HIV/AIDS and ART

Presentation

Once for: all adults <66, new dx of TB or STI, each pregnancy, victims of sexual assault.
More frequent screening for high-risk populations: IVDU, MSM with new partner(s), sex workers, HIV+ partners

Initial: HIV p24 Ag +1/2 Ab Assay – If reactive, reflexes to HIV-1/2 Ab Confirmation Assay
Obtain HIV RNA (Viral Load) if above testing is positive, indeterminate, or c/f acute infection

Pts with well controlled HIV should be continued on home ART. Special considerations include new renal or hepatic dysfunction (call pharmacy for dose adjustment) or concern for nonadherence (hold am dose). Careful med rec to ensure the pt’s complete ART regimen is ordered. Combination pills may need to be ordered as separate components which pharmacy can help with.
Check Liverpool HIV Interactions website before starting new medications, especially if a pt is taking ritonavir or cobicistat.
Do not order CD4 or VL for pts with well controlled HIV, good adherence, and prior labs within the last 3-6 months.

ID consult if not on Rogers ID. (important for initiation, follow up [CCC], social work)
Obtain HIV VL, genotype, CD4 count (Epic order: Flow T lymphocytes), CBC w diff, CMP, UA, pregnancy test, Hep A/B/C panel, quant gold, Treponemal IgG, GC/CT, toxoplasma IgG/IgM, +/- HLA*B5701 (needed before using abacavir containing regimen).
Start OI Tx vs ppx early

Should occur in all HIV+ patients as quickly as SAFELY possible. Factors affecting timing include drug interactions, HIV resistance patterns, adherence barriers, and need for treatment of OIs prior to ART Initiation.
Treatment of OIs (particularly, crypto meningitis, CMV retinitis, and TB) may delay initiation of ART for several weeks given associated risk of immune reconstitution inflammatory syndrome (IRIS) once ART is started. IRIS can be seen with other infections, such as disseminated MAC and PML, and can manifest as an unmasking of previously unknown infections.
The choice of the initial antiretroviral regimen depends on multiple patient factors, including medical and mental health comorbidities, patient preferences, insurance coverage, drug interactions, and prior HIV PrEP usage.
Recommended initial ART regimens for most patients (as long as they have not used cabotegravir PrEP) are integrase inhibitor-based, including either Biktarvy®, Dovato®, or dolutegravir + Descovy®. Dovato® should only be used in those with HIV RNA <500,000 copies/mL and without HBV coinfection. If a patient has used cabotegravir PrEP, then the initial regimen should consist of a protease inhibitor (instead of an integrase inhibitor).
Most patients will achieve undetectable VL within 12 to 16 weeks. CD4 response is typically rapid in first 3-6mo followed by a more gradual increase over 3 to 6 years.