EXECUTIVE SUMMARY
Human immunodeficiency virus (HIV) infection has evolved into a manageable, chronic illness, much like diabetes and hypertension, thanks to the wise use of antiretroviral therapy (ART). These recommendations provide the most up-to-date, scientifically supported approach to using ART in the Indian context.
When to initiate ART ?
No matter their CD4 counts or Plasma Viral Load (PVL) levels, all symptomatic (HIV)-infected individuals require antiretroviral therapy. ART should be offered to asymptomatic patients with CD4 counts of 200/mm3 or higher, and it should be considered for those with CD4 counts between 200 and 250/mm3. Patients with CD4 counts exceeding 350/mm3 are not advised to start therapy. It is essential to involve the patient in all treatment decisions and assess their readiness before commencing ART.
What to start with ?
A regimen based on a non-nucleoside reverse transcriptase inhibitor (NNRTI) is recommended for antiretroviral-naive patients. The choice between Nevirapine and Efavirenz depends on different adverse event profiles, cost, the availability of practical fixed-dose combinations, and the need for concurrent rifampicin use. The NNRTI is combined with a base of two nucleoside reverse transcriptase inhibitors (NRTIs).
How to follow up?
Recommendations have been established for baseline evaluation and monitoring of patients on ART, encompassing guidelines for laboratory and clinical assessments. A plasma viral load test at 6 months after initiating first-line ART is highly recommended, and an annual assessment of the lipid profile is advised.
How to identify and manage ART failure ?
The guidelines acknowledge the challenge of late identification of ART failure when relying solely on CD4 counts for monitoring. In the absence of resistance testing, several second-line regimens have been listed. In such cases, a boosted protease-inhibitor based regimen is recommended, combined with 2-NRTIs.
Special situations
Recommendations have been provided for the use of ART in HIV-TB, HIV-HBV, and HIV-HCV co-infected patients. In patients with active TB and a CD4 count < 200/mm3, initiation of ART is recommended as soon as the anti-TB treatment is tolerated. Efavirenz is the only ARV drug that can be safely used with rifampicin. In pregnancy, the use of single-dose Nevirapine to reduce the risk of mother-to-child transmission of HIV is not recommended due to the risk of developing resistance. For post-exposure prophylaxis, knowledge of the source patient's ART treatment history is crucial in designing an effective regimen.