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
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
