HIV Treatment Regimens CDC Guidelines, Adult/Adolescent 

Updated: Oct 04, 2021
  • Author: Rachel Weihe, MD; more...
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HIV Treatment Guidelines per the Centers for Disease Control

The Centers for Disease Control (CDC) and other federal government agencies have issued several guidelines and recommendations regarding the prevention, screening, diagnosis, treatment, and management of HIV infection. [1] The CDC references the most current Department of Health and Human Services (DHHS) guidelines for the use of antiretroviral agents in HIV-1–infected adults and adolescents, as summarized below. [2]

Initial Combination Regimens for Antiretroviral-Naive Patients with HIV Infection

An initial antiretroviral regimen generally consists of two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) in combination with a third active drug from one of the following classes: non-nucleoside reverse transcriptase inhibitor (NNRTI), protease inhibitor (PI; boosted with ritonavir or cobicistat), or an integrase strand transfer inhibitor (INSTI).

Selection of a regimen should be individualized based on virologic efficacy, potential adverse effects, pill burden, dosing frequency, drug-drug interaction potential, the patient's resistance test results, comorbid conditions, drug availability, and cost.  Clinicians should also discuss patient's intentions toward pregnancy and perform a pregnancy test before initiating therapy.

Recommended Initial Antiretroviral Therapy (ART) Regimen Options for Most Patients with HIV Infection

Recommended ART regimens for treatment-naive patients with HIV infection are INSTI-based, and are as follows:

  • Bictegravir/tenofovir alafenamide/emtricitabine
  • Dolutegravir/abacavir/lamivudine (only for patients who are HLA-B*5701 negative and do not have chronic hepatitis B (HBV) co-infection)
  • Dolutegravir plus  either  emtricitabine or  lamivudine, plus either  tenofovir disoproxil fumarate or tenofovir alafenamide
  • Dolutegravir/lamivudine [3]  (only if HIV RNA < 500,000 copies/mL, there is no HBV co-infection, or in cases where ART is started prior to known HIV genotype resistance testing and HBV testing) 

Long active intra-muscular cabotegravir plus rilpivirine is not currently approved as an initial ART regimen.

Considerations in Pregnancy

Prior to starting dolutegravir in patients with childbearing potential, clinicians should discuss the risk and benefits with the patient. Preliminary data from a study in Botswana raised concerns about an increased risk for neural tube defects in infants born to patients who were receiving dolutegravir at the time of conception. [4]  Further results from this study showed that the prevalence of infant neural tube defects was lower than what was reported in the preliminary data. [5, 6]   

Bictegravir should not be used in patients who are pregnant, as there is insufficient data in this population.

In all cases of patients with childbearing potential, clinicians should refer to the Perinatal HIV guidelines to help determine appropriate ART regimens during pregnancy. [7]  

Recommended Initial ART Regimens in Certain Clinical Situations

The following regimens are effective and tolerable alternatives to the ART regimens listed above, but they differ in that they have some potential disadvantages. These may include but are not limited to: contraindications in certain patient populations with co-morbid conditions or in patients who are pregnant; drug toxicity; cost; variable pill burden; or when there is less supporting data from randomized clinical trials. 

INSTI plus 2 NRTIs regimens include:

  • Elvitegravir/cobicistat/tenofovir alafenamide/emtricitabine
  • Elvitegravir/cobicistat/tenofovir disoproxil fumarate/emtricitabine
  • Raltegravir plus either  tenofovir alafenamide or  tenofovir disoproxil fumarate plus either  emtricitabine or lamivudine

NNRTI plus 2 NRTIs regimens include:

  • Doravirine/tenofovir disoproxil fumarate/lamivudine or  doravirine plus tenofovir alafenamide/emtricitabine
  • Efavirenz plus either  tenofovir disoproxil fumarate or  tenovofir alafenamide plus either  emtricitabine or lamivudine
  • Rilpivirine plus either  tenofovir disoproxil fumarate or  tenofovir alafenamide plus emtricitabine (if HIV RNA < 100,000 copies/mL and CD4 >200 cells/µL)

Boosted PI plus 2 NRTIs regimens are as follows: (boosted darunavir is generally preferred over boosted atazanavir) 

  • Darunavir/cobicistat or  darunavir/ritonavir plus either  tenofovir disoproxil fumarate or  tenofovir alafenamide plus either  emtricibatine or lamivudine
  • Atazanavir/cobicistat or  atazanavir/ritonavir plus either  tenofovir disoproxil fumarate or  tenofovir alafenamide plus either  emtricitabine or lamivudine
  • Darunavir/cobicistat or  darunavir/ritonavir plus abacavir/lamivudine (if HLA-B*5701 negative)

If abacavir, tenofovir alafenamide, and/or tenofovir disoproxil fumarate cannot be used or are suboptimal, consider one of the following regimens:

  • Dolutegravir/lamivudine (only if HIV RNA < 500,000 copies/mL, there is no HBV co-infection, or in cases where ART is started prior to known HIV genotype resistance test results and HBV test results)
  • Darunavir/ritonavir plus raltegravir twice a day (if HIV RNA < 100,000 copies/mL and CD4 cell count >200 cells/µL)
  • Darunavir/ritonavir once daily plus lamivudine
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