Antiretroviral Guidelines

US DHHS Guidelines with Australian commentary

Acute and Recent (Early) HIV Infection

Last Updated: December 18, 2019; Last Reviewed: December 18, 2019

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, including those with earlya HIV infection (AI). ART should be initiated as soon as possible after HIV diagnosis (AII).
  • The goal of ART is to suppress plasma HIV RNA to undetectable levels (AI) and to prevent transmission of HIV (AI). Testing for plasma HIV RNA levels, CD4 T lymphocyte cell counts, and toxicity monitoring should be performed as recommended for persons with chronic HIV infection (AII).
  • A sample for genotypic testing should be sent before initiation of ART (AIII). ART can be initiated before drug resistance testing and HLA B*5701 test results are available. In this setting, one of the following ART regimens is recommended (AIII):
    • Bictegravir (BIC)/tenofovir alafenamide (TAF)/emtricitabine (FTC)
    • Dolutegravir (DTG) with (TAF or tenofovir disoproxil fumarate [TDF])b plus (FTC or lamivudine [3TC])
    • Boosted darunavir (DRV) with (TAF or TDF)b plus (FTC or 3TC)
  • Pregnancy testing should be performed in individuals of childbearing potential before initiation of ART (AIII).
  • Data from an observational study in Botswana suggest there may be an increased risk of neural tube defects in infants born to individuals who were receiving DTG at the time of conception. Before initiating an integrase strand transfer inhibitor-based regimen in a person of childbearing potential, clinicians should review Table 6b for information to consider when choosing an ART regimen.
  • As there are no safety data for BIC use around the time of conception, an approach similar to that outlined for DTG should be considered for BIC-containing ART (AIII).
  • When the results of drug resistance and HLA-B*5701 testing are available, the treatment regimen can be modified if needed (AII).
  • Providers should inform individuals starting ART of the importance of adherence to achieve and maintain viral suppression (AIII).

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

a Early infection represents either acute or recent infection.
TAF and TDF are two forms of tenofovir that are approved in the United States. TAF has fewer bone and kidney toxicities than TDF, while TDF is associated with lower lipid levels. Safety, cost, and accessibility are among the factors to consider when choosing between these drugs.

Panel’s Recommendations