Therapy and Drug Combinations
Identifying HIV Infection
Antiretroviral therapy (ART) is recommended for all human immunodeficiency virus (HIV) infected individuals to reduce the risk of disease progression. ART is also recommended for HIV-infected individuals for the prevention of transmission of HIV. Patients starting ART should be willing and able to commit to treatment and understand the benefits and risks of therapy and the importance of adherence •
Selecting an ART regimen
HIV screening is recommended as a routine part of medical care for all patients 13-64 years of age.
Identifying and Staging HIV
- HIV antibody testing
- CD4 T-cell count (CD4 count)
- Plasma HIV RNA (viral load)
- Complete blood count, chemistry profile, transaminase levels, blood urea nitrogen (BUN), and creatinine, urinalysis, and serologies for hepatitis A, B, and C viruses
- Fasting blood glucose and serum lipids
- Genotypic resistance testing at entry into care, regardless of whether ART will be initiated immediately
- For patients who have HIV RNA levels <500 to 1,000 copies/mL, viral amplification for resistance testing may not always be successful
- Patient education and counseling regarding: HIV modes of transmission, HIV effects on the immune system, treatment methods and transmission prevention should be part of obtaining a voluntary informed consent for HIV screening.
- HIV antibody test is the most common HIV screening test. The test checks for HIV antibodies in blood, urine, or fluids from the mouth.
- HIV antigen/antibody test can detect both HIV antigen (a part of the virus) and HIV antibodies in blood. An antigen/antibody test can detect HIV infection before an HIV antibody test.
- Confirming a positive HIV screening test can be done by
- Antibody differentiation test, which distinguishes HIV-1 from HIV-2
- HIV-1 nucleic acid test, which looks directly for HIV
- Western blot or indirect immunofluorescence assay, which detect antibodies
- HIV drug-resistance testing is recommended for persons with HIV infection regardless of whether antiretroviral therapy (ART) will be initiated immediately or deferred. If therapy is deferred, repeat testing should be considered at the time of ART initiation.
- Genotypic testing is recommended as the preferred resistance testing to guide therapy in antiretroviral (ARV)-naive patients and for those patients experiencing suboptimal virologic response. Standard genotypic drug-resistance testing in ARV-naive persons involves testing for mutations in the reverse transcriptase (RT) and protease (PR) genes. If integrase strand transfer inhibitor (INSTI) resistance is a concern, providers may wish to supplement standard genotypic resistance testing with an INSTI genotype test.
- An ART regimen is a structured treatment plan designed to improve and maintain health. Recommended regimens for the initial treatment of HIV include a combination of three or more antiretroviral (ARV) drugs from at least two different HIV drug classes.
- Choosing medications to include in HIV regimen depends on a person's individual needs. Factors considered when choosing an HIV regimen should include
- Possible side effects of HIV medications
- Potential interactions between HIV medication or other medications and treatments
- Results of drug-resistance testing (and other tests).
- Convenience of the regimen.
- Cost of HIV medications
2015 Health and Human Services Recommended Initial Combination Regimens
An antiretroviral regimen for a treatment-naive patient generally consists of two nucleoside reverse transcriptase inhibitors in combination with a third active antiretroviral drug from one of three drug classes: an integrase strand transfer inhibitor, a non-nucleoside reverse transcriptase inhibitor, or a protease inhibitor with a pharmacokinetic enhancer (cobicistat or ritonavir).
Alternative Regimen Options may be the preferred regimen for some patients:
- Integrase Strand Transfer Inhibitor-Based Regimens:
- Dolutegravir (DTG)/abacavir/lamivudinea (3TC) only for patients who are HLA-B*5701 negative
- DTG plus tenofovir disoproxil fumarate/emtricitabine (TDF/FTC)
- Elvitegravir/cobicistat/tenofovir/emtricitabine only for patients with pre-antiretroviral therapy Creatinie Clearance >70 mL/min
- Raltegravir plus tenofovir/(either emtricitabine or lamivudine)
- Protease Inhibitor-Based Regimen:
- Darunavir/ritonavir (DRV/r) plus TDF/FTC
- NNRTI-Based Regimens:
- RPV/TDF/FTC—only for patients with pre-treatment HIV RNA <100,000 copies/mL and CD4 cell count >200 cells/mm3
- PI-Based Regimens:
- ATV/c plus TDF/FTC —only for patients with pre-treatment estimated CrCl ≥70 mL/min
- ATV/r plus TDF/FTC
- (DRV/c or DRV/r) plus ABC/3TC —only for patients who are HLA-B*5701 negative
- DRV/c plus TDF/FTC —only for patients with pre-treatment estimated Creatinine Clearance ≥70 mL/min
Key to Acronyms: 3TC = lamivudine; ABC = abacavir; ARV = antiretroviral; ATV/c = cobicistat-boosted atazanavir; ATV/r = ritonavir- boosted atazanavir; CrCl = creatinine clearance; DRV/c = cobicistat-boosted darunavir; DRV/r = ritonavir-boosted darunavir; DTG = dolutegravir; EFV = efavirenz; EVG/c/TDF/FTC = elvitegravir/cobicistat/tenofovir DF/emtricitabine; FTC = emtricitabine; INSTI = integrase strand transfer inhibitor; LPV/r = ritonavir-boosted lopinavir; NNRTI = non-nucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; PI = protease inhibitor; RAL = raltegravir; RPV = rilpivirine; RTV = ritonavir; TDF = tenofovir disoproxil fumarate