HIV - ART Revisited 2024 Med - Guidelines - SP

HIV and ART Revisited 2024
Prof Rai Mra

Prof Htun Lwin Nyein
Prof Sabai Phyu
24th March 2024
“Knowledge that is not shared is lost
forever”
2
Knowledge shared = Knowledge
Knowledge shared is Knowledge squared

Recommended rapid test kits for 3-assay HIV
Testing Strategy
A1 = Alere Determine HIV-1/2 (D) ICT (sensitivity 100% and specificity
99.75% ) .
A2 = Uni-Gold HIV (UG) ICT (sensitivity 100% and specificity 100 %)

A3 = HIV 1/2 STAT-PAK (SP) ICT (sensitivity 99% and specificity 100 %)
All 3 tests must be positive to say HIV positive

Testing algorithm for HIV screening and diagnosis
WHO recommendation on HIVST - 2019
 Safe and accurate

 Highly acceptable
 Increased access
 Increased uptake and
frequency of HIV testing
among those at high risk
and who may not test
otherwise
 Comparable linkage and
HIV+
 Empowering
 Can be affordable and cost-
effective when focused
Retesting prior to enrollment in care
 Retest all clients diagnosed HIV-positive with a second
specimen and preferably second operator using the same
testing strategy and algorithm before initiating ART.
 Retesting people on ART is not recommended, as there are
potential risks of incorrect diagnosis
Clinical Presentation –
 Asymptomatic – found out to be HIV positive on
screening for job or to go
overseas,
pregnancy, surgery
 Opportunistic infections - late cases  Prolonged fever
 Weight loss
 Chronic diarrhoea
 Oral thrush
 Herpes zoster
 Lymphadenopathy
 Pruritic dermatitis
Most common opportunistic
infections
Tuberculosis – Imunity
• Pulmonary
• lymphadenopathy
• Extrapulmonary
• Disseminated TB
• TB meningitis
• atypical TB
• Non-reactive TB
• Gene X-pert
• 2nd generation Urinary
LAM
Pneumocystis jiroveci pneumonia
•Bilateral diffuse symmetric finely granular / reticular interstitial / airspace

infiltrates in 80%
o Characteristic central location
o Rapid progression to diffuse airspace disease
§ Resembles non-cardiogenic pulmonary edema
Cerebral Toxoplasmosis
Cryptococcal Meningitis
Cryptococcaemia
Lumbar puncture available No lumbar puncture available or

contraindicated
Rapid cryptococcal antigen test CSF cryptococcal antigen Serum, plasma or whole blood
available (preferably lateral flow assay) cryptococcal antigen (preferably
lateral flow assay or latex
agglutination assay), treat
immediately and refer for further
investigation
No rapid cryptococcal antigen test CSF India ink Prompt referral for further
available investigation
Talaromyces (Penicillium)
marneffei
Histoplasmosis
In skin and bone marrow
Secondary syphilis rash
in palms and soles
Primary Brain Lymphoma in HIV patient
Cervical cancer
HIV HPV
Kaposi’s sarcoma
Pictures by Prof Sabai Phyu
When to start ART in adults and
adolescents
 Initiate ART in all adults living with HIV, regardless of WHO
clinical stage and at any CD4 cell count.
 As a priority, initiate ART in all adults with severe or advanced

HIV clinical disease (WHO clinical stage 3 or 4) and adults with
a CD4 count ≤350 cells/mm3
Timing of ART for adults and children with
TB
 Initiate ART in all TB patients living with HIV regardless of CD4 count.
 TB treatment should be initiated first, followed by ART as soon as possible

within the first 2 weeks of treatment, in particular HIV-positive TB patients
with profound immunosuppression (e.g. CD4 counts less than 50 cells/ mm3).
 ART should be started in any child with active TB disease as soon as possible
and within 2 weeks following the initiation of anti-tuberculosis treatment
regardless of the CD4 cell count and clinical stage.
Timing of ART for adults and children with
cryptococcal meningitis
 Immediate ART initiation is not recommended for adults,
adolescents and children living with HIV who have cryptococcal
meningitis because of the risk of increased mortality and should
be deferred by 4–6 weeks from the initiation of antifungal
treatment
First-line ART for adults and adolescents
Recommended regimen:
 TDF + 3TC (or FTC) + DTG
[ Tenofovir DF + Lamivudine/Emtricitabine + Dolutigravir ]
Alternative first line regimen:
 TAF + 3TC (or FTC) + DTG [ Tenofovir AF + Lamivudine/Emtricitabine +
Dolutigravir ]
 ABC + 3TC + DTG [ Abacavir + Lamivudine + Dolutigravir ]
 TDF + 3TC (or FTC) + EFV low dose (400mg) as a fixed-dose combination
[ Tenofovir DF + Lamivudine/Emtricitabine + Efavirenz 400 mg }
Integrase strand transfer inhibitors –
• Raltigravir
Integrase • Dolutegravir
• Bictegravir
• Carbotegravir inj
Dolutegravia –
 Highly potent, OD dose
 Superior resistance profile
 Low drug-drug interaction
 Favourable safety profile
 Favoured first line drug in current
guidelines
First-line ART for pregnant and
breastfeeding women
• Preferred regimen: TDF + 3TC (or FTC) + DTG as a fixed-dose
combination
• Alternative first line regimen:
 TAF + 3TC (or FTC) + DTG
 ABC + 3TC + DTG
 TDF + 3TC (or FTC) + EFV low dose (400mg) as a fixed-dose combination
Lab monitoring before and after initiating
ART
Routine viral load monitoring - at 6 months of ART, at 12 months of ART and then every
12 months if the patient is stable on ART.
 In settings where routine viral load monitoring is available, CD4 cell count monitoring
can be stopped in individuals who are stable on ART and virally suppressed.
(WHO defines people stable on ART according to the following criteria: on ART for at
least 1 year, no current illness or pregnancy, good understanding of lifelong adherence
and evidence of treatment success)
Viral load is recommended as the preferred monitoring approach to diagnose and
confirm treatment failure.
Viral failure is defined by a persistently detectable viral load exceeding 1000 copies/ml
(that is, two consecutive viral load measurements within a 2-3 month interval, with
adherence support between measurements) after at least 6 months of starting a new
ART regimen.
WHO guidelines for virological failure
23 – 26 July · Brisbane and virtual ias2023.org

Preferred second line ART regimen
Failing first line regimen Second line regimen
TDF (or ABC ) + 3TC (or FTC) + DTG AZT+ 3TC + LPV/r (or ATV/r)
TDF (or ABC ) + 3TC (or FTC) + EFV AZT +3TC + DTG
(or NVP)
AZT + 3TC +EFV (or NVP) TDF (or ABC ) + 3TC (or FTC) + DTG
Long-acting ART
Carbotegravia –rilpivirine
• LA injectable formulations of CAB and RPV approved for
virologically suppressed HIV-infected patients ≥18 years of
age with oral CAB/RPV lead-in and monthly injections
Lanacapavia-islatravia
• Oral once weekly regimen ( Lanacapavia – capsid inhibitor;
Islatravia – NRTTI )
• Lanacapavir inj 2/year plus other ARVs for drug resistant cases
Prophylaxis of Opportunistic Infections
WHO-recommended four-symptom screen for TB :
 At ART centers, all PLHIV are screened for TB at every

visit, using the 4-symptom (4S) complex which includes -
1. cough of any duration
2. fever
3. weight loss, and
4. night sweats among adults.
TB prophylaxis/ TB preventive treatment TPT –
 Isoniazid and Rifapentine weekly for 3 months)
 After exclusion of active TB
12 Dose Regimen ( 3 HP ) for Latent TB infection Treatment–
Short course weekly combination regimen of once weekly isoniazid –
rifapentine for 12 weeks .
Co-trimoxazole prophylaxis is
recommended for adults (including
pregnant women) with severe or
advanced HIV clinical disease
(WHO stage 3 or 4) and/or with a
CD4 count of ≤350 cells/mm3.
Prophylaxis for cryptococcal meningitis
 Screeningc for cryptococcal antigen followed by pre-
emptive antifungal therapy
 To prevent the development of invasive cryptococcal
disease - recommended before initiating or reinitiating
ART for people with HIV with CD4 cell count <100
cells/mm3.
 When cryptococcal antigen screening is not available,
fluconazole primary prophylaxis should be given to adults
and adolescents living with HIV who have a CD4 cell
count <100 cells/mm3.
Fluconazole 200 mg 3/wk or 400 mg once /week

PrEP
Daily PrEP
Long-acting injectable cabotegravir
(CAB-LA)
 Long-acting injectable cabotegravir (CAB-LA) may be offered
as an additional prevention choice for people at substantial
risk of HIV infection as part of combination prevention
approaches Dose of 600 mg, intramuscularly, four weeks apart
for the first two injections and every eight weeks thereafter.
In persons taking HIV PrEP, doxycycline
PEP reduced syphilis by 87% and
chlamydia by 88% while reductions of
77% in syphilis and 74% in chlamydia
were observed for PLHIV.
Post-exposure prophylaxis
A regimen for post-exposure prophylaxis for HIV with two drugs is
effective, but three drugs are preferred.
 Post-exposure prophylaxis ARV regimens for adults and
adolescents:
 Preferred backbone regimen: TDF + 3TC (or FTC)

 Preferred third drug: DTG
 Alternative third drug options: ATV/r, DRV/r, LPV/r and RAL
A full 28-day prescription of antiretroviral drugs should be
provided for HIV post-exposure prophylaxis following initial risk
assessment.
MULTIMORBIDITIES IN HIV
HIV-
ART-
COINFECTIONS-
LIFESTYLE ASSO
COMORBIDITIES-
NCDs-
POLYPHARMACY-
AGING.
Guideline Recommendations on ART and
Weight Gain
• “Significant weight gain may occur IAS-USA Recommendations3
with all ARV regimens, but it appears • Document weight and BMI at
to be more pronounced with DTG, baseline and Q6M
BIC, and TAF”1 • Counsel on possibility of weight gain
• “ARV-associated weight gain should and potential cardiometabolic
be a factor to consider when initiating complications
or changing ART, particularly in Black • Perform yearly diabetes screening
women”2 and assessment of CV risk score of
patients receiving INSTI-based ART
• “To date, it remains unclear whether • Recommend lifestyle changes in
switching to a non-INSTI–based people living with HIV who gain
regimen results in the reversal of >5% body weight
weight gain”2
1. DHHS pediatric ART guidelines. April 2022. 2. DHHS adult and adolescent ART guidelines. June 2021. 3. Gandhi. JAMA. 2023;329:63.
HIV mRNA Vaccine ?
• HIV virus mutation rate v v high
• Millions of HIV strains
• No natural occurring immunity
• Rarely HIV produces Broadly
Neutralizing Antibodies after a
long time.
• Hope to induce specialized B cells
to produce these bNAbs
• HIV vaccine not seen in near future
Monday, March 14, 2022

NIH launches clinical trial of three mRNA HIV
vaccines

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HIV and ART Revisited 2024

Prof Rai Mra

Knowledge shared is Knowledge squared

A2 = Uni-Gold HIV (UG) ICT (sensitivity 100% and specificity 100 %)

All 3 tests must be positive to say HIV positive

 Safe and accurate

•Bilateral diffuse symmetric finely granular / reticular interstitial / airspace

Lumbar puncture available No lumbar puncture available or

 As a priority, initiate ART in all adults with severe or advanced

 TB treatment should be initiated first, followed by ART as soon as possible

• Alternative first line regimen:

 TAF + 3TC (or FTC) + DTG

 ABC + 3TC + DTG

23 – 26 July · Brisbane and virtual ias2023.org

 At ART centers, all PLHIV are screened for TB at every

Fluconazole 200 mg 3/wk or 400 mg once /week

 Preferred backbone regimen: TDF + 3TC (or FTC)

Monday, March 14, 2022

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