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Sep18
  1. Patients must be told to undertake lifelong ART.
  2. Start treatment for symptomatic patients regardless of CD4 cell count.
  3. Start drugs for asymptomatic individuals with CD4 cell counts <500/L.
  4. Do risk reduction counseling at each patient–clinician interaction.
  5. Regimen: Consider resistance–testing results and predicted virologic efficacy, toxicity and tolerability, pill burden, dosing frequency, drug–drug interactions, comorbidities, patient and practitioner preference, and cost and affordability.
  6. Combine two nucleoside reverse transcriptase inhibitors and a potent third agent from another class.
  7. Prefer a fixed–dose formulations and once–daily regimen.
  8. Suppress HIV to less than 50 copies/mL (polymerase chain reaction) or 75 copies/μL (branched DNA) by 24 weeks.
  9. To detect Failure: repeat testing of HIV–1 RNA 2 to 8 weeks after initiation, every four to eight weeks until suppressed, and then every 3 to 4 months for at least the first year.
  10. Monitor CD4 cell counts at least every 3 to 4 months after starting therapy, especially in patients with counts <200/μL, to assess whether prophylaxis is needed for opportunistic infections.
  11. Do more frequent monitoring in patients who have changed therapy because of virologic failure.
  12. Even if one or more regimens have failed, the therapeutic goal should still be undetectable plasma HIV–1 RNA levels.
  13. Achieve this goal with new drugs and regimens.
  14. If an elevation in viral load occurs after complete suppression is achieved, consider poor adherence, drug–drug interactions, concurrent infections and recent vaccinations as possible causes before changing regimens.
  15. Repeat testing for an isolated detectable viral load to exclude errors or self–resolving low–level viremia.
  16. When changing regimens after first– or multiple–regimen failure, consider the stage of HIV, nadir and current CD4 cell count, comorbidities, treatment history, current and previous drug resistance tests, and drug interactions.
  17. Include at least two drugs, and preferably three fully active drugs or drugs from new classes.
  18. Single–agent switches to decrease toxicity, avoid drug interactions, or improve convenience and adherence are possible, provided the potency of the regimen is maintained and drug interactions are managed.
  19. Boosted protease inhibitor monotherapy is not recommended, except when other drugs raise issues of toxicity or tolerability.
  20. Delaying such switches may affect adherence and risk development of resistance


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