ART Guidelines

ART Guidelines

Please review the disclaimer before proceeding with these guidelines



  • ×
    /r ritonavir-boosted
    3TC lamivudine
    ABC abacavir
    ADR adverse drug reaction
    AKI acute kidney injury
    ALT alanine transaminase
    ART antiretroviral therapy
    ARV antiretroviral
    AST aspartate transaminase
    ATV atazanavir
    ATV/r ritonavir-boosted atazanavir
    AZT zidovudine
    bd twice daily
    CD4+ cluster of differentiation 4
    CM cryptococcal meningitis
    CrAg cryptococcal antigen
    CrCl creatinine clearance rate
    CSF cerebrospinal fluid
    CTX cotrimoxazole
    CVS cardiovascular
    d4T stavudine
    DILI drug-induced liver injury
    DNA deoxyribonucleic acid
    DOR doravirine
    DRV darunavir
    DRV/r ritonavir-boosted darunavir
    DTG dolutegravir
    eGFR estimated glomerular filtration rate
    ELISA enzyme-linked immunosorbent assay
    ETR etravirine
    FBC full blood count
    FDC fixed dose combination
    FTC emtricitabine
    GI gastrointestinal
    Hb haemoglobin
    HBsAg hepatitis B surface antigen
    HBV hepatitis B virus
    HIV human immunodeficiency virus
    ICU intensive care unit
    InSTI integrase strand transfer inhibitor
    IPT isoniazid preventive therapy
    LAM lipoarabinomannan
    LDL-C low-density lipoprotein cholesterol
    LP lumbar puncture
    LPV lopinavir
    LPV/r ritonavir-boosted lopinavir
    MDRD modification of diet in renal disease
    MTCT mother-to-child transmission of HIV
    MVC maraviroc
    NGT nasogastric tube
    NNRTI non-nucleoside reverse transcriptase inhibitor
    NRTI nucleoside reverse transcriptase inhibitor
    NTDs neural-tube defects
    NtRTI nucleotide reverse transcriptase inhibitor
    NVP nevirapine
    OI opportunistic infection
    PCR polymerase chain reaction
    PI protease inhibitor
    PI/r ritonavir-boosted protease inhibitor
    PMTCT prevention of mother-to-child transmission of HIV
    PPIs proton pump inhibitors
    PrEP pre-exposure prophylaxis
    PWH people with HIV
    RAL raltegravir
    RCTs randomised controlled trials
    RIF rifampicin
    RFB rifabutin
    RNA ribonucleic acid
    RPV rilpivirine
    RTV or /r ritonavir
    sCr serum creatinine
    sCrAg serum cryptococcal antigen
    TAF tenofovir alafenamide
    TAM thymidine analogue mutation
    TB tuberculosis
    TB-IRIS tuberculosis immune reconstitution inflammatory syndrome
    TBM tuberculosis meningitis
    TC total cholesterol
    TDF tenofovir disoproxil fumarate
    TG triglycerides
    TST tuberculin skin test
    ULN upper limit of normal
    VL viral load
    VTP vertical transmission prevention of HIV
    WHO World Health Organization

            Key points
    • Many patients return to care after treatment interruption when they experience clinical deterioration – screening for opportunistic infections should be performed.
    • VL measurement should be performed 3 months after ART re-initiation.
    • The majority of patients returning to care should be re-initiated on tenofovir/lamivudine/dolutegravir (TLD) unless there is a reason not to use one of these drugs or the patient requires a more robust third line regimen.

    Patients receiving ART may interrupt their treatment for a variety of reasons (e.g. treatment fatigue, denial, life event, depression, new job, relocation). Many patients return to care after an interruption, often precipitated by clinical deterioration. Patients who have clinical symptoms of an opportunistic infection (OI) when returning to care should be investigated and, if appropriate, started on treatment for the infection before restarting ART. In particular, patients should be screened for symptoms of meningitis and for TB symptoms when returning to care. Reasons for delaying ART re-initiation are the same as for delaying initiation in ART-naïve patients (see module 6). Patients who are asymptomatic when they return to care can be re-initiated on ART the same day with appropriate counselling. A counselling plan should be implemented to ensure retention in care going forward and to address reasons for disengagement in a non-judgemental manner.

    We recommend performing a CD4+ count when the patient returns to care (to guide OI prophylaxis) and a VL measurement 3 months after re-initiation of ART. If this VL is suppressed, then VL monitoring could revert to annually. If it is not suppressed, follow standard guidance in response to the result (see module 8). If the patient is restarted on TDF then an eGFR should also be checked at baseline and at 3 months.

    The majority of patients returning to care should be re-initiated on TDF/3TC/DTG (TLD). This is supported by data demonstrating the virological efficacy of TLD in first- and second-line ART, and the convenience of a well-tolerated single daily tablet in patients with prior adherence problems.

    Patients who should not be restarted on TLD include:

    • Patients with renal impairment or prior nephrotoxicity due to TDF. These patients should be recommenced on ABC/3TC/DTG or ABC/3TC/ DRV/r or ABC/3TC/ATV/r, or TAF/FTC/DTG if eGFR > 30mL/min/1.73m2.
    • Patients previously on a third-line regimen including DRV/r. These patients should be restarted on the same regimen although, in consultation with an HIV expert, consideration could be given to rationalising the regimen to fewer drugs after review of their treatment history and prior resistance tests.

    Common pitfall: Performing a resistance test after an ART treatment interruption of > 4 weeks.

    Such testing is of limited value. Many resistance mutations are overtaken by wild-type virus when ART is stopped and thus the resistance test may not accurately reflect the true resistance pattern.