- The International Antiviral Society–USA Panel has updated its 2016 antiretroviral therapy (ART) recommendations, highlighting rapid start (immediately after diagnosis) of treatment whenever feasible.
- Early HIV diagnosis is essential.
Why this matters
- Clinicians treating newly HIV-infected patients should gain familiarity with new recommendations on rapid start, noting that after excluding active hepatitis, treatment can begin without results of supporting laboratory tests, including resistance testing.
- Exceptions:1) HLA-B*5701 test findings needed if an abacavir-containing regimen is considered, 2) patients at-risk for immune reconstitution inflammatory syndrome in setting of active tuberculosis, cryptococcal meningitis, other opportunistic infections (OIs), 3) unclear HIV infections.
- Rapid ART requires care linkage, coordination between testing/treatment settings, staffing, and services considerations.
- Preferred rapid start agents: dolutegravir/tenofovir/alafenamide (TAF) or tenofovir/disoproxil/fumarate (TDF)/emtricitabine (or lamivudine) or bictegravir/TAF/emtricitabine or boosted darunavir TAF (or TDF)/emtricitabine (or lamivudine).
- Consult 2016 recommendations for initiating ART in the patients with OIs.
- For patients with malignancies, choice of ART should be guided by drug-drug interactions with antimicrobial/chemotherapy regimens.
- Primary reasons for switching ART regimens: simplification, newly diagnosed comorbidities (or to prevent comorbidities), management of drug/other interactions.
- Familiarity with switching guidelines in presence of non- and nucleoside reverse transcriptase inhibitors, virologic suppression/failures, and resistance is important.