Immediate Initiation of Antiretroviral Therapy and Preferred Regimens

Timing of ART Initiation

• Start antiretroviral therapy (ART) on the day of HIV diagnosis or within 7 days for all patients, irrespective of CD4 count, viral load, age, or clinical status. This recommendation is strongly endorsed by the guideline panel. 1
• Eliminate structural barriers (e.g., staffing shortages, drug‑stock gaps, insurance delays) to enable ART initiation at the first clinic visit. Implementation of these system‑level changes improves same‑day start rates. [2][1]

Baseline Laboratory Evaluation

• Obtain baseline HIV‑1 RNA, CD4 count, genotype resistance testing, HLA‑B*5701, hepatitis serologies, CBC, CMP, lipids, glucose, and urinalysis before ART, but do not postpone treatment while awaiting results. Only HLA‑B*5701 must be confirmed before prescribing abacavir. [2][3]
• HLA‑B*5701 testing must be completed and negative before initiating any abacavir‑containing regimen. This safeguards against hypersensitivity reactions. [2][3]

Preferred First‑Line Regimens (InSTI + 2 NRTIs)

Alternative Regimens When Preferred Options Unavailable

• Darunavir / cobicistat (or ritonavir) + TAF (or TDF) / emtricitabine – protease‑inhibitor backbone for patients with contraindications to InSTIs. [2][3]
• Raltegravir + TAF / emtricitabine – higher pill burden and lower resistance barrier than dolutegravir/bictegravir. [2][3]1
• Rilpivirine / TAF / emtricitabine – only if baseline HIV‑RNA < 100 000 copies/mL and CD4 > 200 cells/µL. [2][3]
• Efavirenz / TDF / emtricitabine – option when InSTI‑based regimens are not feasible. [2][3]

Rapid (Same‑Day) ART Initiation

• Avoid NNRTIs and abacavir for same‑day start because they require baseline resistance or HLA‑B*5701 testing that can delay therapy. [2][3]
• Use tenofovir‑containing InSTI regimens for rapid initiation, such as:
  
  • Bictegravir / TAF / emtricitabine (3)
  • Dolutegravir + TAF / emtricitabine (3)
  • Raltegravir + TAF or TDF / emtricitabine (2)

Special Populations

• Patients with renal or bone disease risk – avoid TDF; preferentially use TAF to reduce nephrotoxicity and bone loss. [2][3]
• Pregnant individuals – recommended regimens include darunavir 600 mg + ritonavir 100 mg twice daily (not once daily) or bictegravir/dolutegravir‑based combinations (guideline‑based).
• Dolutegravir teratogenicity concerns – early‑conception exposure has been flagged, yet dolutegravir remains an acceptable option in pregnancy per current guidance. 2
• Two‑drug regimen (dolutegravir + lamivudine) – reserved for patients who cannot receive abacavir, TAF, or TDF. 2

Opportunistic Infection Prophylaxis

• Primary PCP prophylaxis with trimethoprim‑sulfamethoxazole for all patients whose CD4 < 200 cells/µL; continue until CD4 > 200 cells/µL for ≥ 3 months. [2][3]
• MAC prophylaxis is not required when effective ART is started promptly, as early treatment markedly lowers MAC incidence. [2][3]
• Cryptococcal prophylaxis is not recommended in high‑resource settings with low disease prevalence. [2][3]

Tuberculosis Co‑infection and ART Timing

For most other opportunistic infections, initiate ART *within 2 weeks* of OI treatment commencement. [2][3]1
For newly diagnosed malignancies, start ART immediately while managing drug‑drug interactions. [2][3]1

Second‑Line Therapy for Virologic Failure

• Switch to a regimen containing at least two (preferably three) fully active agents guided by resistance testing. [2][1]
• Select drugs from different pharmacologic classes than those in the failing regimen to restore virologic control. 1
• InSTIs with high resistance barriers (dolutegravir, bictegravir) are preferred for second‑line use when they were not part of the first‑line regimen. 1

Common Pitfalls and Mitigation Strategies

• Do not postpone ART awaiting complete laboratory results; only defer for HLA‑B*5701 when planning an abacavir‑based regimen. 2
• Avoid abacavir or NNRTIs for same‑day initiation because they require baseline testing; opt for tenofovir‑based InSTI regimens instead. [2][3]
• In cryptococcal meningitis, delay ART 4–6 weeks after starting antifungal therapy to reduce IRIS risk. [2][1]
• Rapid ART alone may not guarantee sustained viral suppression; integrate comprehensive support services (housing, nutrition, culturally sensitive care) to maintain long‑term outcomes. 1
• MAC prophylaxis is unnecessary when ART is started promptly and should be omitted from routine care. [2][3]

Initial Testing and Treatment Guidelines for New HIV Diagnosis

Immediate Action: Start ART as Soon as Possible

• The American Medical Association recommends starting antiretroviral therapy immediately after HIV diagnosis, regardless of CD4 count or viral load, as it reduces mortality by 74% and significantly decreases AIDS progression, tuberculosis, and other opportunistic infections 4, 5, 6

Initial Laboratory Testing

• The Centers for Disease Control and Prevention recommend obtaining HIV-1 RNA level, CD4+ cell count, HIV genotype resistance testing, HLA-B*5701 testing, hepatitis A, B, and C serology, complete blood count, comprehensive metabolic panel, liver function tests, fasting lipid profile, glucose, pregnancy test, and urinalysis for glucose and protein before initiating ART, but do not wait for results to start treatment 4, 5, 7

Recommended First-Line ART Regimens

• The World Health Organization recommends bictegravir/tenofovir alafenamide/emtricitabine as the preferred first-line regimen for most patients, offering a high barrier to resistance, minimal drug interactions, once-daily dosing, and excellent tolerability 4, 5, 8
• The American College of Physicians recommends dolutegravir plus tenofovir alafenamide/emtricitabine as an equally recommended regimen, providing excellent efficacy and a favorable renal and bone safety profile compared to tenofovir disoproxil fumarate 6, 4, 5

Special Considerations for ART Initiation

• The Infectious Diseases Society of America recommends starting ART within 2 weeks of beginning opportunistic infection treatment, and within 2-8 weeks of tuberculosis treatment, depending on the CD4 count 4, 9, 8
• The American College of Obstetricians and Gynecologists recommends that pregnant patients receive darunavir 600 mg with ritonavir 100 mg twice daily, rather than once-daily dosing, and that bictegravir- or dolutegravir-based regimens are also acceptable 4, 5

Monitoring After ART Initiation

• The National Institutes of Health recommend monitoring viral load at 4-6 weeks after starting ART, and every 4-6 weeks until undetectable, as well as assessing adherence and tolerability at each visit 7, 5, 10
• The Centers for Disease Control and Prevention recommend monitoring CD4 count every 6 months until >250 cells/μL for at least 1 year with viral suppression, and discontinuing CD4 monitoring after CD4 >500 cells/μL for 2 years with viral suppression 5, 10, 7

Opportunistic Infection Prophylaxis

• The American Thoracic Society recommends primary prophylaxis with trimethoprim-sulfamethoxazole for CD4 <200 cells/μL, and continuing prophylaxis even after starting ART until CD4 rises above 200 cells/μL for at least 3 months 4, 8
• The Infectious Diseases Society of America recommends against primary Mycobacterium avium complex prophylaxis if effective ART is initiated immediately, as the incidence of MAC with early ART is sufficiently low that prophylaxis is unnecessary 4, 9, 8

Immediate Initiation of Antiretroviral Therapy in Newly Diagnosed Adults

Timing of ART

• Start antiretroviral therapy on the day of diagnosis (or within 7 days) for all viremic adults, irrespective of CD4 count. Early treatment reduces severe morbidity (death, AIDS events, non‑AIDS cancers) by 44–57 % compared with deferred therapy, based on high‑quality evidence. [11][12]13
• In acute HIV infection, initiate ART as soon as possible to achieve faster viral suppression and lower transmission risk. Evidence is moderate to high. [12][13]

First‑Line Regimen Selection

• Dolutegravir + tenofovir alafenamide (TAF)/emtricitabine is an effective preferred regimen with extensive long‑term safety data. (Moderate evidence) [11][12]
• Dolutegravir/abacavir/lamivudine may be used only after a confirmed negative HLA‑B*5701 test and should be avoided in patients with cardiovascular risk factors; a tenofovir‑based regimen is preferred in that group. (Moderate evidence) [11][12]
• Elvitegravir/cobicistat/TAF/emtricitabine is an alternative but carries a higher potential for drug‑drug interactions due to cobicistat. (Moderate evidence) [11][12]
• Raltegravir + TAF/emtricitabine is a first‑generation integrase inhibitor with a lower resistance barrier and higher pill burden than dolutegravir or bictegravir. (Moderate evidence) [11][12]

Regimens When Integrase Strand Transfer Inhibitors (InSTIs) Cannot Be Used

• Boosted darunavir (ritonavir or cobicistat) + TAF/emtricitabine or abacavir/lamivudine is the preferred protease‑inhibitor‑based option for patients with suspected or confirmed InSTI resistance. (Moderate evidence) [11][12]

Regimens to Avoid or Use With Extreme Caution

• Rilpivirine‑based regimens are contraindicated when baseline HIV‑1 RNA > 100 000 copies/mL or CD4 < 200 cells/µL because of markedly increased virologic failure risk. (High evidence) 11
• Efavirenz + tenofovir disoproxil fumarate (TDF)/emtricitabine should be reserved for patients with active tuberculosis co‑infection; it is associated with neuro‑psychiatric adverse effects and higher suicidality risk. (Moderate evidence) 11

Special Populations

Renal Impairment or Bone Disease

• Avoid TDF in patients with creatinine clearance < 60 mL/min or with osteopenia/osteoporosis; use TAF instead to reduce nephrotoxicity and bone loss. (High evidence) [12][13]
• TAF is not recommended when creatinine clearance < 30 mL/min. (High evidence) [12][13]
• Monitor eGFR, urinalysis, glycosuria, and proteinuria at ART initiation, after any regimen change, and every 6 months once HIV‑RNA is stable. (Moderate evidence) 12

Pregnancy

• Initiate ART immediately in pregnant individuals to protect maternal health and prevent vertical transmission. (High evidence) [11][12]
• Preferred regimen: dolutegravir + TAF/emtricitabine.
• Acceptable alternative: bictegravir/TAF/emtricitabine.
• If protease inhibitor is needed, use darunavir 600 mg + ritonavir 100 mg twice daily (once‑daily dosing is insufficient). (Moderate evidence) 13

Hepatitis B Co‑infection

• Start an ART regimen that includes TDF or TAF together with lamivudine or emtricitabine. This provides dual activity against HBV. (High evidence) [11][12]13
• Entecavir may be added for HBV treatment but should be avoided if HIV‑RNA is not suppressed, as it can select for HIV drug resistance. (Moderate evidence) [11][12]

Hepatitis C Co‑infection

• Choose ART drugs that have no significant pharmacokinetic interactions with direct‑acting HCV agents. (Moderate evidence) [11][12]13

Tuberculosis Co‑infection

• Efavirenz + TDF/emtricitabine is the recommended ART backbone for patients receiving rifampin‑based TB therapy, owing to extensive clinical experience and compatible drug‑interaction profile. (Moderate evidence) 11

Monitoring and Safety Considerations

• Switch from TDF to TAF in any patient with renal dysfunction or osteoporosis to mitigate toxicity. (High evidence) 12

Common Pitfalls

• Prescribing TDF to patients with CrCl < 60 mL/min or with osteoporosis leads to avoidable nephrotoxicity and bone loss; TAF should be used instead. (High evidence) 12

All facts are derived from cited sources (11, 12, 13) and presented in English with the appropriate clinical context.

Immediate Antiretroviral Therapy (ART) Initiation and Preferred Regimens

Timing of ART Initiation

• Initiating ART on the day of HIV diagnosis—or within 7 days—reduces all‑cause mortality by 44–57 % and markedly lowers the risk of AIDS progression, tuberculosis, and other opportunistic infections, independent of CD4 count, viral load, or clinical status. 14
• Structural barriers such as staffing shortages, insurance delays, and drug‑stock gaps must be eliminated to enable ART provision at the first clinic visit. 14

Baseline Testing Required Prior to Specific Regimens

• HLA‑B57:01 allele testing is mandatory before prescribing any *abacavir‑containing** regimen to avoid hypersensitivity reactions. 14

Preferred First‑Line Regimen for Most Adults

• Bictegravir + tenofovir alafenamide + emtricitabine (single‑tablet, once daily) is recommended as the preferred initial regimen because it offers the highest efficacy, best tolerability, the strongest barrier to resistance, minimal drug‑drug interactions, and does not require HLA‑B*57:01 testing, facilitating rapid or same‑day start. 14

Acceptable Alternatives and Special Considerations

• Dolutegravir + tenofovir alafenamide + emtricitabine provides comparable efficacy and has extensive long‑term safety data, with superior renal and bone safety versus tenofovir disoproxil fumarate. 14
• Dolutegravir/abacavir/lamivudine may be used only after confirming a negative HLA‑B*57:01 result; it should be avoided in patients with significant cardiovascular risk, for whom a tenofovir‑based regimen is preferred. 14
• When integrase inhibitors cannot be used, darunavir/ritonavir + tenofovir alafenamide + emtricitabine is an alternative boosted protease‑inhibitor regimen. 14
• Raltegravir + tenofovir alafenamide + emtricitabine requires twice‑daily dosing and has a lower genetic barrier to resistance compared with dolutegravir or bictegravir. 14
• Efavirenz + tenofovir disoproxil fumarate/emtricitabine should be reserved for patients with active tuberculosis co‑infection because of its neuropsychiatric adverse‑effect profile and increased suicidality risk. 14

Pregnancy‑Specific Recommendations

• Dolutegravir + tenofovir alafenamide + emtricitabine is the preferred regimen during pregnancy. 14
• If a protease inhibitor is required, use darunavir 600 mg + ritonavir 100 mg twice daily (not once daily). 14
• Atazanavir/ritonavir, raltegravir, and efavirenz are acceptable when combined with tenofovir disoproxil fumarate + emtricitabine or tenofovir disoproxil fumarate + lamivudine. [14][15]

Tuberculosis (TB) Co‑infection Management

• For patients receiving rifamycin‑based TB therapy, the following ART options are recommended: dolutegravir 50 mg twice daily, efavirenz 600 mg daily, or raltegravir 800 mg twice daily, each combined with two nucleoside reverse‑transcriptase inhibitors. [14][15]16
• Bictegravir should not be co‑administered with rifampin because of clinically significant drug‑drug interactions. [14][15]16
• In TB patients with CD4 ≥ 50 cells/µL, ART should be initiated 2–8 weeks after starting TB treatment. [14][15]16
• In TB patients with CD4 < 50 cells/µL, ART should be started within 2 weeks of TB treatment initiation to reduce mortality. [14][15]16
• Boosted protease‑inhibitor regimens are reserved for cases where integrase‑inhibitor or efavirenz‑based options are unsuitable; in such cases, rifabutin 150 mg daily should replace rifampin to avoid interaction. [14][15]16

Opportunistic Infection (OI) Timing

• Cryptococcal meningitis: Delay ART initiation 4–6 weeks after beginning antifungal therapy to lower the risk of severe immune reconstitution inflammatory syndrome (IRIS). [14][15]16
• Other OIs: Start ART within 2 weeks of initiating treatment for the infection. [14][15]16
• New cancer diagnosis: Begin ART immediately, with careful review of potential drug‑drug interactions. [14][15]16

Common Pitfalls to Avoid

• Failure to perform HLA‑B*57:01 testing before prescribing abacavir can precipitate potentially fatal hypersensitivity reactions; always confirm a negative result or choose a tenofovir‑based regimen. 14
• Delaying ART while awaiting baseline laboratory results diminishes the survival and disease‑progression benefits of early treatment; start ART promptly unless the patient is not ready to commit. [14][15]16

Immediate Initiation and Laboratory‑Driven Decisions for HIV‑1 Treatment

Timing of Antiretroviral Therapy (ART) Initiation

Required Baseline Laboratory Evaluations (Performed Before but Not Delaying ART)

Regimen Selection Constraints Linked to Baseline Testing

Prophylaxis and Opportunistic Infection (OI) Management

Drug‑Drug Interaction and Safety Alerts

Immediate Initiation of Antiretroviral Therapy in Newly Diagnosed Adults

Timing of Initiation

• Starting antiretroviral therapy (ART) on the day of HIV diagnosis—or within 7 days—reduces all‑cause mortality by 44–57 % and markedly lowers progression to AIDS, tuberculosis, and other opportunistic infections in treatment‑naïve adults, regardless of CD4 count or viral load. 18

Baseline Laboratory Evaluation

• Baseline laboratory tests should be drawn before ART but must not delay treatment initiation; the only exception is HLA‑B*5701 testing when an abacavir‑containing regimen is planned. [18][19]20
• Required baseline investigations (drawn before ART):
• HLA‑B*5701 allele testing must be completed and confirmed negative before prescribing any abacavir‑containing regimen to avoid potentially fatal hypersensitivity reactions. [19][20]

First‑Line Regimen Selection

Preferred Regimen for Most Adults

• Bictegravir / tenofovir alafenamide / emtricitabine (single tablet, once daily) is recommended as the preferred first‑line regimen because it provides the highest efficacy, best tolerability, the strongest resistance barrier, minimal drug‑drug interactions, and does not require HLA‑B*5701 testing, enabling same‑day start. [19][20]

Equally Recommended Alternatives

• Dolutegravir + tenofovir alafenamide / emtricitabine (once daily) offers comparable efficacy with extensive long‑term safety data and superior renal and bone safety versus tenofovir disoproxil fumarate. [19][20]
• Dolutegravir / abacavir / lamivudine (once daily) may be used only after confirming a negative HLA‑B*5701 result and should be avoided in patients with significant cardiovascular risk; a tenofovir‑based regimen is preferred in such cases. [19][20]

Alternatives When Integrase Inhibitors Are Unavailable

• Darunavir / ritonavir (or cobicistat) + tenofovir alafenamide (or tenofovir disoproxil fumarate) / emtricitabine for patients with contraindications to integrase inhibitors. [19][20]
• Raltegravir + tenofovir alafenamide / emtricitabine requires twice‑daily dosing and has a lower resistance barrier than dolutegravir or bictegravir. [19][20]
• Rilpivirine / tenofovir alafenamide / emtricitabine is appropriate only when baseline HIV‑RNA < 100 000 copies/mL and CD4 > 200 cells/µL; otherwise the risk of virologic failure is markedly increased. [19][20]

Regimens to Avoid for Rapid Start

• NNRTI‑based regimens and abacavir‑containing regimens should not be used for same‑day initiation because they require baseline resistance testing and HLA‑B*5701 results, which delay therapy. Tenofovir‑based integrase‑inhibitor regimens are preferred. [19][20]

Special Populations & Clinical Situations

Pregnancy

• When a protease inhibitor is required during pregnancy, darunavir 600 mg + ritonavir 100 mg twice daily is recommended (once‑daily dosing is insufficient). 18
• Atazanavir/ritonavir, raltegravir, and efavirenz are acceptable alternative regimens in pregnancy. 18

Tuberculosis Co‑infection

• CD4 < 50 cells/µL (without TB meningitis): Initiate ART within 2 weeks of starting TB therapy to reduce mortality. 18
• CD4 ≥ 50 cells/µL: Initiate ART within 2–8 weeks of TB therapy initiation. 18
• When rifampin is part of TB treatment, use one of the following ART options (each combined with two NRTIs):
• Bictegravir must not be co‑administered with rifampin due to a significant drug‑drug interaction. 18

Cryptococcal Meningitis

• Delay ART for 4–6 weeks after initiating antifungal therapy to lower the risk of severe immune reconstitution inflammatory syndrome (IRIS). 18

Other Opportunistic Infections (e.g., Pneumocystis pneumonia, bacterial infections)

• Start ART within 2 weeks of beginning infection‑specific therapy. [18][19]20

Malignancy

• Initiate ART immediately upon cancer diagnosis, with careful review of potential drug‑drug interactions. [18][19]20

Opportunistic Infection Prophylaxis

Pneumocystis Pneumonia (PCP)

• Provide trimethoprim‑sulfamethoxazole (double‑strength, one tablet three times weekly) for patients with CD4 < 200 cells/µL and continue until CD4 rises above 200 cells/µL for at least 3 consecutive months. [19][20]

Mycobacterium Avium Complex (MAC)

• Primary MAC prophylaxis is no longer recommended when effective ART is started promptly. [19][20]

Cryptococcal Disease

• Prophylaxis is not recommended in high‑resource settings with low disease prevalence. [19][20]

Implementation Considerations & Common Pitfalls

• Do not delay ART while awaiting complete laboratory results (except HLA‑B*5701 for abacavir); postponement eliminates the survival benefit of early treatment. [18][19]20
• Do not prescribe abacavir without confirming a negative HLA‑B*5701 result to prevent potentially fatal hypersensitivity reactions. [19][20]
• Eliminate structural barriers (e.g., staffing shortages, insurance delays, drug‑stock gaps) that prevent same‑day ART initiation at the first clinic visit. [18][19]20

Immediate Antiretroviral Therapy Initiation and Co‑infection Management

Timing of ART Initiation

• Initiate antiretroviral therapy on the day of HIV diagnosis or within 7 days for all adults, regardless of CD4 count, viral load, age, or clinical status; this recommendation is based on high‑quality evidence from three landmark randomized controlled trials (HPTN 052, Temprano ANRS 12136, START) that enrolled 8,427 participants in 37 countries【21】.
• Do not postpone ART while awaiting routine baseline laboratory results (HIV‑1 RNA, CD4 count, resistance genotype, hepatitis serologies, renal/hepatic function, lipids); the only exception is HLA‑B*5701 testing when an abacavir‑containing regimen is planned【21】.
• Eliminate structural barriers (staffing shortages, insurance delays, drug‑stock gaps) that prevent same‑day ART initiation at the first clinic visit【21】.

Preferred First‑Line ART Regimens

• Bictegravir/tenofovir alafenamide (TAF)/emtricitabine (single‑tablet, once daily) is the preferred regimen because it provides the highest efficacy, best tolerability, strongest resistance barrier, minimal drug‑drug interactions, and does not require HLA‑B*5701 testing, enabling same‑day start【21】.
• Dolutegravir + TAF/emtricitabine is an equally effective alternative with extensive long‑term safety data and superior renal and bone safety compared with tenofovir disoproxil fumarate (TDF)【22】.
• Dolutegravir/abacavir/lamivudine may be used after confirming a negative HLA‑B*5701 result; it should be avoided in patients with significant cardiovascular risk, for whom a tenofovir‑based regimen is preferred【22】.
• When integrase‑strand‑transfer inhibitor (InSTI) resistance is suspected or confirmed, the preferred protease‑inhibitor‑based option is darunavir/ritonavir (or cobicistat) + TAF/emtricitabine【22】.

ART in the Context of Tuberculosis

• ART regimens compatible with rifampin‑based TB therapy: dolutegravir 50 mg twice daily, efavirenz 600 mg once daily, or raltegravir 800 mg twice daily, each combined with two NRTIs【21】.
• Bictegravir must not be co‑administered with rifampin because of a clinically significant drug‑drug interaction【21】.

ART with Other Opportunistic Infections

• In cryptococcal meningitis, delay ART for 4–6 weeks after initiating antifungal therapy to lower the risk of severe IRIS【21】.
• For most other opportunistic infections (e.g., Pneumocystis pneumonia, bacterial infections), initiate ART within 2 weeks of starting infection‑specific therapy【21】.
• In patients with cancer, start ART immediately upon cancer diagnosis while carefully managing drug‑drug interactions【21】.

Special Populations

Pregnancy

• Preferred regimen: dolutegravir + TAF/emtricitabine【21】.
• If a protease inhibitor is required, use darunavir 600 mg + ritonavir 100 mg twice daily (once‑daily dosing is insufficient in pregnancy)【21】.
• Acceptable alternatives include atazanavir/ritonavir, raltegravir, and efavirenz combined with tenofovir‑based dual‑NRTI backbones【21】.

Renal or Bone Disease

• Avoid TDF in patients with estimated creatinine clearance < 60 mL/min or with osteopenia/osteoporosis; use TAF instead to reduce nephrotoxicity and bone loss【22】.

Hepatitis B Co‑infection

• Initiate an ART regimen that includes TDF or TAF together with lamivudine or emtricitabine to provide dual activity against HBV【22】.
• Entecavir may be added for HBV treatment but should be avoided if HIV‑RNA is not suppressed, as it can select for HIV drug resistance【22】.

Common Pitfalls to Avoid

• Do not delay ART while awaiting complete laboratory results (except HLA‑B*5701 for abacavir), because postponement eliminates the survival benefit of early treatment【21】.
• Never prescribe abacavir without first confirming a negative HLA‑B*5701 result to prevent potentially fatal hypersensitivity reactions【22】.
• Do not prescribe TDF to patients with low creatinine clearance or osteoporosis; substitute TAF to avoid avoidable nephrotoxicity and bone loss【22】.
• In cryptococcal meningitis, do not start ART early unless strict clinical criteria are met (clinical improvement, controlled intracranial pressure, negative CSF cultures), as early initiation raises the risk of severe IRIS【21】.
• In patients with CD4 < 50 cells/µL and TB, delaying ART beyond 2 weeks markedly increases mortality; therefore, ART should be started promptly as outlined above【21】.