Synopsis
Choose and use complete ART through shared decisions, interpret viral-load change, and manage interactions, toxicity, pregnancy and HBV without sacrificing suppression.
- Treat HIV with a complete combination acting at two or more replication steps; a single antiretroviral drug is not HIV therapy.
- An integrase inhibitor plus two nucleoside or nucleotide agents is a frequent starting framework, but resistance, HBV, pregnancy, kidney function and interactions decide the actual regimen.
- Obtain baseline viral load and genotype, while allowing prompt complete treatment to begin before every result is back when clinically appropriate.
Key red flags
Suspected abacavir hypersensitivity makes abacavir permanently contraindicated; re-exposure can provoke a faster and potentially fatal reaction.
Removing tenofovir with emtricitabine or lamivudine from a patient with chronic HBV can unleash viral rebound and severe hepatitis.
A newly detectable HIV viral load needs confirmation plus adherence, supply, absorption and interaction assessment before a resistance-informed regimen change.
Rifamycins, enzyme-inducing anticonvulsants, acid suppression and polyvalent cations can reduce particular antiretroviral exposures enough to jeopardise control.
Pregnancy with missed treatment, persistent vomiting or detectable viraemia requires same-day review by the HIV maternity team.
Rash accompanied by mucosal injury, fever, hepatitis or systemic compromise demands urgent assessment for a serious drug reaction.
Fever, rash, respiratory or gastrointestinal features after abacavir, or mucosal and organ involvement with any agent, requires urgent expert action.
Repeat detectable viraemia after previous suppression directs attention to supply, dosing, absorption, interaction and resistance rather than an automatic empiric add-on.
Clinical deterioration despite a falling viral load can reveal immune restoration around an occult or recently treated infection and needs syndrome-specific review.
Investigation priorities
Determine whether a new regimen suppresses replication and whether control remains durable.
Management branches
A person with confirmed HIV is ready to begin ART.
- Gather genotype, viral load, CD4, HBV status, HLA-B*57:01, organ function, pregnancy context, prior ART and tuberculosis treatment.
- Select a complete guideline-supported combination whose components remain active, using a high resistance barrier when uncertainty is material.