HIV treatment

When to Start

Start in all viremic patients regardless of CD4 count and in all patients with declining CD4 regardless of viremia
- Decreased AIDS-related morbidity, non-AIDS-related morbidity, and mortality12
Start as soon as possible in patients with acute HIV, as it decreases the HIV reservoir
- Less loss-to-follow-up, time-to-virologic-suppression decreased
- Rapid linkage to care within 5 working days of diagnosis
Do not stop treatment
Unclear whether treatment needed for elite controllers
Only delay treatment in:
- Cryptococcal meningitis, which should be delayed by 2 to 10 weeks
- Tuberculosis
  - CD4 <50 cells/mL: start within 2 weeks
  - CD4 ≥50 cells/mL: start within 8 weeks
  - Tuberculous meningitis: start within 2 to 8 weeks

Arrange their first clinic visit, and do the appropriate investigations
Choose an appropriate single-tablet regimens, and start
- Preference for regimen that includes integrase inhibitor
Book follow-up

Refer to HIV medications for information about specific medications
In general, use two nucleoside reverse-transcriptase inhibitors (NRTIs) and one non-NRTI (usually an integrase inhibitor)
- New evidence in favour of two-drug regimens that include an integrase inhibitor
Preference for single-tablet regimens for HIV, which improve adherence
Recommended first-line regimens include:
- Bictegravir/tenofovir alafenamide/emtricitabine (Biktarvy)
- Dolutegravir/abacavir/lamivudine (Triumeq), only for individuals who are HLA-B*5701 negative and without chronic hepatitis B virus (HBV) coinfection
- Dolutegravir plus (emtricitabine or lamivudine) plus (tenofovir alafenamide or tenofovir disoproxil fumarate)
- Dolutegravir/lamivudine (Dovato), except for individuals with HIV RNA >500,000 copies/mL, HBV co-infection, or in whom ART is to be started before the results of HIV genotypic resistance testing for reverse transcriptase or HBV testing are available

Treat!
NRTI backbone: abacavir/lamivudine, tenofovir/emtricitabine, or tenofovir/lamivudine
3rd agent
- Dolutegravir is preferred given preponderance of data
- Raltegravir
- Protease inhibitor: ATV/r or DRV/r

Regimen should contain tenofovir plus another HBV-active agent
Ideally, use tenofovir, lamivudine or emtricitabine, and a third agent
- Tenofovir/lamivudine + other
- Tenofovir/emtricitabine + other
If cannot use tenofovir (severe renal or hepatic dysfunction), then add entecavir to the HIV regimen

See also HIV-Hepatitis C coinfection for details
In general, there's no need to delay either treatment; they can be treated concurrently
Beware significant interactions with HCV medications
- Avoid elvitegravir/cobicistat whenever possible, as it interacts with most regimens
- Sofosbuvir can increase TDF (though not TAF) levels

Probably don't need to wait to treat
Avoid TAF if using rifampin/rifamycin
If using rifampin
- Efavirenz probably the best option
- Raltegravir needs dose increase to 800 mg BID
- Dolutegravir 50 mg BID only without selected INSTI mutations
If using PI, rifabutin can be used instead of rifampin

In general, try to avoid starting tenofovir disoproxil fumarate with eGFR <60 mL/min and TAF if <30 mL/Min; avoid ATV
Can use TAF on hemodialysis

May be indicated to simplify regimens (single-pill), interactions, tolerability, comorbidities, pregnancy, or cost
Goal is to maintain viral suppression to avoid resistance
Consider:
- Previous exposure to ART
- Previous pattersn of resistance
- Likelihood of adherence
- Drug-drug and drug-food interactions
- Comorbidities
Can switch within- or between-class
- Within-class
  - EFV to RPV
  - RAL to EVG or DTG
  - DTG to BIC
  - TDF or ABC to TAF
- Between-class
  - Boosted PI to RPV
  - Boosted PI to EVG, DTG, or BIC
  - NNRTI to EVG or DTG
TDF to TAF may see an increase in cholesterol

^ Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. New England Journal of Medicine. 2015;373(9):795-807. doi:10.1056/nejmoa1506816.
^ A Trial of Early Antiretrovirals and Isoniazid Preventive Therapy in Africa. New England Journal of Medicine. 2015;373(9):808-822. doi:10.1056/nejmoa1507198.