What is the best treatment approach for an individual living with HIV in a specific location?

HIV Treatment Approach

Initiate antiretroviral therapy (ART) immediately upon HIV diagnosis regardless of CD4 count or viral load, as early treatment reduces morbidity, mortality, and HIV transmission risk. 1

Core Treatment Principles

Immediate ART Initiation

• Start ART as soon as possible after diagnosis without delay, even in treatment-naïve patients, as this approach improves individual health outcomes and prevents transmission 2, 1
• Never interrupt ART once started, as viral suppression is essential for immune recovery and prevention of disease progression 2
• For patients considering stopping therapy due to side effects, counsel that discontinuation will likely return CD4 count and viral load to pretreatment levels, increasing risk for opportunistic infections and transmission to partners 3

Regimen Selection

• Use modern combination ART regimens that achieve viral suppression (HIV-1 RNA <50 copies/mL) 4
• For virologically suppressed adults and adolescents ≥12 years and ≥35 kg with no treatment failure history and no resistance to cabotegravir or rilpivirine, long-acting injectable cabotegravir plus rilpivirine is an option 4
• Tenofovir disoproxil fumarate-based regimens are effective across age groups, including pediatric patients ≥2 years 5

Optimizing Treatment Adherence

Substance Use Disorders

For opioid-dependent patients, integrate buprenorphine or methadone maintenance treatment into HIV care, as this significantly improves ART adherence, uptake, and virologic outcomes. 3

• Offer methadone or buprenorphine to all opioid-dependent patients, as both improve medication adherence, ART uptake, and biomarkers 3
• Implement directly administered antiretroviral therapy (DAART) for individuals with active substance use disorders, as four RCTs demonstrate significant HIV-1 RNA and CD4 improvements compared to self-administered therapy 3
• Integrate DAART into methadone maintenance programs when possible, as this combination improves viral suppression over 24 weeks 3

Mental Health Management

• Screen all patients for depression and mental illness, as depression significantly correlates with ART nonadherence across all settings 3
• Provide cognitive-behavioral therapy for depression combined with adherence counseling, as RCTs show this improves both depressive symptoms and treatment outcomes 3
• Prescribe pharmacologic treatment for depression when indicated, as evidence demonstrates benefit for ART adherence and virologic outcomes 3

Incarcerated Populations

• Implement DAART during incarceration, as observational data show improved outcomes 3
• Consider continuing DAART upon release to community to maintain treatment continuity during this high-risk transition period 3

Structural Interventions for Retention

Implement structural interventions addressing environmental, social, and economic barriers, as these produce more sustainable outcomes than individual-level approaches alone. 6

Clinic-Level Modifications

• Extend clinic hours beyond standard business hours to address joblessness and inability to afford time off work 6
• Implement walk-in or "open access" models combined with low-threshold care for patients with complex needs, as these show dramatic improvements in viral suppression 6
• Use print reminders and brief verbal messages from all clinic staff as part of clinic-wide interventions 6

Support Services Integration

• Provide case management addressing food insecurity, housing, and transportation needs, as these services improve ART adherence, retention, and clinical outcomes 6
• Integrate social services and housing programs, particularly for homeless populations, as this improves HIV-1 RNA levels 6
• Implement patient navigation interventions and community/peer outreach, which increase retention in care for underserved populations including persons of color 6

Special Population Considerations

Pregnant Women

• Provide targeted prevention of mother-to-child transmission (PMTCT) treatment including HIV testing and serostatus awareness, as this improves adherence compared to untargeted approaches 3
• Offer labor ward-based PMTCT adherence services for women not receiving ART before labor, as cluster RCTs demonstrate significantly improved nevirapine coverage and adherence 3
• Continue ART throughout pregnancy and postpartum period without interruption 5

Pediatric Patients

• Dose tenofovir disoproxil fumarate appropriately for children ≥2 years, as pharmacokinetic profiles at recommended doses are similar to safe and effective adult dosing 5
• Provide pill-swallowing training for younger patients with identified difficulties, as this improves adherence in cohort studies 3
• Consider DAART for perinatally infected children and adolescents to improve short-term immunologic outcomes 3

Monitoring and Quality Improvement

Systematic Tracking

• Monitor time from diagnosis to care linkage, retention in care, and viral suppression rates systematically to identify ongoing barriers 6
• Conduct more frequent viral load testing (monthly for first 3 months) when drug interactions are possible 2
• Use real-time surveillance-based messaging through health information exchanges to increase engagement rates for patients no longer in care 6

Prevention Integration

• Discuss sexual and needle-sharing practices as routine part of clinical care 3
• Screen periodically (at minimum annually) for sexually transmitted diseases based on patient sex, risk behaviors, and local epidemiology 3
• Provide partner counseling and referral services including partner notification, as this helps infected partners access earlier medical evaluation and treatment 3

Critical Pitfalls to Avoid

• Do not recommend DAART for routine clinical care in general populations, as well-controlled RCTs from multiple settings show no benefit on adherence or biological markers 3
• Do not interrupt ART for analytical treatment purposes in patients with history of progressive multifocal leukoencephalopathy (PML), as this risks disease progression 2
• Do not delay ART initiation for cancer treatment workup in treatment-naïve patients diagnosed with opportunistic infections 2
• Recognize that investments in retention and linkage are more economically efficient than those devoted solely to increasing HIV screening 6