IM6.13-17 | HIV Treatment and Prophylaxis — Summary & Reflection

KEY TAKEAWAYS

ART initiation: Start ART for all PLHIV ('Treat All'). Timing exceptions: TB co-infection (start within 2 weeks if CD4 <50, within 8 weeks otherwise; except TB meningitis — defer 8 weeks); cryptococcal meningitis (defer 4–6 weeks to reduce IRIS risk).

NACO first-line regimen: TLD = TDF 300 mg + 3TC 300 mg + DTG 50 mg once daily. Monitor renal function (TDF), use with caution in early pregnancy (DTG).

Drug classes: NRTIs (TDF, 3TC, AZT — chain terminators); NNRTIs (EFV, NVP — allosteric reverse transcriptase inhibition, low genetic barrier to resistance); INSTIs (DTG — integrase inhibition, high resistance barrier); PIs (LPV/r, ATV/r — protease inhibition, boosted with ritonavir/cobicistat, high resistance barrier); Entry inhibitors (maraviroc — requires tropism testing).

IRIS: Paradoxical or unmasking; 2–12 weeks after ART start; rising CD4 + falling viral load; most common with TB and Cryptococcus. Management: CONTINUE ART; NSAIDs (mild) or prednisolone 1 mg/kg/day (severe).

PEP: Start within 72 hours (ideally <2 hours); TDF + 3TC + DTG × 28 days; retest HIV at 6 weeks and 3 months.

PrEP: TDF + FTC daily for high-risk HIV-negative individuals; monitor HIV test and renal function every 3 months.

OI prophylaxis: Co-trimoxazole DS daily at CD4 <250 (NACO); IPT (INH + pyridoxine) for all PLHIV without active TB; CrAg screen at CD4 <100 → pre-emptive fluconazole if CrAg+; MAC prophylaxis (azithromycin) at CD4 <50 in selected patients.

GI diarrhoea management: Cryptosporidium → ART (no specific antibiotic); Isospora → TMP-SMX; MAC → ART + clarithromycin + ethambutol; CMV colitis → ganciclovir/valganciclovir.

REFLECT

Return to the three patients from the opening hook. Patient one (CD4 180, no active OI) — you now know: start ART immediately (no OI to defer for; CD4 185 = co-trimoxazole prophylaxis indicated; IPT indicated after excluding TB). Patient two (nurse with needlestick, 6 hours post-exposure) — start TDF + 3TC + DTG immediately, baseline HIV test, 28 days, retest at 6 and 12 weeks. Patient three (worsening CXR 4 weeks after ART, CD4 rising) — paradoxical TB-IRIS, continue both ART and anti-TB therapy, add prednisolone if severe. Now reflect on the broader picture: in India, every district hospital should have these three capabilities — immediate PEP availability, ART initiation on the same day as diagnosis, and co-trimoxazole prophylaxis as a standard prescription for all newly diagnosed PLHIV with CD4 <250. How does this compare to the reality of the setting you are most likely to work in? What systemic barriers exist, and what is your individual clinical responsibility within those constraints?