Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults

Publication Date: December 1, 2022
Last Updated: December 2, 2022

Key Recommendations for When to Start Antiretroviral Therapy (ART)

  • Initiation of ART is recommended as soon as possible after diagnosis, ideally within 7 days, including on the same day as diagnosis or at the first clinic visit if the patient is ready and there is no suspicion for a concurrent opportunistic infection (evidence rating: AIII)
  • Structural barriers that could delay receipt of ART (including same-day), and impede care engagement, continuous ART access, and ART adherence should be identified and addressed using evidence-informed strategies (evidence rating: AIIa)
  • Initiation of ART at the time of diagnosis of acute HIV infection is recommended (evidence rating: AIIa)
  • Initiation of ART is recommended within 2 weeks of initiation of treatment for most opportunistic infections
    • For persons with active tuberculosis without evidence of tuberculous meningitis, ART should be initiated within 2 weeks after initiation of tuberculosis treatment, especially for those with CD4 cell count less than 50/μL (evidence rating: AIa)
    • For those with tuberculous meningitis, high-dose steroids should be initiated along with tuberculosis treatment and ART should be initiated within 2 weeks after starting tuberculosis treatment and steroids (evidence rating: BIa)
    • For individuals with cryptococcal meningitis with access to close monitoring and supportive care for adverse events, ART should be initiated 2 to 4 weeks after starting antifungal therapy (evidence rating: BIIb); ART-naive individuals who have asymptomatic cryptococcal antigenemia and a negative lumbar puncture result with no evidence of cryptococcal meningitis should start ART immediately (evidence rating: BIII)
    • Initiation of ART is recommended immediately in the setting of a new diagnosis of cancer with attention to drug-drug interactions (evidence rating: BIIa)

Recommended Initial Antiretroviral Therapy (ART) Regimens

Recommended for Most People With HIV
  • The following are recommended (in alphabetical order) for most people with HIV:
    • BIC/TAF/FTC (evidence rating: AIa)
    • Dolutegravir plus TXF/XTC (evidence rating: AIa)
    • DTG/3TC (only if HIV RNA <500 000 copies/mL and HBV coinfection not present). This regimen should not be used for rapid initiation when genotype, HIV RNA, and HBV serology results are not yet available (evidence rating: AIa)
  • Persons who acquired HIV while receiving preexposure prophylaxis with tenofovir alafenamide or tenofovir disoproxil fumarate with emtricitabine should have a blood sample for genotyping drawn prior to initiating therapy and a 3-drug regimen, preferably dolutegravir or bictegravir plus TXF/XTC, should be initiated if ART is to be started before genotype results are available (evidence rating: AIII)
  • Persons who acquired HIV after exposure to cabotegravir for preexposure prophylaxis should have a blood sample for InSTI genotyping drawn prior to beginning therapy with an InSTI-based regimen (evidence rating: AIII)
    • If therapy is desired before genotype results are available or if InSTI-resistance is present, a boosted PI regimen containing darunavir and TXF/XTC should be used (evidence rating: AIII)

Recommended During Pregnancy
  • TAF/XTC plus dolutegravir (evidence rating: AIa), withTDF/XTC plus dolutegravir a suitable alternative if tenofovir alafenamide is not available (evidence rating: AIa)
  • The following drugs may be used if dolutegravir is not an option:
    • Raltegravir (400 mg twice daily) (evidence rating: AIIa)
    • Atazanavir plus ritonavir (evidence rating: BIIa)
    • Darunavir plus ritonavir (evidence rating: BIIa)
    • Rilpivirine (evidence rating: BIIa)

Not Recommended to Initiate During Pregnancy Because of Inadequate Data to Support Use (Evidence Rating: AIII for All)
  • Bictegravir
  • Doravirine
  • Cabotegravir
  • DTG/3TC
  • DTG/RPV
  • If patient is already taking, and stable while taking, bictegravir- or doravirine-containing regimens or the 2-drug regimens DTG/3TC or DTG/RPV and wishes to continue, counsel patient about uncertainties regarding safety during pregnancy and monitor HIV RNA more frequently

Should Not Be Used During Pregnancy Because of Inadequate Drug Levels
  • Cobicistat-containing regimens (evidence rating: AIIb)

Recommended During Tuberculosis Treatment (in Alphabetical Order by Anchor Drug)
  • TXF/XTC is recommended with 1 of the followinga:
    • Dolutegravir (50 mg twice daily) (evidence rating: BIa)
    • Efavirenz (600 mg) (evidence rating: AIa)
    • Raltegravir (800 mg twice daily) (evidence rating: BIa)
  • A ritonavir-boosted PI regimen with TXF/XTC may be used only if it is not possible to use any of the above regimens. In that case, rifabutin (150 mg) should be substituted for rifampin (evidence rating: BIII)
  • Bictegravir, darunavir boosted with ritonavir or cobicistat, doravirine, EVG/COBI, long-acting cabotegravir plus rilpivirine, etravirine, and rilpivirine are not recommended with rifampin because of drug-drug interactions (evidence rating: AIIa)
  • DTG/3TC is not recommended with rifampin because of drug-drug interactions and inadequate data (evidence rating: BIII)
a There is a pharmacokinetic interaction between rifampin and tenofovir alafenamide; clinical data with coadministration are limited.

Overview

Title

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults

Authoring Organization