What is the recommended treatment regimen for managing Human Immunodeficiency Virus (HIV)?

HIV Treatment: Recommended Management

Start antiretroviral therapy (ART) immediately upon HIV diagnosis—ideally within 7 days or even at the first clinic visit—using an integrase strand transfer inhibitor (InSTI)-based regimen combined with 2 nucleoside reverse transcriptase inhibitors (NRTIs). 1

When to Initiate ART

• Initiate ART for all viremic patients with established HIV infection, regardless of CD4 cell count 2
• Start treatment as soon as possible after diagnosis, with same-day initiation acceptable if the patient is ready to commit to treatment 1
• For acute HIV infection, immediate ART initiation is strongly recommended 2, 1
• Never plan discontinuation of ART after a specific duration outside a research setting 2

First-Line Recommended Regimens

Preferred InSTI-based regimens (listed by strength of evidence):

• Bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC) - single daily pill with high efficacy 1
• Dolutegravir plus tenofovir alafenamide (TAF)/emtricitabine - excellent option for patients with or at risk for kidney or bone disease 2, 1
• Dolutegravir/abacavir/lamivudine - requires mandatory HLA-B5701 testing before use; approximately 50% of HLA-B5701 positive individuals will experience potentially life-threatening hypersensitivity reactions if given abacavir 2, 1, 3
• Elvitegravir/cobicistat/TAF/emtricitabine - effective but watch for drug interactions with cobicistat 2
• Raltegravir plus TAF/emtricitabine - alternative InSTI option 2

Alternative Regimens (When InSTI Not an Option)

• Darunavir (boosted with ritonavir or cobicistat) plus TAF/emtricitabine or abacavir/lamivudine 2
• Efavirenz/TDF/emtricitabine 2
• Rilpivirine/TAF or TDF/emtricitabine 2

Critical Pre-Treatment Testing

Perform these tests before initiating therapy:

• HLA-B*5701 testing is mandatory before prescribing any abacavir-containing regimen; those who test positive must never receive abacavir 2, 3
• Baseline HIV drug resistance testing to guide regimen selection 4, 3
• Hepatitis B virus (HBV) screening 1
• Hepatitis C virus (HCV) screening 2
• Baseline renal function (estimated glomerular filtration rate, urinalysis, glycosuria, albuminuria/proteinuria) 2
• CD4+ cell count and plasma HIV-1 RNA viral load 5

Special Populations and Situations

Pregnancy

• Initiate ART for both maternal health and prevention of vertical transmission 2
• Dolutegravir combined with tenofovir/emtricitabine or lamivudine is recommended 1

HBV Coinfection

• Use ART containing tenofovir (TDF or TAF) plus lamivudine or emtricitabine 2, 1
• Avoid entecavir if HIV RNA is not suppressed, as it can select for drug-resistant HIV 2

HCV Coinfection

• Select ART regimen with minimal drug interactions with HCV therapies 2

Renal Disease

• Avoid tenofovir disoproxil fumarate (TDF) in patients with or at risk of kidney disease (creatinine clearance <60 mL/min requires dose adjustment or avoidance) 2, 1
• Tenofovir alafenamide (TAF) has fewer renal and bone toxicities compared to TDF and is preferred 1, 3
• TAF is not recommended if creatinine clearance is below 30 mL/min 2
• Discontinue tenofovir if renal function worsens, particularly with proximal tubular dysfunction 2

Bone Disease

• Avoid TDF in patients with osteopenia or osteoporosis; use TAF instead 2, 1

Opportunistic Infections

• Initiate ART within 2 weeks of starting treatment for most opportunistic infections 1
• For tuberculosis: Start ART within 2-8 weeks of TB treatment if CD4 ≥50/μL; within 2 weeks if CD4 <50/μL 1
• For cryptococcal meningitis: Delay ART for 2-4 weeks after starting antifungal therapy to reduce risk of immune reconstitution inflammatory syndrome 1

Monitoring and Follow-Up

• Monitor HIV RNA viral load every 6 months once stable to identify treatment failures early and minimize resistance 2, 3
• Monitor renal function (estimated glomerular filtration rate, urinalysis, glycosuria, albuminuria/proteinuria) every 6 months 2
• Assess adherence at each visit, as this is critical for treatment success 3
• Monitor for drug-specific toxicities, particularly during the first few months 3

Expected Outcomes

• Rapid viral suppression occurs faster with InSTI-based regimens compared to protease inhibitor-based regimens 6
• Same-day ART initiation can achieve viral suppression in median 1.8 months versus 4.3 months with delayed initiation 7
• Among those starting ART at intake visit, 79% achieve viral suppression at week 12,82% at week 24, and 88% at week 48 6
• Survival rates among HIV-infected adults retained in care can approach those of uninfected adults 2, 1
• Patients with continuously undetectable viral load on ART pose virtually no risk of transmitting infection through sexual contact 5

Common Pitfalls to Avoid

• Never prescribe abacavir without first performing HLA-B*5701 testing—this can cause life-threatening hypersensitivity reactions 3
• Do not use TDF in patients with existing or at-risk kidney or bone disease 1
• Do not overlook drug interactions, particularly with cobicistat-boosted regimens 3
• Do not delay ART initiation—early treatment is associated with better outcomes 3, 7, 6
• Do not use 2-drug regimens except in rare situations when abacavir, TAF, or TDF cannot be used 2