HIV treatment: Difference between revisions

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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
**Decreased AIDS-related morbidity, non-AIDS-related morbidity, and mortality[[CiteRef::2015in]][[CiteRef::2015a]]
*Start as soon as possible in patients with acute HIV, as it decreases the HIV reservoir
*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
**Less loss-to-follow-up, time-to-virologic-suppression decreased
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*Do not stop treatment
*Do not stop treatment
*Unclear whether treatment needed for elite controllers
*Unclear whether treatment needed for elite controllers
*Only delay treatment in cryptococcal meningitis, which should be delayed by 2 to 10 weeks
*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


==Starting Treatment==
==Starting Treatment==

Revision as of 21:48, 13 September 2020

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:

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

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

References

  1. ^   Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. New England Journal of Medicine. 2015;373(9):795-807. doi:10.1056/nejmoa1506816.
  2. ^   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.