Acute and early HIV infection: Treatment

Official reprint from UpToDate® www.uptodate.com

©2021 UpToDate®

Acute and early HIV infection: Treatment

Author: Paul E Sax, MD
Section Editor: Rajesh T Gandhi, MD, FIDSA
Deputy Editor: Jennifer Mitty, MD, MPH

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Sep 2021. | This topic last updated: Jan 21, 2020.

INTRODUCTION

The first description of acute HIV infection, a "mononucleosis-like" illness, based upon the
clinical records of 12 men with documented seroconversion to HIV during the preceding
six months, was published in 1985 [1]. Since then, the early period following acquisition of
HIV has been a subject of tremendous clinical and research interest, yet many challenges
remain in its diagnosis, management, and impact on public health.

Difficulties in identifying patients with early HIV infection have hindered the performance
of trials to evaluate the long-term clinical benefits of initiation of antiretroviral therapy
during this stage of infection. Thus, decisions for treatment initiation during this period
must balance the potential benefits based on indirect evidence, including effects on
surrogate markers, and the potential risks of earlier therapy. In addition, the general trend
in treatment guidelines in favor of treating all individuals with HIV influences the approach
in early infection toward treatment [2].

The treatment of early HIV infection will be reviewed here. The pathogenesis,
epidemiology, clinical manifestations, and diagnosis of acute and early infection with HIV
are discussed separately. (See "Acute and early HIV infection: Pathogenesis and
epidemiology" and "Acute and early HIV infection: Clinical manifestations and diagnosis".)

DEFINITIONS

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Acute and early HIV infection: Treatment

Different terms, including acute, recent, primary, and early HIV infection, have been used
in the literature to refer to variable intervals following initial infection with the virus. In this
topic, we use the term "early HIV infection" to refer to the approximate six-month period
following HIV acquisition. We use the term "acute HIV infection," to refer to symptomatic
early infection, as this reflects common usage in clinical care.

INITIATING ANTIRETROVIRAL THERAPY DURING EARLY HIV INFECTION

For patients with HIV, a growing body of evidence from trials and large observational
studies that demonstrate a reduction in AIDS and non-AIDS morbidity and mortality with
antiretroviral therapy (ART) across a wide range of CD4 cell counts has led to the
recommendation for ART initiation regardless of CD4 cell count. (See "When to initiate
antiretroviral therapy in persons with HIV", section on 'Rationale for universal treatment'.)

However, because of difficulties in identifying patients with early infection, there are fewer
clear data on the clinical long-term benefits of initiating treatment during this particular
stage of HIV infection. Thus, most of the rationale for initiating treatment in early HIV
infection is extrapolated from indirect evidence, theoretical benefits, and effects of ART on
surrogate markers of HIV disease progression (ie, CD4 cell count and HIV RNA). The
decision to initiate antiretroviral therapy in early infection must balance these potential
benefits with the potential risks of ART.

Our approach — As with patients with established HIV, we recommend that all patients
with acute or early HIV initiate ART because the potential benefits to the individual and to
public health outweigh the possible drawbacks of earlier ART. Individuals with acute
symptomatic infection, in particular, may be at greatest risk of delaying therapy given the
association between symptomatic disease and more rapid progression, and our
recommendation to start therapy is thus stronger for this group.

Our approach is consistent with recommendations from expert guidelines in United States
[2,3]. For resource-limited settings, the World Health Organization does not make specific
recommendations regarding identification or treatment of acute or early HIV but does
recommend ART initiation rapidly (within days of diagnosis) for patients at any CD4 cell
count [4,5]. Links to these and other expert guidelines can be found elsewhere. (See
'Society guideline links' below.)

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Rationale for initiation of ART in early infection

Effect on symptomatic disease — The presence and severity of symptoms during early
HIV infection appear to portend more rapid disease progression [6-8]. As an example, in a
study of 218 female sex workers with well-documented dates of HIV seroconversion based
on longitudinal screening, in the absence of HIV treatment, each additional symptom
present at the time of acute infection was associated with an increasing risk of overall
mortality after a median follow-up of 4.6 years [8]. Thus, those with acute symptomatic HIV
infection may represent a subset of patients in whom earlier initiation of ART would be
more likely to confer improvement in morbidity and mortality that would thus outweigh
potential risks.

Additionally, because symptoms of acute HIV infection are thought to be related to the
high level of circulating virus, either through direct effect or indirectly through the immune
response to viral infection, early treatment with ART, through rapid reduction in the HIV
RNA level, may be able to attenuate the severity of symptoms. However, there are no
clinical data that clearly demonstrate this theoretical effect.

Improved clinical markers of disease — As in chronic infection, ART is effective in

suppressing serum viral RNA levels and increasing CD4 cell counts in the vast majority of
patients with acute and early HIV infection. As an example, in a prospective longitudinal
study of 102 patients infected with HIV within the preceding 12 months who initiated ART,
97 percent achieved undetectable viral levels at a median of 11 weeks, and 66 of 72
patients (92 percent) maintained virologic suppression at 18 months [9]. The CD4 cell count
increased from a mean nadir of 422 cells/microL to a mean of 702 cells/microL.

Furthermore, initiation of ART earlier after initial HIV infection is associated with a greater
chance of immune reconstitution to normal or near normal CD4 cell levels. In a prospective
study of predominantly White men with a well-estimated date of HIV infection, a peak in
the CD4 cell count at four months after infection followed by a progressive decline was
observed in the absence of ART [10]. Among the 97 patients who initiated ART within that
four-month window, the likelihood and rate of CD4 cell count recovery were both greater
compared with the 116 patients who initiated ART at a later time (64 versus 34 percent
achieved a CD4 cell count >900 cells/microL by 48 months of ART and at a median of 3.8
versus 15.2 months after ART initiation, respectively). CD4 cell count recovery to this
threshold was also more likely and rapid in patients who initiated therapy at a baseline CD4

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cell count greater than 500 cells/microL versus less than 500 cells/microL. Although
patients treated within four months of infection had higher average CD4 cell counts at
initiation than those treated later, in multivariate analyses, initiation of ART earlier and at a
higher CD4 cell count each remained independent predictors of CD4 cell count recovery.

Limitations of this observational study include heterogeneity between the two groups (ie,
there were a greater number of non-White patients in the group who initiated ART later),
the possibility that those treated earlier may have had other unspecified clinical
characteristics that would have impacted CD4 cell count recovery, and the lack of clinical
end-points. Nevertheless, the results support the concept that earlier treatment following
HIV acquisition is associated with improvements in an important surrogate marker of HIV
disease.

Interval until treatment criteria are met is short — With mounting data
demonstrating benefits of ART for chronically infected HIV patients at increasingly higher
CD4 cell counts, the interval following initial infection until the CD4 cell count declines to a
threshold at which there is clinical evidence for a benefit with ART is likewise relatively
short. Data from controlled trials and observational studies suggest that initiation of ART in
chronically infected patients with CD4 cell counts greater than 350 cells/microL and even
greater than 500 cells/microL decreases AIDS-related events and improves survival [11-16].
These data are discussed in greater detail elsewhere. (See "When to initiate antiretroviral
therapy in persons with HIV", section on 'Rationale for universal treatment'.)

The time to reach these CD4 cell count levels following HIV acquisition appears relatively
short. In one study of patients acutely infected with HIV, the probability of having a CD4
cell count less than 500 cells/microL was 0.57, 0.72, 0.79 and 0.84 at baseline, two, four,
and six years [17]. Similarly, in a large prospective study of patients with well-estimated
dates of HIV infection (the Concerted Action on Seroconversion to AIDS and Death in
Europe, or CASCADE cohort), the estimated median time from infection to CD4 cell count
decline to <500 cells/microL was 1.19 years [18]. Even if lower CD4 cell count thresholds are
used, the time to meeting them may also be relatively short. As an example, one trial
evaluating treatment of patients with early HIV infection was halted prematurely because a
considerable proportion of the 40 patients randomly assigned to delay ART required ART
initiation within the trial period; specifically, 28 and 50 percent at 36 and 72 weeks,
respectively, reached a CD4 cell count <350 cells/microL [19].

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Thus, patients with early HIV who start therapy would likely not have a significant excess of
ART exposure compared with deferring therapy until CD4 cell counts decline to a level at
which ART has been demonstrated to provide clinical benefit. A limitation to these data is
that they largely focus on individuals who are diagnosed with early HIV infection after
presenting with acute symptoms and thus focus on a population likely to have a more
rapid CD4 decline.

Decreased risk of transmission — Early HIV infection is associated with high levels of
HIV RNA and a corresponding high risk of viral transmission [20,21]. Although the
estimated contribution of early HIV infection to new infections within a community differs
by population studied and model used, in some cases, up to 50 percent of new infections
are thought to be transmitted from acutely infected individuals [20,22-27]. (See "Acute and
early HIV infection: Pathogenesis and epidemiology", section on 'Infectivity'.)

No clinical trials have directly assessed the effect of treatment of early HIV infection on
subsequent transmission rates. However, data from studies of chronically infected patients
demonstrates that reduction of viral load through effective ART substantially reduces
transmission to uninfected sexual partners [15] (see "HIV infection: Risk factors and
prevention strategies"). It is reasonable to assume that a reduction in transmission risk
would similarly occur with lowering and suppressing viral RNA level through ART in
patients with early HIV infection.

Decreased viral reservoir and improved markers of immune cell function and
activation — Several studies have suggested that ART initiated early during HIV infection
can lead to improvements in the ability of immune cells to control the virus and limit the
size of the cellular viral reservoir, which contributes to the persistence of infection despite
active ART [28-35].

In a study of young men who have sex with men (MSM) diagnosed with early HIV infection,
levels of CD4 and CD8 cell activation (which are associated with chronic inflammation)
decreased to a greater extent following ART initiation among 34 patients who initiated ART
early compared with 32 patients who waited at least two years to initiate ART [30]. Early
ART was also associated with lower HIV DNA and RNA cellular reservoir sizes. Even among
those treated during early infection, the effect on HIV viral reservoirs may be greatest
among those treated the earliest. In a study of 68 patients who were initiated on ART
during very early HIV infection (prior to the development of a positive Western Blot), the

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quantity of HIV DNA integrated into long lasting peripheral blood mononuclear cells, and
central memory CD4 cells was lowest at the time of diagnosis among those diagnosed the
earliest after infection (prior to the development of detectable HIV antigen and reactive
HIV antibody) [31]. After 24 weeks of ART, nearly all participants had undetectable levels of
HIV DNA in peripheral blood mononuclear cells. Other studies have suggested that ART in
early infection leads to more rapid declines in cellular viral reservoirs compared with
treatment in chronic infection [28,29,33].

Furthermore, there is evidence that the effect of early ART on the latent reservoir occurs
early and increases over time. As an example, in a study of 80 individuals with early HIV
infection, initiation of early ART (mostly within the first two weeks of infection) was
associated with total HIV DNA levels that were 20-fold lower at two weeks following
initiation than in those who had no ART and over 300-fold lower levels three years later
[36].

In addition, initiation of ART during acute infection appears to preserve HIV-specific T cell
function that would otherwise deteriorate [37,38]. Markers of B cell dysfunction and
apoptosis that are seen in chronic infection appear during early HIV infection and can also
be reversed with early ART initiation [39].

Early ART may also have an effect on the chronic immune activation that occurs in the
central nervous system of patients with HIV. In a group of 89 patients with acute HIV
infection who underwent cerebrospinal fluid (CSF) sampling, levels of CSF immune
activation markers returned to normal at 24 weeks and remained normal at 96 weeks after
ART was initiated [40].

Whether restriction of the viral reservoir and changes in markers of immune function or
activation translate into clinical benefits is as yet unclear. Nevertheless, these observations
have continued to fuel interest in to potential of early ART to alter the natural history of
HIV disease such that ART may not have to be continued indefinitely or other cure
strategies may be more effective. Studies evaluating this theory are discussed in more
detail below. Of note, treatment interruption strategies are not recommended at any stage
of HIV infection; hence these studies are summarized primarily because of the lessons
learned about this distinctive population with recently acquired HIV. (See 'Can ART in early
infection alter disease course?' below.)

Potential risks — One concern for initiating ART during early infection, when the rate of
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viral replication is particularly rapid, is that suboptimal adherence could more readily lead
to the evolution of drug resistance mutations. However, there is no clinical evidence that
resistance is more likely to occur in patients treated during early HIV infection than with
long-established disease. Nevertheless, commitment to strict adherence if treatment is
initiated at this time is important.

Additionally, although current antiretroviral options have more favorable side effect
profiles than their predecessors, concerns about toxicities with the long-term use of ART
remain, including the metabolic risks of protease inhibitors and the effect of tenofovir on
bone density and renal function. However, whether delaying ART until criteria for
treatment in chronic infection are met would attenuate these risks is unknown.
Furthermore, the current trend towards initiating ART at higher CD4 cell counts minimizes
the amount of ART exposure that a patient would be spared by deferring treatment until
those criteria are met, as above. (See 'Interval until treatment criteria are met is short'
above.)

MANAGEMENT OF EARLY HIV INFECTION

Prompt treatment — We agree with the United States Department of Health and Human
Services guidelines that recommend initiation of antiretroviral therapy (ART) as soon as
possible following the diagnosis of acute and early HIV infection [2]. Patients should ideally
be referred to a provider with experience in HIV management.

If resources allow, initiation of ART on the same day of diagnosis, even in the setting of
acute or early HIV infection, can be a safe and effective treatment strategy. One study
evaluated a program model that linked newly diagnosed individuals to immediate care by
providing a same-day visit with an HIV provider, starter packs for an antiretroviral regimen,
accelerated insurance approval protocols for medications, and telephone follow up [41].
This rapid care model was well received by patients, most of whom had acquired HIV
infection within the six months prior to diagnosis, and was associated with a more rapid
time to virologic suppression without major adverse effects.

We also offer all patients with early HIV the opportunity to participate in clinical studies
exploring the pathogenesis of HIV disease and its immunologic response. Listings of
available trials can be found at www.clinicaltrials.gov.

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Selection of antiretroviral regimen — Although the ultimate choice of antiretroviral

regimen should be informed by the results of drug resistance testing, we initiate treatment
as soon as feasible, even if results of baseline resistance testing are not yet known. In such
cases, we agree with the United States Department of Health and Human Services
recommendations to initiate one of the following regimens [2]:

● Dolutegravir plus tenofovir and either emtricitabine or lamivudine

● Bictegravir-tenofovir alafenamide-emtricitabine
● Ritonavir-boosted darunavir plus tenofovir and either emtricitabine or lamivudine

For individuals of childbearing potential, there are special considerations when choosing
among these options. Additionally, such individuals should undergo pregnancy testing
prior to ART initiation. These issues are discussed in detail elsewhere. (See "HIV and
women", section on 'Individuals of childbearing potential'.)

The above regimens are preferred if treatment is started prior to the availability of
resistance testing results because clinically significant transmitted resistance to second-
generation integrase strand transfer inhibitors (INSTIs) and ritonavir-boosted protease
inhibitors (PI) is uncommon [2]. In a study of 109 patients with primary HIV infection, the
13 patients infected with virus that harbored minority variant resistance mutations
(including the M184V mutation that confers resistance to lamivudine and emtricitabine) all
achieved virologic suppression on a PI-based regimen [42].

We do not use an abacavir-containing regimen before the results of HLA*B5701 testing are
known and do not delay therapy for these results.

Once the results of resistance testing are available, treatment modifications can be made if
necessary. Transmission of virus harboring at least one resistance mutation has been
reported in up to 20 percent of patients with early HIV infection [43-45].

In the event that a patient is infected with wild-type virus, one of the first-line regimens
recommended for chronic HIV infection can be used [2]. Data comparing the efficacy of
various ART regimens in patients with early HIV infection are limited [46]. (See "Selecting
antiretroviral regimens for treatment-naïve persons with HIV-1: General approach".)

There does not appear to be a benefit to using intensified regimens in early or acute HIV
infection. In one study of 92 patients with symptomatic acute HIV infection randomly

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assigned to a three- or five-antiretroviral drug regimen, there were no differences in HIV

DNA levels in peripheral blood mononuclear cells (thought to reflect the blood reservoir),
rates of viral suppression, or increases in CD4 cell counts between the groups at 24 months
[47].

Monitoring during antiretroviral therapy — Following initiation of ART during early HIV
infection, viral RNA levels should be checked regularly to document and ensure viral
suppression. This can be done at intervals recommended for patients starting ART during
chronic infection, as time to viral suppression on ART is comparable in early and chronic
infection [9].

Routine monitoring of other laboratory tests and for side effects is also similar to that
recommended for chronic infection.

Duration of treatment — Once treatment is initiated, ART is continued indefinitely.

Although many studies have attempted to evaluate the benefit of a discrete course of ART
initiated during acute or early infection followed by treatment interruption, results from
these studies have been mixed and there is no clear evidence of long-term benefit of such
an approach (see 'Can ART in early infection alter disease course?' below). In contrast,
controlled trials have demonstrated that treatment interruption following initiation of ART
during chronic infection is strongly associated with an increase in mortality as well as AIDS
and non-AIDS morbidity [48,49]; thus treatment interruption is not a recommended
strategy.

Although the rebound in viral load following treatment interruption may be lower among
those who initiated ART during early compared with chronic infection [50], there is no
evidence that treatment interruptions are safer in this setting.

Monitoring those who defer therapy — Although we recommend earlier initiation of ART
for patients with early HIV infection, some patients will opt to defer ART or otherwise not
be ready to commit to lifelong ART. If a patient declines initiation of ART, we perform close
clinical and laboratory (CD4 cell count and viral load testing) monitoring (ie, every three
months) for evidence of rapid immunologic decline, which would indicate a greater
urgency for initiation of ART to prevent poor clinical outcomes. Additionally, patients
should be counseled on the high risk of transmission in the setting of primary HIV
infection, when viral RNA levels are typically very high.
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CAN ART IN EARLY INFECTION ALTER DISEASE COURSE?

There has long been interest in whether a discrete course of antiretroviral therapy (ART)
started in the earliest stages of infection could alter the natural progression of the disease,
decreasing the viral load set point, increasing the time to CD4 cell count decline, and thus
delaying the time to reinitiate ART for clinical indications. Studies that demonstrate very
low viral reservoirs in patients who are treated at the earliest periods after infection have
raised the possibility that early ART could induce a "functional cure" or even prevent
establishment of a latent reservoir [30,31,51]. However, reports of viral rebound following
discontinuation of ART in such patients indicate that even the earliest ART does not
preclude the need for continued ART to maintain control of HIV infection. Furthermore,
given the substantial evidence from clinical trials of poor clinical outcomes associated with
treatment interruption in the setting of chronic HIV infection, we do not recommend a
temporary course of early ART for acutely infected patients [48,49].

In a case report of two individuals (Participants A and B) who were identified in early Fiebig
stage 1 (HIV RNA detectable but fourth-generation enzyme immunoassay negative) and
initiated ART approximately 10 and 12 days after infection, extensive molecular testing of
plasma, circulating CD4 cells, gastrointestinal tissue, lymph nodes, bone marrow, and
cerebrospinal fluid over two years (while on ART) found no evidence of HIV in Participant A
and only intermittent, low-level HIV genetic material from CD4 cells in Participant B [52].
Nevertheless, about seven months after Participant A discontinued ART, HIV RNA
rebounded, prompting reinitiation of ART.

Similarly, in a highly publicized case, an infant diagnosed with HIV and initiated on ART
within 30 hours of birth maintained an undetectable HIV viral load two years after
discontinuing treatment at 18 months of age [53]. However, on routine follow-up at age
four, ART was reinitiated because the child was found to have detectable virus and decline
in the CD4 cell count [54].

These cases have dampened optimism about the potential for functional cure following
early treatment that had been fueled by earlier reports of individuals, including the original
"Berlin patient," who had experienced a persistent control of viral replication after a
discrete course of ART during early infection [53,55,56]. One of these was a description of
the Visconti cohort, which consisted of 14 individuals who achieved prolonged (median 89

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months) viral suppression after an approximate three-year course of ART initiated within
ten weeks of presentation of acute HIV infection [55]. These individuals had genetic
backgrounds and initial presentations distinct from those individuals who are able to
spontaneously control HIV (ie, elite controllers), yet maintained similarly low levels of HIV
DNA in peripheral blood mononuclear cells after ART discontinuation.

It has been difficult to identify and enroll patients in studies to evaluate the hypothesis that
a short course of ART can alter HIV natural history, and results from the few controlled
trials [19,57-60] and observational studies [61-67] that have been performed are mixed.
Even in those trials that demonstrate a benefit to short-term ART in the acute setting with
regards to HIV disease parameters, the duration and clinical significance of these benefits
are unclear. As an example, in one trial of 366 patients with HIV seroconversion within the
preceding six months who were randomly assigned to receive 12 weeks of ART, 48 weeks
of ART, or no ART, there was a longer time following treatment interruption to meet criteria
for long-term ART with 48 weeks of ART after early infection (median 222 weeks) compared
with 12 weeks of ART (median 184 weeks) and no ART (median 157 weeks) [60]. In a post-
hoc analysis, there was a nonsignificant trend towards a longer time to CD4 cell count
decline among patients who initiated the 48-week ART course earlier following
seroconversion. Additionally, the mean decrease in viral RNA level from baseline was
greater in patients who received 48 weeks of ART compared with those who received no
ART when measured at 36 weeks following treatment interruption or randomization,
respectively (difference -0.44 log copies/mL). Nevertheless, there were no differences
between the three groups in AIDS diagnoses or death within the limited follow-up period.

The aggregate message from these data is that a course of early therapy does provide
some benefits in surrogate markers of HIV disease (ie, the CD4 cell count and HIV RNA).
However, since treatment interruption is not a recommended strategy in HIV disease
management, the practical importance of the particular strategies evaluated in these
studies for clinical management is presently limited. They are summarized here primarily
because of the lessons learned about this distinctive population with recently acquired HIV.
Nevertheless, the greater likelihood of CD4 preservation [10], the possibility of an
alteration in disease course, the potential implications for future cure strategies, and the
reduction in HIV transmission risk on balance support initiation of ART during acute or
early HIV infection. (See 'Rationale for initiation of ART in early infection' above.)

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SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and

regions around the world are provided separately. (See "Society guideline links: HIV
treatment in nonpregnant adults and adolescents".)

SUMMARY AND RECOMMENDATIONS

● In this topic, we use the term "early HIV infection" to refer to the approximate six-
month period following HIV acquisition. We use the term "acute HIV infection," to refer
to symptomatic early infection. (See 'Definitions' above.)

● Because of difficulties in identifying patients with early HIV infection for enrollment in
controlled trials, most of the rationale for initiating antiretroviral treatment (ART) in
early HIV infection is based on indirect evidence from chronic infection, benefits to the
individual and public health, and the effects of ART during early infection on surrogate
markers of HIV disease progression (ie, CD4 cell count and HIV RNA). (See 'Initiating
antiretroviral therapy during early HIV infection' above.)

● The presence and severity of symptoms during early HIV infection appear to portend
more rapid disease progression. Thus, those with acute symptomatic HIV infection
may represent a subset of patients in whom earlier initiation of ART would be more
likely to confer improvement in morbidity and mortality. (See 'Effect on symptomatic
disease' above.)

● As in chronic infection, ART is effective in suppressing serum viral RNA levels and
increasing CD4 cell counts in the vast majority of patients with acute and early HIV
infection. Furthermore, initiation of ART earlier after initial HIV infection is associated
with a greater chance of immune reconstitution to normal or near normal CD4 cell
levels. (See 'Improved clinical markers of disease' above.)

● The interval following initial infection until the CD4 cell count declines to a threshold at
which there is clinical evidence for a benefit with ART is relatively short. Thus, patients
with early HIV who start therapy would likely not have a significant excess of ART
exposure compared with deferring therapy. This may ameliorate concerns about the

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possible risk of additional toxicity from greater time on ART. (See 'Interval until
treatment criteria are met is short' above and 'Potential risks' above.)

● Early HIV infection is associated with high levels of HIV RNA and a corresponding high
risk of viral transmission. Reduction of this transmission risk through viral suppression
is a theoretical but plausible benefit to earlier ART initiation. (See 'Decreased risk of
transmission' above.)

● For patients with acute HIV infection, we recommend prompt initiation of ART (Grade
1B). The potential benefits of earlier ART outweigh the potential risks of increased
exposure to the toxicity of ART and emergence of viral resistance in the setting of
suboptimal adherence. In particular, we feel most strongly about treatment initiation
in patients with symptomatic acute infection given the association between
symptomatic disease and more rapid disease progression. (See 'Our approach' above.)

● Treatment does not have to be delayed while awaiting results of resistance testing.
While awaiting results of resistance testing, we suggest one of the following regimens
(Grade 2C):

• Dolutegravir plus tenofovir and either emtricitabine or lamivudine

• Bictegravir-tenofovir alafenamide-emtricitabine
• Ritonavir-boosted darunavir plus tenofovir and either emtricitabine or lamivudine

Once initiated, ART is continued indefinitely.

● Studies evaluating the effects of a discrete course of ART early in HIV infection suggest
an improvement in surrogate markers of HIV disease with earlier versus delayed
therapy, but the durability of these benefits following ART discontinuation is unclear. In
contrast, substantial evidence from clinical trials in chronic infection demonstrate
increased AIDS and non-AIDS related morbidity and mortality with treatment
discontinuation. Thus, we recommend not using a treatment interruption strategy in
patients with acute or early HIV infection (Grade 1A). (See 'Can ART in early infection
alter disease course?' above.)

ACKNOWLEDGMENT

We are saddened by the death of John G Bartlett, MD, who passed away in January 2021.
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UpToDate gratefully acknowledges Dr. Bartlett's role as section editor on this topic, his
tenure as the founding Editor-in-Chief for UpToDate in Infectious Diseases, and his
dedicated and longstanding involvement with the UpToDate program.

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