Antiretroviral Guidelines

US DHHS Guidelines with Australian commentary

Acute and Recent (Early) HIV Infection

Last Updated: October 25, 2018; Last Reviewed: October 25, 2018

Panel's Recommendations for Acute and Recent (Early) HIV Infection

AU comment: Diagnosis of early HIV infection

Panel’s Recommendations

  • Antiretroviral therapy (ART) is recommended for all individuals with HIV-1 infection (AI), including those with earlya HIV-1 infection.
  • Once initiated, the goal of ART is to suppress plasma HIV-1 RNA to undetectable levels (AIII). Testing for plasma HIV-1 RNA levels, CD4 T lymphocyte cell counts, and toxicity monitoring should be performed as recommended for patients with chronic HIV-1 infection (AII).
  • Genotypic drug resistance testing should be performed before initiation of ART to guide the selection of the regimen (AII).
  • ART can be initiated before drug resistance test results are available. Either boosted darunavir (DRV) or dolutegravir (DTG) with emtricitabine (FTC) plus either tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF) are recommended regimens in this setting (AIII). The rationales and precautions for these regimens are discussed below.
  • A DRV-based regimen is a good option for people with early HIV-1 infection, because resistance to pharmacokinetically enhanced protease inhibitors (PIs) emerges slowly and clinically significant transmitted resistance to PIs is uncommon.
  • A DTG-based regimen is also a reasonable option; however, data regarding transmission of integrase strand transfer inhibitor (INSTI)-resistant HIV and the efficacy of DTG regimens in early HIV infection are more limited (AIII).
  • Preliminary data from Botswana suggested that infants born to women who were receiving dolutegravir (DTG) at the time of conception have an increased risk of neural tube defects. Until more information are available, DTG should not be prescribed for individuals:
    • Who are pregnant and within 12 weeks post-conception;
    • Who are of childbearing potential, who are sexually active, and who are not using effective contraception; or
    • Who are contemplating pregnancy.
  • When results of drug resistance testing are available, the treatment regimen can be modified if warranted (AII). In patients without transmitted drug-resistant virus, therapy should be initiated with one of the combination regimens that is recommended for patients with chronic HIV-1 infection (see What to Start) (AIII).
  • Patients starting ART should be willing and able to commit to life-long treatment and should understand the importance of adherence (AIII). Patients may choose to postpone ART, and providers, on a case-by-case basis, may recommend that patients defer therapy because of clinical or psychosocial factors.

Rating of Recommendations:  A = Strong; B = Moderate; C = Optional
Rating of Evidence:  I = Data from randomized controlled trials; II = Data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Early infection represents either acute or recent infection.

Panel’s Recommendations