HIV treatment

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:
- 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

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

Refer to HIV medications for information about specific medications
In general, use two nucleoside reverse-transcriptase inhibitors (NRTIs) and one non-NRTI (usually an integrase inhibitor)
Preference for single-tablet regimens for HIV, which improve adherence
Recommended first-line regimens include:
- Bictegravir/tenofovir alafenamide/emtricitabine (Biktarvy)
- Dolutegravir/abacavir/lamivudine (Triumeq), only for individuals who are HLA-B*5701 negative and without chronic hepatitis B virus (HBV) coinfection
- Dolutegravir plus (emtricitabine or lamivudine) plus (tenofovir alafenamide or tenofovir disoproxil fumarate)
- Dolutegravir/lamivudine (Dovato), except for individuals with HIV RNA >500,000 copies/mL, HBV co-infection, or in whom ART is to be started before the results of HIV genotypic resistance testing for reverse transcriptase or HBV testing are available.
- Raltegravir plus (emtricitabine or lamivudine) plus (tenofovir alafenamide or tenofovir disoproxil fumarate)

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)

Absolutely prefer regimen containing tenofovir
Ideally, use tenofovir, lamivudine or emtricitabine, and a third agent
- Tenofovir/lamivudine + other
- Tenofovir/emtricitabine + other
If cannot use tenofovir (severe renal or hepatic dysfunction), then add entecavir to the HIV regimen

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
- Avoid elvitegravir/cobicistat whenever possible, as it interacts with most regimens
- Sofosbuvir can increase TDF (though not TAF) levels

Probably don't need to wait to treat
Avoid TAF if using rifampin/rifamycin
If using rifampin
- Efavirenz probably the best option
- Raltegravir needs dose increase to 800 mg BID
- Dolutegravir 50 mg BID only without selected INSTI mutations
If using PI, rifabutin can be used instead of rifampin

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

^ 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.