What is the current treatment and follow-up plan for a patient diagnosed with Human Immunodeficiency Virus (HIV)?

Current Treatment and Follow-Up for HIV Patients

All patients with HIV should initiate antiretroviral therapy (ART) immediately upon diagnosis, regardless of CD4 count, with the goal of achieving and maintaining viral suppression. 1, 2

Initial Evaluation and Testing

Before or at the time of ART initiation, obtain the following baseline assessments:

• CD4 cell count with percentage to establish immune status 1
• HIV RNA viral load to determine baseline viremia 1
• Genotypic resistance testing to guide regimen selection and identify transmitted resistance 1
• HLA-B*5701 testing if considering abacavir-containing regimens to prevent hypersensitivity reactions 1
• Hepatitis B and C serology, basic chemistry panel, and liver function tests 2
• Screening for sexually transmitted infections, tuberculosis, and other opportunistic infections 3

Recommended Initial ART Regimens

First-line therapy should consist of an integrase strand transfer inhibitor (InSTI) plus two nucleoside reverse transcriptase inhibitors (NRTIs). 1, 2 The preferred regimens include:

• Bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC) - single tablet, once daily 2
• Dolutegravir plus tenofovir (TAF or TDF)/emtricitabine or lamivudine 2
• Dolutegravir/lamivudine (DTG/3TC) - only if HIV RNA <500,000 copies/mL, no lamivudine resistance, and no hepatitis B co-infection 2

These regimens are preferred because they provide potent viral suppression with favorable tolerability profiles and once-daily dosing to enhance adherence. 1

Timing of ART Initiation

ART should be started at the first clinic visit after diagnosis if the patient is ready to commit to treatment. 2 Structural barriers that delay ART receipt should be removed. 2

Special Timing Considerations for Opportunistic Infections:

• Most opportunistic infections: Start ART within 2 weeks of beginning treatment for the infection 2
• Tuberculosis with CD4 ≥50 cells/μL: Initiate ART within 2-8 weeks of starting TB treatment 2
• Cryptococcal meningitis: Delay ART for 2-4 weeks after starting antifungal therapy due to increased mortality risk with earlier initiation 2
• TB meningitis: Start ART when TB meningitis is controlled, typically 2-4 weeks after TB treatment begins 2

Monitoring Treatment Response

Viral Load Monitoring:

• Measure HIV RNA 4-6 weeks after starting ART to assess initial virologic response 3, 1
• If viral load has not declined by 4-6 weeks, discuss adherence and medication tolerability; if adherence appears sufficient, perform genotypic resistance testing 3, 1
• After initial suppression, monitor every 3 months until viral suppression is maintained for at least 1 year 1
• Once suppressed for ≥1 year with consistent adherence, monitor every 6 months 3, 1
• If viral load rebounds above 50 copies/mL, repeat within 4 weeks to confirm and assess for virologic failure 3

CD4 Cell Count Monitoring:

• Monitor every 6 months until counts are above 250 cells/μL for at least 1 year with concomitant viral suppression 3, 1
• Once CD4 count is persistently stable above 500 cells/μL for at least 2 years with viral suppression, repeat CD4 monitoring is not necessary unless virologic failure occurs or immunosuppressive conditions/treatments are initiated 3

Management of Virologic Failure

For persistent quantifiable HIV RNA between 50-200 copies/mL, reassess for causes of virologic failure, re-evaluate within 4 weeks, and institute close monitoring. 3, 1 Common causes include:

• Medication non-adherence - the most common cause of virologic failure 3
• Drug-drug interactions affecting ART levels 3
• Malabsorption or pharmacokinetic issues 3
• Transmitted or acquired drug resistance 1

If viral load remains above the limit of quantification by 24 weeks or rebounds above 50 copies/mL at any time, repeat the assay within 4 weeks and perform genotypic resistance testing if adherence is adequate. 3

Adherence Support Strategies

Systematic adherence monitoring and support are critical for treatment success. 3, 1 Implement the following:

• Brief, strengths-based case management after HIV diagnosis to facilitate linkage to care 3, 1
• Personal telephone and interactive text reminders in advance of scheduled appointments and within 24-48 hours after missed appointments 3
• Adherence monitoring using validated self-report instruments and pharmacy refill data 3
• Rapid intervention following missed clinic visits 3
• Routine screening and treatment for depression, which significantly impacts adherence 3
• Opioid substitution therapy for opioid-dependent patients 3
• Integration of directly observed ART in methadone maintenance programs for patients with substance use disorders 3
• Screening for and addressing housing instability, food insecurity, ongoing substance use, psychiatric disorders, medication adverse effects, and pill burden 3, 1

Prevention and Transmission Risk

Patients achieving viral suppression on ART pose virtually no risk of transmitting HIV through sexual contact (Undetectable = Untransmittable, U=U). 3 However, condoms remain necessary to prevent acquisition of other sexually transmitted infections. 3

Pre-exposure prophylaxis (PrEP) with daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) should be offered to HIV-negative partners of HIV-infected persons who do not have viral suppression and to anyone from populations with HIV incidence ≥2% per year. 3, 1 TDF-based PrEP is contraindicated in individuals with osteopenia, osteoporosis, or creatinine clearance <60 mL/min. 3, 1

Common Pitfalls to Avoid

• Delaying ART initiation beyond the first clinic visit leads to poorer outcomes, increased mortality, and higher healthcare costs 2, 4
• Failing to perform baseline resistance testing before starting ART, which may result in selecting a regimen with reduced efficacy 1
• Inadequate adherence counseling at treatment initiation, leading to suboptimal adherence and virologic failure 3
• Starting ART too early in cryptococcal meningitis (before 2 weeks of antifungal therapy), which increases mortality risk 2
• Discontinuing CD4 monitoring prematurely before achieving stable counts >500 cells/μL for at least 2 years with viral suppression 3
• Not screening for hepatitis B before initiating or discontinuing emtricitabine or tenofovir, as severe hepatitis B exacerbations can occur upon discontinuation in co-infected patients 5