Initiating Antiretroviral Therapy in Newly Diagnosed HIV Patients

General Recommendations

The American Academy of HIV Medicine recommends starting antiretroviral therapy (ART) as soon as possible after HIV diagnosis, including same-day start, unless the patient is not ready to commit to starting therapy 1, 2, 3
ART should be initiated immediately upon diagnosis for all newly diagnosed HIV patients who are ready to commit to treatment, regardless of CD4 count or viral load 1, 2, 3, 4
Same-day or rapid start (within 7-14 days) is strongly recommended, with benefits including improved viral suppression rates, faster time to viral suppression, and better retention in care 5, 6
Structural barriers must be removed to allow ART initiation at the first clinic visit if the patient and clinician determine this is appropriate 1, 2, 3, 4

Baseline labs, including HIV-1 RNA level, CD4 cell count, HIV genotype for resistance testing, hepatitis B and C screening, and basic chemistries, should be drawn before starting ART, but treatment should not be delayed while waiting for results 1, 4, 7, 8
HLA-B*5701 testing must be available before starting abacavir-containing regimens 1, 4, 7

The International AIDS Society recommends avoiding NNRTIs and abacavir for rapid ART start, and instead using regimens such as bictegravir/TAF/emtricitabine, dolutegravir plus TAF/emtricitabine, or raltegravir plus TAF (or TDF)/emtricitabine 1, 4, 7, 8
Dolutegravir/abacavir/lamivudine and rilpivirine-based regimens are not recommended for rapid start due to requirements for baseline testing and specific patient characteristics 1, 4, 8

For most opportunistic infections, ART should be started within 2 weeks of diagnosis 1, 2, 3, 4, 9
For tuberculosis, ART should be started within 2 weeks of TB treatment initiation for patients with CD4 <50 cells/μL, and within 2-8 weeks for patients with CD4 ≥50 cells/μL 1, 2, 3, 4, 6, 9
For cryptococcal meningitis, ART should be delayed for 4-6 weeks after starting antifungal therapy, except in cases where the patient has clinically improved and can be closely monitored 2, 3, 10
For malignancy, ART should be started immediately, with attention to drug-drug interactions 1, 4, 7, 8, 9, 11

Pneumocystis pneumonia prophylaxis should be initiated for patients with CD4 <200 cells/μL 1, 4, 7, 8, 11
MAC prophylaxis is no longer recommended if effective ART is initiated 1, 4, 7, 8, 11
Cryptococcal prophylaxis is not recommended in high-resource settings with low disease prevalence 1, 4, 7, 8, 11

Pregnant individuals should initiate ART immediately for their own health and to reduce vertical transmission risk 1, 4, 7, 8, 11
ART should not be delayed waiting for complete laboratory results, except for HLA-B*5701 testing if using abacavir 1, 4, 7
Abacavir and NNRTIs should not be used for same-day start due to requirements for baseline testing 1, 4, 7
ART should not be started early in cryptococcal meningitis without meeting strict clinical criteria 2, 3, 10