HIV treatment: Difference between revisions
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+ | * See also [[HIV medications]] |
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− | == When to start == |
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+ | ==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 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 |
||
+ | *Start in all viremic patients regardless of CD4 count and in all patients with declining CD4 regardless of viremia |
||
− | == Starting Treatment == |
||
+ | **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 |
||
+ | **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 |
||
+ | ==Starting Treatment== |
||
− | * Arrange their [[Initial assessment for patients with HIV|first clinic visit]], and do the appropriate investigations |
||
− | * Choose an appropriate [[Single-tablet regimens for HIV|single-tablet regimens]], and start |
||
− | ** Preference for regimen that includes integrase inhibitor |
||
− | * Book follow-up |
||
+ | *Arrange their [[Initial assessment for patients with HIV|first clinic visit]], and do the appropriate investigations |
||
− | == Antiretroviral therapy (ART) regimens == |
||
+ | *Choose an appropriate [[Single-tablet regimens for HIV|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 [[single-tablet regimens for HIV]], which improve adherence |
||
− | * Refer to [[HIV medications]] for information about specific medications |
||
+ | *Refer to [[HIV medications]] for information about specific medications |
||
− | == Special populations == |
||
+ | *In general, use two nucleoside reverse-transcriptase inhibitors (NRTIs) and one non-NRTI (usually an integrase inhibitor) |
||
+ | **New evidence in favour of two-drug regimens that include 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 |
||
− | == |
+ | ==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) |
||
+ | *Treat! |
||
− | === Hepatitis B coinfection === |
||
+ | *NRTI backbone: [[abacavir]]/[[lamivudine]], [[tenofovir]]/[[emtricitabine]], or [[tenofovir]]/[[lamivudine]] |
||
+ | *3rd agent |
||
+ | **[[Dolutegravir]] is preferred given preponderance of data |
||
+ | **[[Raltegravir]] |
||
+ | **Protease inhibitor: ATV/r or DRV/r |
||
+ | ===Hepatitis B Coinfection=== |
||
− | * Prefer ART containing tenofovir, lamivudine or emtricitabine, and a third agent |
||
− | ** Tenofovir/lamivudine + other |
||
− | ** Tenofovir/emtricitabine + other |
||
+ | *Regimen should contain [[tenofovir]] plus another HBV-active agent |
||
− | === Hepatitis C coinfection === |
||
+ | *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 |
||
+ | ===Hepatitis C Coinfection=== |
||
− | * Treat both concurrently, no need to delay |
||
− | * Beware significant interactions with HCV medications |
||
+ | *See also [[HIV-Hepatitis C coinfection]] for details |
||
− | === Tuberculosis === |
||
+ | *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 |
||
− | ** 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 |
||
+ | *''Probably'' don't need to wait to treat |
||
− | === Cryptococcal meningitis === |
||
+ | *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 |
||
+ | *Delay treatment for risk of [[Immune reconstitution inflammatory syndrome|IRIS]] |
||
− | == Switching regimens == |
||
+ | === Patients with Feeding Tubes === |
||
− | * 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 |
||
+ | * Needs crushable or dissolvable medications |
||
− | == Side effects == |
||
+ | * Good pick is [[Truvada]] + [[raltegravir]] |
||
+ | * See also [https://www.hivclinic.ca/main/drugs_extra_files/Crushing%20and%20Liquid%20ARV%20Formulations.pdf HIVClinic.ca list of crushable and liquid formulations] |
||
− | + | === Chronic Kidney Disease === |
|
+ | |||
− | * [https://www.ncbi.nlm.nih.gov/pubmed/12439201 Metabolic complications] |
||
+ | * In general, try to avoid starting [[tenofovir disoproxil fumarate]] with eGFR <60 mL/min and [[TAF]] if <30 mL/Min; avoid [[ATV]] |
||
− | ** Osteoporosis |
||
+ | * Can use TAF on hemodialysis |
||
− | ** [https://doi.org/10.1086/378131 Dyslipidemia] |
||
+ | |||
− | ** [https://doi.org/10.1056/NEJMra041811 Cardiovascular disease] |
||
+ | ==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 |
||
+ | *[https://www.ncbi.nlm.nih.gov/pubmed/12439201 Metabolic complications] |
||
+ | **Osteoporosis |
||
+ | **[https://doi.org/10.1086/378131 Dyslipidemia] |
||
+ | **[https://doi.org/10.1056/NEJMra041811 Cardiovascular disease] |
||
[[Category:HIV]] |
[[Category:HIV]] |
Latest revision as of 22:07, 1 April 2023
- See also HIV medications
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, 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
- 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)
- New evidence in favour of two-drug regimens that include 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
Special Populations
Pregnancy
- Treat!
- NRTI backbone: abacavir/lamivudine, tenofovir/emtricitabine, or tenofovir/lamivudine
- 3rd agent
- Dolutegravir is preferred given preponderance of data
- Raltegravir
- Protease inhibitor: ATV/r or DRV/r
Hepatitis B Coinfection
- Regimen should contain tenofovir plus another HBV-active agent
- 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
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
Patients with Feeding Tubes
- Needs crushable or dissolvable medications
- Good pick is Truvada + raltegravir
- See also HIVClinic.ca list of crushable and liquid formulations
Chronic Kidney Disease
- In general, try to avoid starting tenofovir disoproxil fumarate with eGFR <60 mL/min and TAF if <30 mL/Min; avoid ATV
- Can use TAF on hemodialysis
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.