US guideline recommends two-drug ART regimen for initial treatment of HIV infection
The US Panel on Antiretroviral Guidelines for Adults and Adolescents has updated its guidance to now include a two-drug regimen as an initial treatment option for most people with HIV infection. Previously, only three-drug regimens were recommended.
Dolutegravir (an integrase strand transfer inhibitor) plus lamivudine (a nucleoside reverse transcriptase inhibitor) is recommended as an initial regimen in all patients, except patients with pre-treatment HIV RNA >500,000 copies/mL or active hepatitis B co-infection, or those who will initiate antiretroviral therapy (ART) before results of HIV genotype testing or hepatitis B virus testing are available. There are no data available on two-drug regimens in pregnant women and they are not recommended in these patients at this time.
This recommendation is based on the results of two large, randomised controlled trials that showed that dolutegravir plus lamivudine was non-inferior to dolutegravir plus tenofovir plus emtricitabine.[78]
A combination formulation of dolutegravir/lamivudine has been approved in the US and Europe as a complete regimen for the treatment of HIV-1 infection in adults with no ART history.
See Management: treatment algorithm
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Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- fevers and night sweats
- weight loss
- skin rashes and post-inflammatory scars
- oral ulcers, angular cheilitis, oral thrush, or oral hairy leukoplakia
- diarrhoea
- wasting syndrome
- changes in mental status or neuropsychiatric function
- recent hospital admissions
- tuberculosis (TB)
- medical comorbidities
- sexual activity
- generalised lymphadenopathy
- Kaposi's sarcoma
- genital STIs
- chronic vaginal candidiasis
- shingles
- headaches
- periodontal disease
- retinal lesions on fundoscopy
- shortness of breath on exertion, cyanosis on exertion, dry cough, silent chest on auscultation
Other diagnostic factors
- current and prior use of other substances
- peripheral neuropathy
- recurrent herpes simplex
- hepatomegaly or splenomegaly
- meningeal signs (bacterial or viral meningitis)
Risk factors
- needle sharing with intravenous drug use
- unprotected receptive anal intercourse
- unprotected receptive penile-vaginal sexual intercourse
- percutaneous needle stick injury
- high maternal viral load (mother to child transmission)
- use of progestin-only injectable contraceptives
- herpes simplex virus type 2 (HSV-2) infection
Diagnostic investigations
1st investigations to order
- serum HIV enzyme-linked immunosorbent assay (ELISA)
- serum HIV rapid test
- HIV non-invasive tests
- serum Western blot
- serum p24 antigen
- serum HIV DNA polymerase chain reaction (PCR)
- CD4 count
- serum viral load (HIV RNA)
- drug resistance testing
- pregnancy test
- serum hepatitis B serology
- serum hepatitis C serology
- serum venereal disease research laboratory test
- Treponema pallidum haemagglutination test
- rapid plasma reagin
- tuberculin skin test
- FBC with differential
- serum electrolytes
- serum creatinine
- urinalysis
Investigations to consider
- chest x-ray
- liver function tests (LFTs)
- random or fasting lipid profile
- random or fasting plasma glucose
- hepatitis A serology (IgG)
- toxoplasma serology (IgG)
- gonorrhoea and chlamydia testing
- human leukocyte antigen-B*5701 testing
Treatment algorithm
Contributors
Authors
Assistant Professor of Medicine
Infectious Diseases
Northwestern Medicine
Feinberg School of Medicine, Northwestern University
Chicago
IL
Disclosures
CJA is a consultant on an educational programme on HIV and ageing with ViiV, has received speaker fees for talks on HIV and ageing with ViiV, and has received a grant for investigator sponsored research from Gilead Sciences.
Dr Chad J. Achenbach would like to gratefully acknowledge Dr Richard Rothman, Dr Michael Ehmann, Dr Linda-Gail Bekker, Dr Catherine Orrell, and Dr Lisa Capaldini, the previous contributors to this topic.
Peer reviewers
Clinical Assistant Professor
University of British Columbia
Vancouver
Canada
Disclosures
MH is a member of an advisory board and/or speakers' bureau for Gilead Sciences Canada Inc, Merck Canada Inc, and ViiV Healthcare.
Assistant Professor of Medicine
Harvard Medical School
Director of Research
Global Health Delivery Project
Harvard School of Public Health
Boston
MA
Disclosures
WR declares that he has no competing interests.
Infectious Disease Physician
Oxford University Clinical Research Unit
Hospital for Tropical Diseases
Ho Chi Minh City
Vietnam
Disclosures
JD declares that he has no competing interests.
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