpivirine administered intramuscularly every 4-8 weeks has demonstrated efficacy in maintaining viral suppression and may improve adherence in selected patients. 5

Special Clinical Situations Requiring Modified Timing

Opportunistic Infections

• For most opportunistic infections: Start ART within 2 weeks of initiating OI treatment 1, 2

• For tuberculosis:

  • If CD4 ≥50/μL: Start ART within 2-8 weeks of TB treatment initiation 2
  • If CD4 <50/μL: Start ART within 2 weeks of TB treatment initiation 2
  • Monitor for drug-drug interactions, particularly with rifamycins

• For cryptococcal meningitis: Start ART 2-4 weeks after antifungal therapy initiation, with earlier initiation (at 2 weeks) for those clinically improved with controlled intracranial pressure 2

• Primary Pneumocystis pneumonia prophylaxis: Initiate for CD4 counts <200/μL 1

• Primary MAC prophylaxis: No longer recommended if effective ART is initiated 1

Monitoring During Treatment

Initial Monitoring

• Measure HIV RNA level 4-6 weeks after starting ART to assess early virologic response 1, 5
• If viral load has not declined and adherence appears adequate, obtain genotype resistance testing 1

Ongoing Monitoring

• Every 3 months until HIV RNA <50 copies/mL for at least 1 year, then every 6 months if adherence is consistent 1, 5

• CD4 cell counts every 6 months until counts are >250/μL for at least 1 year with viral suppression, then can be discontinued 1

• If viral load >50 copies/mL is detected: Repeat measurement within 4 weeks and reassess adherence and tolerability 1

• Age- and risk-appropriate screening for sexually transmitted infections, anal/cervical dysplasia, tuberculosis, and medication toxicities 1

HIV Prevention: Vaccination Status

There is currently no effective HIV vaccine available for clinical use. 1 Research continues on:

• Broadly neutralizing antibodies for passive immunization 1
• Therapeutic vaccines as part of cure strategies 1
• These approaches remain investigational and are not recommended for routine clinical practice

HIV Prevention: Pre-Exposure Prophylaxis (PrEP)

Daily tenofovir disoproxil fumarate/emtricitabine is recommended as PrEP for individuals at high risk of HIV infection. 1, 6

PrEP Indications

• HIV testing recommended at least once for anyone who has ever been sexually active 1, 6
• More frequent testing for individuals at ongoing risk for infection 1, 6
• PrEP requires appropriate monitoring for safety and effectiveness 1, 6

Emerging PrEP Options

• Long-acting injectable cabotegravir and vaginal rings containing dapivirine are in development for HIV prevention 1

Critical Pitfalls to Avoid

Regimen Selection Errors

• Never use abacavir without HLA-B*5701 testing—positive patients will develop hypersensitivity reactions 1, 5

• Do not use TDF in patients with renal impairment (CrCl <60 mL/min) without dose adjustment or consider TAF instead 1, 2, 5

• Avoid abacavir-based regimens in hepatitis B co-infection—abacavir has no activity against HBV 5

Monitoring Failures

• Do not ignore virologic blips (transient low-level viremia) in otherwise suppressed patients, but recognize these do not require regimen changes and result from release of virus from latently infected cells 7

• Ensure viral load testing occurs within 6 weeks of ART initiation—delayed monitoring misses early treatment failure 5

Adherence Support Gaps

• Implement systematic monitoring of missed clinic visits with rapid intervention within 24-48 hours 1

• Use validated adherence instruments and pharmacy refill data rather than relying solely on patient self-report 1

• Consider long-acting injectable ART for patients with documented adherence challenges 5

Expected Clinical Outcomes

With modern ART regimens and consistent adherence, survival rates among HIV-infected adults retained in care approach those of uninfected adults. 1, 2, 6 Patients with continuously undetectable viral load on ART pose virtually no risk of transmitting infection through sexual contact (U=U: Undetectable = Untransmittable). 7