Assessment and Diagnosis
Table 1. Indications for Initiating Antiretroviral Therapy (Updated March 2012)
Clinical Condition and/or CD4 Count
ART is indicated for all HIV-infected individuals. The strength of the recommendations is based on
CD4 count: • CD4 count < 350 cells/mm3 • CD4 count 350-500 cells/mm3 • CD4 count > 500 cells/mm3
(AI) (BIII) (AII)
ART is strongly recommended, regardless of CD4 count, in patients with the following conditions: • History of AIDS-defining illness (AI) • Pregnant womena
• Persons with HIV-associated nephropathy (AII) • Persons coinfected with HBV. (AII)
(AI)
ART should be offered to patients at risk of transmitting HIV to sexual partners (AI [heterosexual] or AIII [other transmission risk groups]) a
Table 2. Coinfections Disease
Comments
Patients initiating ART should be willing and able to commit to lifelong treatment and should understand the benefits and risks of therapy and the importance of adherence (AIII). Patients may choose to postpone therapy, and providers may elect to defer therapy, based on clinical and/or psychosocial factors, on a case-by-case basis.
For women who do not require ART for their own health, consideration can be given to discontinuing ARV drugs postpartum.
Recommendation
Hepatitis B When treatment is indicated, use an ART regimen containing either tenofovir and emtricitabine OR tenofovir and lamivudine.
Hepatitis C Consider ART regardless of CD4 count. If CD4 > 500, may defer ART until after HCV therapy. If CD4 < 200, start ART and defer HCV therapy until after CD4 increase.
Tuberculosis (TB)
The presence of active TB requires immediatea
Patient Status CD4 (cells/mm3 All
< 50 Severea Not Severe Pregnant MDR/XDR TB a
50-200 > 200
50-500 > 500 – –
(AI). • Include a rifamycin (rifabutin preferred) in regimens for patients receiving ART, with dosage adjustment if necessary (AII).
) Initiate ART
≤ 2 wks after TB Rx (AI) 2-4 wks after TB Rx (BI) 2-4 wks after TB Rx (BIII) 2-12 wks after TB Rx (AI) 2-12 wks after TB Rx (BIII) As early as feasible (AIII)
2-4 wks after confirmed Dx of resistance and initiation of 2nd-line TB therapy (BIII)
By clinical evaluation (including low Karnofsky score, low body mass index [BMI], low hemoglobin, low albumin, organ system dysfunction, or extent of disease)
1 initiation of treatment
