Current Guidelines for HIV Management

Initial Evaluation and Testing

The American Academy of HIV Medicine recommends a comprehensive medical history, physical examination, and review of systems for all patients upon HIV diagnosis 2, 3
HIV serologic testing should be performed for patients without documentation of their HIV status, as recommended by the Infectious Diseases Society of America 3
CD4 cell count with percentage should be obtained at initial evaluation, according to the Centers for Disease Control and Prevention 3
HIV RNA (viral load) level should be measured at baseline, as suggested by the Clinical Infectious Diseases society 4
Genotypic resistance testing should be performed before initiating ART to guide regimen selection, as recommended by the International AIDS Society 4
HLA-B*5701 testing is required before using abacavir to prevent hypersensitivity reactions, according to the American College of Medical Genetics 1
Tropism testing is recommended when considering CCR5 inhibitors, as suggested by the European AIDS Clinical Society 1

The American College of Physicians recommends initiating ART immediately upon diagnosis, regardless of CD4 count 5, 1
Rapid intervention following HIV diagnosis improves linkage to care and viral suppression, as found by the World Health Organization 5
Brief, strengths-based case management is recommended after HIV diagnosis to facilitate linkage to care, according to the National Institute of Mental Health 5

The Department of Health and Human Services recommends preferred regimens including an integrase strand transfer inhibitor (InSTI) plus two nucleoside reverse transcriptase inhibitors (NRTIs) 5, 1
Once-daily regimens are recommended for treatment-naive patients when possible, as suggested by the American College of Physicians 7
Fixed-dose combinations are recommended to decrease pill burden, according to the National Institutes of Health 7

The Centers for Disease Control and Prevention recommend measuring viral load 4-6 weeks after starting ART 1
After initial suppression, viral load monitoring is recommended every 3 months until suppressed for at least a year, then every 6 months if adherence is consistent, as suggested by the Infectious Diseases Society of America 1
CD4 cell counts should be monitored every 6 months until counts are above 250/μL for at least 1 year with viral suppression, according to the European AIDS Clinical Society 1

The World Health Organization recommends systematic monitoring of ART adherence for successful treatment 5
Self-reported adherence should be obtained routinely from all patients, as suggested by the National Institute of Mental Health 7
Pharmacy refill data are recommended for adherence monitoring, according to the American College of Clinical Pharmacy 7
Personal telephone and interactive text reminders improve adherence, as found by the National Institutes of Health 5

If viral load has not declined after starting ART, adherence and medication tolerability should be discussed, as recommended by the International AIDS Society 1
If adherence appears sufficient but viral suppression is not achieved, genotypic resistance testing is recommended, according to the European AIDS Clinical Society 1
For patients with persistent quantifiable HIV RNA between 50 and 200 copies/mL, reassessment for causes of virologic failure and close monitoring are recommended, as suggested by the Infectious Diseases Society of America 8

Pre-exposure prophylaxis (PrEP) should be considered for HIV-negative individuals at high risk, as recommended by the Centers for Disease Control and Prevention 8
Daily TDF/FTC is the recommended PrEP regimen, according to the World Health Organization 8
TDF-based PrEP is not recommended for individuals with osteopenia, osteoporosis, or creatinine clearance less than 60 mL/min, as suggested by the National Institutes of Health 8

For patients with tuberculosis co-infection, timing of ART initiation should be carefully considered, as early ART has been shown to increase mortality in cryptococcal meningitis, according to the World Health Organization 9
For patients with substance use disorders, integration of directly observed ART in treatment programs and opioid substitution therapy are recommended, as suggested by the National Institute on Drug Abuse 5
Screening for and addressing housing instability, food insecurity, psychiatric disorders, and medication adverse effects improves outcomes, according to the National Institutes of Health 5