HIV treatment

From IDWiki

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 mortality2015in2015a
  • 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:

Starting Treatment

Antiretroviral Therapy (ART) Regimens

Special Populations

Pregnancy

Hepatitis B Coinfection

Hepatitis C Coinfection

  • 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

Tuberculosis

Cryptococcal Meningitis

  • Delay treatment for risk of IRIS

Patients with Feeding Tubes

Chronic Kidney Disease

Switching Regimens

  • 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

Side Effects