Initiation of ART: No Prior ART Exposure

Recommendations for Initiation of ART in Persons with Chronic Infection without Prior ART Exposure ⁽ⁱ⁾

Recommendations take into account the level of evidence, the degree of progression of HIV disease and the presence of, or high risk for, developing various types of (co-morbid) conditions.

1. ART is recommended irrespective of the CD4 count. In certain situations (i.e primary HIV infection, lower CD4 count or pregnancy), there is a greater urgency to start ART immediately
   • In persons with OIs, ART initiation may have to be deferred, see Opportunistic Infections, for ART initiation in the presence of specific OIs. For ART initiation in persons with TB, see ART in TB/HIV Co-Infection
   • A possible exception to immediate start of ART might be HIV controllers, persons with high CD4 counts and HIV-VL < 200 copies/ mL, although even in such persons ART initiation has been shown to increase CD4 count, decrease inflammation, lower the risk of clinical events and prevent HIV transmission 
   • Genotypic resistance testing is recommended prior to initiation of ART, ideally at the time of HIV diagnosis. Genotypic testing should not delay ART initiation (it may be re-adjusted after genotypic test results)
   • If ART needs to be initiated before genotypic testing results are available, it is recommended to select a first-line regimen with a high barrier to resistance, preferably a second generation INSTI or alternatively a PI/b 
   • Whether rapid, possibly same-day ART start is proposed to newly diagnosed persons or postponed until complementary assessments depends on the setting and medical circumstances, medical indications to start ART more urgently and risk of loss from care. To reduce loss to follow-up between diagnosis and ART initiation, structural barriers delaying the process should be addressed