What are the DHHS guidelines for initiation of antiretroviral therapy (ART) for HIV infection?

Updated: Jul 27, 2020
  • Author: Shelley A Gilroy, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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Current Department of Health and Human Services (DHHS) guidelines on the timing of initiation of antiretroviral therapy are as follows: [11]

  • Antiretroviral therapy (ART) is recommended in all persons with HIV infection to reduce morbidity and mortality and to prevent HIV transmission to others.
  • The Panel on Antiretroviral Guidance for Adults and Adolescents recommends initiating ART immediately (or as soon as possible) after diagnosis to increase the uptake of ART linkage to care and to hasten and improve the rate of viral suppression.
  • When initiating ART, it is important to educate patients regarding the benefits of ART and to deploy strategies to optimize care engagement and treatment adherence.
  • Initiating ART is particularly important in patients with AIDS-defining conditions, patients with acute or recent HIV infection, and pregnant patients. Delaying therapy in these subpopulations has been associated with high risks of morbidity and mortality and HIV transmission.
  • Durable viral suppression improves immune function and overall quality of life, lowers the risk of both AIDS-defining and non–AIDS-defining complications, and allows persons with HIV infection to live a lifespan approaching that of persons without HIV infection. Two large randomized controlled trials, ART-START and TEMPRANO, demonstrated reductions in morbidity and mortality among individuals with HIV infection who had CD4 T-lymphocyte (CD4) cell counts of greater than 500 cells/uL and who were randomized to receive ART immediately compared with individuals in whom ART initiation was delayed.
  • All persons with HIV infection should be informed that maintaining a plasma HIV RNA (viral load) of less than 200 copies/mL with ART prevents sexual transmission of HIV to their partners. Patients may recognize this concept as “Undetectable = Untransmittable (U=U).” For persons with HIV infection who intend to rely on treatment as prevention (TasP), providers should make an individual assessment of the person's risk tolerance, personal health, history of maintaining viral suppression with treatment, and access to healthcare services and ART, as well as other factors that may affect their ability to maintain a high level of adherence to ART.

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