File 1 of 8 from HHS Adult ART Guidelines: Initial Therapy

Preparing for Antiretroviral Therapy Initiation


Preparing for Antiretroviral Therapy Initiation
Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents

March 2020

About This Presentation
These slides were developed using the Guidelines updated in December 2019.
The intended audience is clinicians involved in the care of patients with HIV.
Because the field of HIV care is rapidly changing, users are cautioned that the information in this presentation may become out of date quickly.
It is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent.
March 2020

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents
Developed by the Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents – A Working Group of the Office of AIDS Research Advisory Council (OARAC)
March 2020

Preparing for Antiretroviral Therapy (ART) Initiation: Outline
ART for individual health
Treatment as prevention (U=U)
When to start
Immediate ART
Special situations and populations: urgent ART, OIs, adolescents, aviremic controllers
Goals of therapy
March 2020

Recommendations for Initiating ART(1)
ART is recommended for treatment:
ART “is recommended for all HIV-infected individuals, regardless of CD4 T lymphocyte cell count, to reduce the morbidity and mortality associated with HIV infection.” (A1)
March 2020

Recommendations for Initiating ART(2)
ART is recommended for prevention:
“ART also is recommended for individuals with HIV to prevent HIV transmission.” (A1)
March 2020

Recommendations for Initiating ART (3)
Early diagnosis and ART initiation is supported by randomized controlled trials
ART should be started immediately (or ASAP) after diagnosis, to:
Increase ART uptake
Decrease time to linkage to care
Decrease time to viral suppression (VS)
Improve rate of VS
Decrease risk of HIV transmission
March 2020

Recommendations for Initiating ART (4)
Clinical and psychosocial factors occasionally require a brief delay
Educate patients about benefits of ART; support their willingness and readiness to start ART
Educate that indefinite treatment is required; ART does not cure HIV
Strategize about optimizing adherence and engagement in care

March 2020

ART to Prevent Sexual Transmission of HIV
“Treatment as Prevention” (TasP) or “Undetectable = Untransmittable” (U = U)
Effective ART with continuous HIV VS (<200 copies/mL) prevents HIV transmission to sexual partners
Providers should inform PWH of this fact
Close adherence is required to maintain VS
PWH should use other means of prevention for at least 6 months after starting ART, and until sustained VS is confirmed
ART does not prevent other STIs
March 2020

Immediate ART
ART started immediately after HIV diagnosis, including on day of HIV diagnosis (rapid ART, immediate ART, same-day ART, etc.)
May increase engagement in HIV care, and increase proportion of people who achieve and maintain VS
RCTs in resource-limited settings show improved clinical outcomes
Cohort and pilot studies in U.S. show shorter time to VS
May be resource-intensive, and long-term clinical benefits not proven in the U.S.
But, removing structural barriers in order to facilitate rapid ART initiation may improve HIV treatment outcomes 

March 2020

Consider Urgent ART Initiation
AIDS-defining condition
Acute opportunistic infection
Lower CD4 count (e.g., <200 cells/µL)
Acute/early HIV infection
HIV-associated nephropathy (HIVAN)
HBV coinfection
HCV coinfection 
March 2020

Starting ART in Person with Opportunistic Infection (OI) or Malignancy
Early/immediate ART usually indicated
Risk of immune reconstitution inflammatory syndrome (IRIS) may be higher, but overall clinical benefit of early ART outweighs
For some specific OIs (e.g., cryptococcal and TB meningitis) there may be risk of serious IRIS with immediate ART: a short delay in ART initiation may be appropriate
See OI Guidelines for further information
March 2020

Starting ART: Adolescents with HIV
Often, lower levels of ART adherence and HIV suppression
Provide effective supports and assessment re starting and adhering to ART
Multidisciplinary care team; psychosocial and adherence support
March 2020

Starting ART: “HIV Controllers”
“Elite (aviremic) HIV controllers”
Plasma HIV RNA below level of quantification without ART
Still have ongoing HIV replication and abnormal immune activation
May have increased risk of non-AIDS diseases
Limited data re benefit of ART
ART strongly recommended if evidence of HIV progression (e.g., decrease in CD4, HIV-related complications)
Theoretic benefit for others
If not on ART, follow closely; start ART if evidence of HIV progression
March 2020

Key Goals of Treatment
Maximally and durably suppress HIV viral load
Restore and preserve immunologic function
Reduce HIV-related morbidity; prolong duration and quality of survival
Prevent HIV transmission
March 2020

Strategies to Achieve Treatment Goals
Selection of ARV regimen
Maximizing adherence
March 2020

Optimize Adherence
Support and reinforcement
Simplified dosing strategies
Reminders, alarms, timers, and pillboxes
Ongoing patient education
Trust in primary care provider
March 2020

Websites to Access the Guidelines
AETC National Coordinating Resource Center
March 2020

About This Slide Set
This presentation was prepared by Susa Coffey, MD, for the AETC National Resource Center in March 2020.
See the AETC NCRC website for the most current version: