Infectious Diseases · Pathway 4
HIV: Anti-Retrovirals
Key points
- CURRENT UK PRACTICE (BHIVA adult HIV-1 treatment guidelines 2022, 2025 interim update): ART is offered to EVERYONE living with HIV regardless of CD4 count. The term 'HAART' and the old 'two NRTIs plus a PI or NNRTI' framework are HISTORICAL.
- PREFERRED FIRST-LINE: tenofovir (tenofovir DF or tenofovir alafenamide) WITH lamivudine or emtricitabine, PLUS one of — DOLUTEGRAVIR, BICTEGRAVIR or boosted DARUNAVIR. Integrase strand transfer inhibitors (INSTIs) are the usual third agent.
- TWO-DRUG option: dolutegravir plus lamivudine is a first-line regimen; the 2025 interim update REMOVED the previous CD4 caveat on its first-line use. Long-acting injectable cabotegravir plus rilpivirine is an option in selected people.
- NO LONGER first-line (2025 interim update): ABACAVIR was removed from first-line for most people, with a recommendation to switch away from it where clinically appropriate. Also not first-line: atazanavir/ritonavir, efavirenz, rilpivirine and elvitegravir/cobicistat.
- Resistance: standard genotypic resistance testing (reverse transcriptase and protease) in ART-naive individuals; baseline INTEGRASE resistance testing in addition if major mutations to other classes are found or transmitted integrase resistance is suspected. Review ART at least annually; switching from a PI to an INSTI or NNRTI is advised where clinically appropriate.
- In pregnancy or when planning conception, follow the BHIVA pregnancy guidelines rather than the adult treatment guidelines.
- maraviroc, enfuvirtide
- prevent HIV-1 from entering and infecting immune cells by blocking CCR5 cell-surface receptor Nucleoside analogue reverse transcriptase inhibitors (NRTI)
- NRTI examples — in CURRENT UK use: tenofovir DF, tenofovir alafenamide, emtricitabine, lamivudine (abacavir is no longer first-line for most). HISTORICAL, retained for mechanism and adverse-effect questions only and NOT current first-line therapy: zidovudine (AZT), didanosine, stavudine, zalcitabine.
- general NRTI side-effects: peripheral neuropathy