Antiretroviral treatment strategies

Acute or primary HIV infection

Improved recognition of the clinical syndrome suggestive of acute HIV or primary HIV infection combined with use of newer diagnostic tests enables early identification of this group of individuals and thus consideration of antiretroviral therapy.

The SPARTAC study randomised patients with primary HIV infection to 48 weeks vs 12 weeks vs standard of care (no treatment) with follow-up to measure end point of CD4 count < 350 cells/μL. The 48-week treatment arm had significantly fewer patients reaching CD4 < 350 cells/μL average follow up 42 months.[39] There are potential benefits from treating patients with primary HIV infection including clinically reducing the flu-like symptoms characteristic of primary infection which can be severe, reduced seeding of the viral reservoirs, alteration of virological set point, reduced immunological damage and rapid immunological recovery, and finally, less opportunity for the development of viral resistance mutations.[40][41] The potential disadvantages of initiating cART in primary infection include patient readiness to commence ART at the time of managing the psychological and physical effects of a new HIV diagnosis, particularly since cART requires ongoing life-long adherence. There can be a delay in obtaining a baseline resistance result before commencement of cART.

ART is recommended for all people with HIV infection and should be offered to those with acute HIV infection (BII), although definitive data are lacking as to whether this approach will result in long-term virologic, immunologic, or clinical benefits.[42] For patients with early HIV infection in whom therapy is initiated, testing for plasma HIV RNA levels, CD4 count, and toxicity monitoring should be performed as described for patients with chronic HIV infection.

Genotypic drug resistance testing should be performed before initiation of ART to guide the selection of the regimen (AII). If therapy is deferred, genotypic resistance testing should still be performed because the results will be useful in selecting a regimen with the greatest potential for achieving optimal virological response when therapy is ultimately initiated. ART can be initiated before drug resistance test results are available. Since resistance to ritonavir (RTV)-boosted PIs emerges slowly and since clinically significant transmitted resistance to PIs is uncommon, these drugs combined with NRTIs should be used in this setting (AIII).

Patients starting ART should be willing and able to commit to treatment and should understand the possible benefits and risks of therapy and the importance of adherence (AIII). Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy because of clinical or psychosocial factors.

Treatment interruption

Treatment interruption following initiation of ART is not recommended apart from specific short-time situations. The SMART study, which examined ART interruption as a potential method of reducing ART exposure and thus ART toxicity, resulted in significantly higher rates of AIDS, severe non-AIDS events and death in the treatment interruption arm.[43][44]