Synopsis
Select and monitor complete combination antiretroviral therapy, prevent interaction and resistance failure, preserve hepatitis B treatment and respond systematically to detectable viral load.
- ART uses a complete combination that blocks at least two viral replication targets; never prescribe HIV monotherapy.
- An integrase inhibitor with two nucleoside or nucleotide agents is a common initial strategy, but resistance, hepatitis B, pregnancy, renal function and interactions determine the exact regimen.
- Take a baseline resistance genotype and viral load, but rapid treatment usually begins before every result returns and is modified if necessary.
- Explain the exact tablet schedule, food requirement, missed-dose plan and interaction separation before the first dose.
- Check all prescribed, over-the-counter, recreational and complementary substances through a current HIV interaction resource.
- Measure viral load after starting or changing ART and continue until suppression; viral load is the main marker of treatment success.
- Do not switch away from two active hepatitis B agents without a deliberate HBV treatment and liver-monitoring plan.
- Investigate confirmed rebound with adherence and resistance testing while the failing regimen still provides interpretable selective pressure.
Key red flags
Never rechallenge abacavir after suspected hypersensitivity because recurrence can be rapidly fatal.
Stopping tenofovir plus emtricitabine or lamivudine in hepatitis B can precipitate a severe hepatic flare.
A newly detectable viral load requires adherence, interaction and resistance assessment before empirically adding one drug.
Rifampicin, anticonvulsants, polyvalent cations and acid suppressants can make an otherwise potent regimen fail.
Pregnancy with detectable viral load, vomiting or missed treatment needs same-day HIV maternity review.
Severe rash with mucosal, liver or systemic involvement requires urgent drug-reaction assessment.
Fever, rash, gastrointestinal or respiratory symptoms after abacavir or systemic mucosal disease with another agent needs urgent cessation planning.
A confirmed rising viral load after previous suppression suggests adherence interruption, interaction, absorption problem or resistance.
Inflammatory deterioration after starting ART may unmask tuberculosis, cryptococcus or another infection despite virological improvement.
Investigation priorities
Quantify response after initiation or switch and detect loss of suppression.
Management branches
ART is starting or a planned switch is being considered.
- Review resistance, viral load, CD4, hepatitis B, HLA-B*57:01, kidney, liver, pregnancy, tuberculosis and previous ART.
- Choose an approved complete regimen with at least two fully active components and a high resistance barrier when uncertainty exists.
- Check every medicine and supplement for interactions and document food and polyvalent-cation instructions.
- Take baseline safety tests, agree adherence supports and prescribe enough supply to prevent avoidable interruption.