HIV treatment

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

• 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)

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

• Absolutely prefer regimen containing tenofovir
• Ideally, use tenofovir, lamivudine or emtricitabine, and a third agent
  • Tenofovir/lamivudine + other
  • Tenofovir/emtricitabine + other

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

Tuberculosis

• 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

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

• Kidney problems
• Metabolic complications
  • Osteoporosis
  • Dyslipidemia
  • Cardiovascular disease