Antiretroviral Therapy Initiation and Management

Immediate Management Actions

The American Medical Association recommends initiating antiretroviral therapy (ART) as soon as possible after confirmed HIV diagnosis, ideally on the same day or within days, while simultaneously obtaining baseline laboratory tests that should not delay treatment initiation 1, 2
Treatment should not be delayed waiting for baseline test results, with the exception that HIV RNA must confirm true infection (not a false positive) 3, 4

The most recent guidelines recommend starting with an integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs), such as bictegravir/tenofovir alafenamide/emtricitabine, dolutegravir plus tenofovir alafenamide (or tenofovir disoproxil fumarate)/emtricitabine, or dolutegravir plus abacavir/lamivudine (if HLA-B*5701 negative) 2, 4

HIV RNA viral load, CD4+ cell count with percentage, and HIV genotype resistance testing (reverse transcriptase and protease) should be obtained before or at ART initiation to confirm active infection, assess immune status, and detect transmitted drug resistance 2, 4
HLA-B*5701 testing must be performed before using abacavir to prevent hypersensitivity reactions 2, 5
Hepatitis B surface antigen, hepatitis B core antibody, and hepatitis B surface antibody should be tested to identify coinfection and guide treatment selection 2, 5

Measure HIV RNA viral load at 4-6 weeks after starting ART to assess response to therapy, and every 3 months until suppressed for at least 1 year, then can extend to every 6 months if adherence is excellent 2, 4
CD4 count should be measured every 6 months until >250 cells/μL for at least 1 year with viral suppression 2, 4

If CD4 <200 cells/μL, consider opportunistic infection prophylaxis (Pneumocystis, toxoplasmosis, MAC depending on CD4 level) 2
If pregnant, immediate ART is critical for maternal health and prevention of vertical transmission 7
If hepatitis B coinfected, select ART regimen that treats both HIV and HBV (tenofovir-containing regimen) 1