HIV treatment: Difference between revisions
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= When to start = |
== When to start == |
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* 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 |
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= Starting Treatment = |
== Starting Treatment == |
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* Arrange their [[First clinic visit for HIV|first clinic visit]], and do the appropriate investigations |
* Arrange their [[First clinic visit for HIV|first clinic visit]], and do the appropriate investigations |
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* Book follow-up |
* Book follow-up |
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= Antiretroviral therapy (ART) regimens = |
== Antiretroviral therapy (ART) regimens == |
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* 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) |
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* 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 |
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= Special populations = |
== Special populations == |
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== Pregnancy == |
=== Pregnancy === |
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* 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) |
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== Hepatitis B coinfection == |
=== Hepatitis B coinfection === |
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* 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 |
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== Hepatitis C coinfection == |
=== Hepatitis C coinfection === |
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* Treat both concurrently, no need to delay |
* Treat both concurrently, no need to delay |
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* Beware significant interactions with HCV medications |
* Beware significant interactions with HCV medications |
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== Tuberculosis == |
=== Tuberculosis === |
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* ''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 |
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== Cryptococcal meningitis == |
=== Cryptococcal meningitis === |
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* Delay treatment for risk of IRIS |
* Delay treatment for risk of IRIS |
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= Switching regimens = |
== Switching regimens == |
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* 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 |
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= Side effects = |
== Side effects == |
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* Kidney problems |
* Kidney problems |
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Revision as of 15:19, 17 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, and do the appropriate investigations
- Choose an appropriate single-tablet regimens, 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
- Within-class
- TDF to TAF may see an increase in cholesterol
Side effects
- Kidney problems
- Metabolic complications
- Osteoporosis
- Dyslipidemia
- Cardiovascular disease
References
- ^ 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.
