HIV treatment: Difference between revisions

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= HIV treatment =
= When to start =

== When to start ==


* Start in all viremic patients regardless of CD4 count and in all patients with declining CD4 regardless of viremia
* Start in all viremic patients regardless of CD4 count and in all patients with declining CD4 regardless of viremia
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* Only delay treatment in cryptococcal meningitis
* Only delay treatment in cryptococcal meningitis


== Starting treatment ==
= Starting treatment =


* Arrange their [first clinic visit](HIV first clinic visit.md), and do the appropriate investigations
* Arrange their [first clinic visit](HIV first clinic visit.md), and do the appropriate investigations
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* Book follow-up
* Book follow-up


== Antiretroviral therapy (ART) regimens ==
= Antiretroviral therapy (ART) regimens =


* Two nucleoside reverse-transcriptase inhibitors (NRTIs) and one non-NRTI (usually an integrase inhibitor)
* Two nucleoside reverse-transcriptase inhibitors (NRTIs) and one non-NRTI (usually an integrase inhibitor)
* Preference for [HIV single-tablet regimens](Single-tablet regimens.md), which improve adherence
* Preference for [HIV single-tablet regimens](Single-tablet regimens.md), which improve adherence


== Special populations ==
= Special populations =


=== Pregnancy ===
== Pregnancy ==


* Treat!
* Treat!
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* Avoid dolutegravir, may cause neural tube defects when on it at the time of conception (but not if started during pregnancy)
* Avoid dolutegravir, may cause neural tube defects when on it at the time of conception (but not if started during pregnancy)


=== Hepatitis B coinfection ===
== Hepatitis B coinfection ==


* Prefer ART containing tenofovir, lamivudine or emtricitabine, and a third agent
* Prefer ART containing tenofovir, lamivudine or emtricitabine, and a third agent
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** Tenofovir/emtricitabine + other
** Tenofovir/emtricitabine + other


=== Hepatitis C coinfection ===
== Hepatitis C coinfection ==


* Treat both concurrently, no need to delay
* Treat both concurrently, no need to delay
* Beware significant interactions with HCV medications
* Beware significant interactions with HCV medications


=== Tuberculosis ===
== Tuberculosis ==


* ''Probably'' don't need to wait to treat
* ''Probably'' don't need to wait to treat
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* If using PI, rifabutin can be used instead of rifampin
* If using PI, rifabutin can be used instead of rifampin


=== Cryptococcal meningitis ===
== Cryptococcal meningitis ==


* Delay treatment for risk of IRIS
* Delay treatment for risk of IRIS


== Switching regimens ==
= Switching regimens =


* May be indicated to simplify regimens (single-pill), interactions, tolerability, comorbidities, pregnancy, or cost
* May be indicated to simplify regimens (single-pill), interactions, tolerability, comorbidities, pregnancy, or cost
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* TDF to TAF may see an increase in cholesterol
* TDF to TAF may see an increase in cholesterol


== Side effects ==
= Side effects =


* Kidney problems
* Kidney problems
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** [https://doi.org/10.1086/378131 Dyslipidemia]
** [https://doi.org/10.1086/378131 Dyslipidemia]
** [https://doi.org/10.1056/NEJMra041811 Cardiovascular disease]
** [https://doi.org/10.1056/NEJMra041811 Cardiovascular disease]

[[Category:HIV]]

Revision as of 23:41, 14 August 2019

When to start

  • Start in all viremic patients regardless of CD4 count and in all patients with declining CD4 regardless of viremia
  • 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

Starting treatment

  • Arrange their [first clinic visit](HIV first clinic visit.md), and do the appropriate investigations
  • Choose an appropriate [single-tablet regimens](Single-tablet regimens.md), and start
    • Preference for regimen that includes integrase inhibitor
  • Book follow-up

Antiretroviral therapy (ART) regimens

  • Two nucleoside reverse-transcriptase inhibitors (NRTIs) and one non-NRTI (usually an integrase inhibitor)
  • Preference for [HIV single-tablet regimens](Single-tablet regimens.md), which improve adherence

Special populations

Pregnancy

  • Treat!
  • NRTI backbone: abacavir/lamivudine, tenofovir/emtricitabine, or tenofovir/lamivudine
  • 3rd agent
    • Protease inhibitor: ATV/r or DRV/r
    • Raltegravir
  • Avoid dolutegravir, may cause neural tube defects when on it at the time of conception (but not if started during pregnancy)

Hepatitis B coinfection

  • Prefer ART containing tenofovir, lamivudine or emtricitabine, and a third agent
    • Tenofovir/lamivudine + other
    • Tenofovir/emtricitabine + other

Hepatitis C coinfection

  • Treat both concurrently, no need to delay
  • Beware significant interactions with HCV medications

Tuberculosis

  • Probably don't need to wait to treat
  • Avoid TAF if using rifampin/rifamycin
  • If using rifampin
    • EFV okay
    • RAL needs dose increase to 800 mg BID
    • DTG at 50 mg BID only without selected INSTI mutations
  • If using PI, rifabutin can be used instead of rifampin

Cryptococcal meningitis

  • Delay treatment for risk of IRIS

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

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