Initial HIV treatment, genotypic viral testing, when to start ART.

[DrMetal]

In the newly diagnosed HIV, say otherwise asymptomatic, normal CD4, etc, I know you're supposed to get genotypic viral resistance testing first to guide your ART.

But you really wait for this to come back before beginning treatment? Say it's a send out lab, takes 2 weeks to come back at your home institution.

Would you let that 25-yo walk out of your clinic with no ART? Or would you rather start something now, then tailor it later after the resistance testing results?

---

Members don't see this ad.

 

[QualityProcess]

as long as the patient doesn't have a contraindication like certain oppo infections or drug interaction, one of the typical starting regimens should be started, and can be adjusted later if indicated. I think the reasoning behind this is that resistance to the starting therapy is not as threatening as risk of being lost to follow up, but I could be mistaken. the higher the cd4 count when they start, the higher they can go when therapy is in full swing

 

[Jaundice101]

Like QualityProcess said, the risk of being lost to follow up greatly outweighs the risk of transmitted resistance in most cases. This is what the NIH recommends in their regularly updated HIV treatment guidelines. Thankfully most resistance mechanisms seem to come with a fitness cost which reduces the virus's transmissibility.

 

[OsteopathicThirdLeg]

Usually you want to start treatment asap to smash the viral load to the undetectable range to prevent transmission. The new movement within HIV medicine is to screen everyone and get positive people on ART. This, ideally, will kill off the virus for good, ideally.

The only time you would not start ART immediately is if you have concern that the patient will be non-compliant. This increases the risk of ART resistance.

Baseline resistance panels are to see if patients have a wildtype (art sensitive) virus or are unlucky to get a resistant bug.

 

[DrMetal]

In the setting of newly diagnosed HIV + some other active unrelated infection (say a bad strep throat, fevers, pharnygitis, etc...or a diverticulitis), you're NOT supposed to start ART right away, right? for fear of IRIS? (UpToDate)

You're supposed to treat the current infection, then start ART after it subsides, right?

 

[InternistDO]

In the setting of newly diagnosed HIV + some other active unrelated infection (say a bad strep throat, fevers, pharnygitis, etc...or a diverticulitis), you're NOT supposed to start ART right away, right? for fear of IRIS? (UpToDate)

You're supposed to treat the current infection, then start ART after it subsides, right?

I believe you only hold ART for crypto and TB, everything else you can start ART simultaneously with treatment of the other infection. This is just what I remember from my ID rotation though.

 

[DrMetal]

I believe you only hold ART for crypto and TB, everything else you can start ART simultaneously with treatment of the other infection. This is just what I remember from my ID rotation though.

That's what I recall too. But in practice, at least in the inpatient setting (where the patient was admitted for something else, PNA, osteo, whatever), I've seen lots of IDs defer starting ART until they follow up in clinic after the admission.