HIV Treatment Regimens CDC Guidelines, Adult/Adolescent 

The Centers for Disease Control (CDC) and other federal government agencies have issued several guidelines and recommendations about 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,[2, 3] summarized below.

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: nonnucleoside reverse transcriptase inhibitor (NNRTI), protease inhibitor (PI; boosted with ritonavir or cobicistat), or 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, and cost.

Recommended initial antiretroviral therapy (ART) regimen options for most patients with HIV infection

Recommended ART regimens for treatment-naive patients with HIV infection are as follows (*lamivudine may be substituted for emtricitabine or vice versa, if a non–fixed-dose NRTI combination is desired):

All regimens are INSTI-based, as follows:

• Bictegravir/tenofovir alafenamide/emtricitabine
• Dolutegravir/abacavir/lamivudine* (only for patients who are HLA-B*5701 negative)
• Dolutegravir plus either tenofovir disoproxil fumarate/emtricitabine* or tenofovir alafenamide/emtricitabine
• Raltegravir plus either tenofovir disoproxil fumarate/emtricitabine* or tenofovir alafenamide/emtricitabine

Preliminary data have raised concerns about an increased risk of neural tube defects in infants born to patients who were receiving dolutegravir at the time of conception. Healthcare providers who are prescribing postexposure prophylaxis (PEP) should avoid dolutegravir in the following female patient groups:

• Nonpregnant women of childbearing potential who are sexually active or have been sexually assaulted and who are not using an effective birth control method
• Pregnant women early in pregnancy, since the risk of an unborn infant developing a neural tube defect is during the first 28 days of pregnancy

Recommended initial regimens in certain clinical situations

The below regimens are effective and tolerable, but have potential disadvantages when compared with the regimens recommended for most people with HIV (listed above), have limitations for use in certain patient populations, or have less supporting data from randomized clinical trials. However, these regimens may be preferred in some patients. Several two-drug treatment options are available for patients who cannot safely be prescribed a combination regimen that contains two NRTIs.

Recommended regimen options in certain clinical situations are listed below (*lamivudine may substituted for emtricitabine or vice versa, if a non-fixed dose NRTI combination is desired).

INSTI plus 2 NRTIs regimens are as follows:

• Elvitegravir/cobicistat/tenofovir alafenamide/emtricitabine
• Elvitegravir/cobicistat/tenofovir disoproxil fumarate/emtricitabine

NNRTI plus 2 NRTIs regimens are as follows:

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

Boosted PI plus 2 NRTIs regimens are as follows:

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

Regimens to consider when abacavir, tenofovir alafenamide, and tenofovir disoproxil fumarate cannot be used or are suboptimal are as follows:

• Dolutegravir plus lamivudine (see information above on use of dolutegravir in nonpregnant women of childbearing potential and pregnant women early in pregnancy)
• Darunavir/ritonavir plus twice-daily raltegravir if HIV RNA < 100,000 copies/mL and CD4 cell count >200 cells/µL
• Darunavir/ritonavir once daily plus lamivudine