01Approach to the Critical Patient/attcp34

Immediate stabilization

›Airway and breathing threats

›Hypoxia with SpO2 <92% on room air — oxygen supplementation and escalation

›PCP pneumonia pattern: bilateral diffuse infiltrates, subacute onset

›HFNC if SpO2 unresponsive to low-flow oxygen

›Intubation if respiratory failure despite escalation

›Altered mental status with airway risk

›Cryptococcal meningitis: headache, meningismus, altered mentation

›Toxoplasmosis: focal neurologic deficits, seizure

›Primary CNS lymphoma: progressive cognitive decline

›Hemodynamic instability

›Sepsis pattern: MAP <65 mmHg, lactate >=2 mmol/l

›Broad spectrum antibiotics within 1 hour of sepsis recognition

›IV fluid resuscitation 30 ml/kg crystalloid if hypoperfusion present

Key decision points

›Identify clinical syndrome on arrival

›Acute retroviral syndrome: mononucleosis-like illness 2–6 weeks post-exposure

›Fever, pharyngitis, lymphadenopathy, rash, myalgias

›Highest infectivity period due to peak viremia

›Advanced AIDS with opportunistic infection: CD4 <200, new or worsening systemic illness

›OI pattern must be identified to guide targeted therapy

›ART timing depends on OI type — see Treatment section

›IRIS presentation: paradoxical worsening in recently ART-initiated patient

›Typically within first 4–8 weeks of ART initiation

›CD4 <100 at ART start is highest-risk group

Escalation triggers

›Mandatory immediate escalation

›New focal neurologic deficit or seizure → urgent CT head, LP if safe

02History/hx47

Exposure and timeline

›HIV transmission risk history

›Condomless receptive anal intercourse — highest per-act transmission risk

›Estimated 1.4% per-act risk without PrEP

›Injection drug use or needle sharing

›Occupational needlestick exposure

›Sexual partner of known HIV-positive individual

›Geographic origin or travel to high-prevalence region (>1% HIV prevalence)

›Symptom onset timeline

›Acute retroviral syndrome: 2–6 weeks after exposure

›Symptom duration typically 1–3 weeks

›Peak viremia correlates with symptom peak

›Advanced AIDS presentation: weeks to months of constitutional symptoms

›Unexplained weight loss >10% body weight

›Chronic diarrhea >1 month

›Persistent night sweats

Symptom characterization

›Core acute retroviral syndrome symptoms

›Fever: most common symptom, present in 93% of acute HIV

›Fatigue: 79% prevalence in acute HIV cohort

›Pharyngitis: 67%, typically non-exudative

›Headache: 64%

›Diffuse maculopapular rash: truncal distribution, non-pruritic

›Myalgias and arthralgias

›Oral or genital ulcers

›Diarrhea — watery, non-bloody

›Advanced AIDS and OI symptom clusters

›Respiratory: dyspnea, dry cough (PCP); productive cough, hemoptysis (TB)

03Physical Exam/exam47

Vitals and general

›Stability assessment

›Temperature: fever most common sign in acute HIV

›Hypothermia as severe sepsis or advanced AIDS marker

›Heart rate: tachycardia with sepsis or severe OI

›Blood pressure: hypotension triggers sepsis protocol

›SpO2: hypoxia suggests PCP, TB, or bacterial pneumonia

›Weight: document for wasting syndrome assessment

Skin and mucous membranes

›Dermatologic findings

›Diffuse maculopapular rash: truncal distribution in acute HIV

›Begins day 2–3 of illness, resolves with viremia

›Kaposi sarcoma lesions: violaceous papules or plaques

›Mucosal, cutaneous, or visceral — AIDS-defining

›Molluscum contagiosum: pearly umbilicated papules at CD4 <200

›Seborrheic dermatitis: nasolabial folds, scalp — marker of immune decline

›HSV or VZV vesicular eruptions: dermatomal or disseminated

›Oropharyngeal findings

›Oral candidiasis (thrush): white plaques that scrape off

›Sensitivity for CD4 <200 when present

›Oral hairy leukoplakia: white corrugated plaques lateral tongue, non-scrapable

›EBV-driven, marker of immune compromise

›Aphthous ulcers in acute retroviral syndrome

›Pharyngeal erythema without exudate in acute HIV

Lymph node and organomegaly exam

›Lymphadenopathy pattern

›Generalized lymphadenopathy: hallmark of acute and chronic HIV

›Typically non-tender, rubbery, symmetric

04Differential Diagnosis/ddx47

Acute retroviral syndrome mimics

›Infectious mononucleosis (EBV)

›ICD-10 B27.0

›Heterophile antibody positive in EBV; absent in acute HIV

›Exudative pharyngitis more common with EBV

›Approximately 1.2% of heterophile-negative mono-like illness is acute HIV

›CMV mononucleosis

›ICD-10 B25.9

›Heterophile-negative, transaminase elevation

›Atypical lymphocytes on smear

›Secondary syphilis

›ICD-10 A51.3

›Rash involves palms and soles; condylomata lata

›RPR or VDRL reactive

›Influenza and COVID-19

›More prominent respiratory symptoms, less rash and lymphadenopathy

›Streptococcal pharyngitis

›Exudative tonsillitis; rapid antigen test positive

›Drug hypersensitivity reaction

›Temporal relationship to new medication initiation

›Acute viral hepatitis (A, B, C)

›Jaundice, significant transaminase elevation

Advanced AIDS differential

›Opportunistic infections — life-threatening

›PCP pneumonia

›ICD-10 B59

›CD4 <200, subacute dyspnea, bilateral diffuse interstitial infiltrates

›Cryptococcal meningitis

05Laboratory Tests/lt61

HIV-specific diagnostics

›4th-generation HIV Ag/Ab combination immunoassay

›First-line ED screening test (detects p24 antigen and HIV-1/2 antibodies)

›Window period approximately 18–45 days from exposure

›Reactive result requires confirmatory HIV-1/2 antibody differentiation assay

›If Ag/Ab reactive but antibody differentiation negative/indeterminate, order HIV RNA

›Quantitative HIV RNA (viral load)

›Confirms acute HIV infection when antibody assay is negative or indeterminate

›Levels typically >100,000 copies/mL (often >1,000,000) in acute infection

›Baseline for ART monitoring

›Repeat at 4–6 weeks after ART initiation to confirm decline

›CD4 count with percentage

›CD4 <200 defines AIDS by immunologic criteria

›CD4 <100: high risk for cryptococcal meningitis, MAC, CMV retinitis, toxoplasmosis

›CD4 <50: immediate ophthalmology referral for CMV retinitis screening

›Genotypic resistance testing

›Includes reverse transcriptase and protease genotype at minimum

›Add integrase genotype if prior injectable cabotegravir PrEP exposure

›Do not delay ART initiation for genotype results to return

Baseline co-infection and metabolic labs

›Complete blood count with differential

›Leukopenia and thrombocytopenia common in acute HIV

›Lymphopenia with atypical lymphocytes on smear

›Leukocytosis with OI or bacterial superinfection

›Comprehensive metabolic panel

›Renal function: guides TDF vs TAF selection (TAF preferred if eGFR <60)

›Hepatic function: transaminase elevation in acute HIV or HBV coinfection

›Electrolytes: baseline for IV fluid and medication management

06Diagnostic Tests/dt69

Scoring Systems

›HIV staging and OI risk stratification

›CDC HIV classification system (2014)

›Stage 1: CD4 >=500 cells/uL

›Stage 2: CD4 200–499 cells/uL

›Stage 3 (AIDS): CD4 <200 cells/uL or AIDS-defining condition

›WHO HIV clinical staging (resource-limited settings)

›Stage 1: Asymptomatic

›Stage 2: Mild symptoms (oral hairy leukoplakia, recurrent URI)

›Stage 3: Advanced (unexplained severe weight loss, chronic diarrhea, pulmonary TB)

›Stage 4: Severe/AIDS (PCP, cryptococcal meningitis, CMV, KS, toxoplasmosis)

›PCP severity scoring

›PaO2 <70 mmHg (room air) or A-a gradient >35 mmHg: severe PCP

›Adjunctive corticosteroids indicated for severe PCP

›Prednisone 40 mg twice daily x5 days, then taper

›CURB-65 or PSI may underestimate severity in HIV/PCP

›IRIS diagnostic criteria (clinical)

›Temporal relationship to ART initiation (usually within 8 weeks)

›Paradoxical worsening of known OI or unmasking of subclinical OI

›Exclusion of: ART failure, drug toxicity, new OI, drug resistance

MRI

›Brain MRI indications in HIV/AIDS

›Preferred over CT for CNS evaluation due to superior soft tissue resolution

›Contrast-enhanced MRI with FLAIR and DWI sequences

›Ring-enhancing lesions with mass effect

›CNS toxoplasmosis: multiple lesions, basal ganglia predilection

›Primary CNS lymphoma: often single periventricular lesion, EBV-associated

›Differentiation: empiric toxoplasmosis treatment and 2-week response assessment

›White matter signal abnormality (PML)

›JC virus infection at CD4 <200

›Asymmetric, non-enhancing, subcortical white matter lesions

›CSF JC virus PCR for confirmation

›HIV encephalopathy (HIVE)

›Diffuse symmetric periventricular white matter signal on T2/FLAIR

›Cortical atrophy

›Spinal cord MRI when myelopathy suspected

›Vacuolar myelopathy: posterior and lateral column signal change

›Longitudinal myelitis: transverse myelitis pattern

CT

›CT head in HIV/AIDS

›Non-contrast CT: initial assessment for mass effect and herniation risk before LP

›Do not delay LP for CT if low pretest probability of mass lesion

›Contrast CT: ring-enhancing lesions for toxoplasmosis vs lymphoma

›ACEP Level B recommendation for CT before LP in immunocompromised patients

›Sensitivity for PML lower than MRI — not preferred for white matter pathology

›CT chest in HIV/AIDS

›High-resolution CT chest for PCP and pulmonary OIs

›PCP: ground-glass opacity bilateral, upper lobe predominance

›Cysts or pneumatoceles in recurrent PCP

›Upper lobe infiltrates: TB pattern, especially with cavitation

›Mediastinal adenopathy: lymphoma, MAC, TB, histoplasmosis

›CT chest for pulmonary KS

›Peribronchovascular nodules, bilateral, lower lobe

›"Flame-shaped" hemorrhagic nodules

›CT abdomen and pelvis

›Hepatosplenomegaly, retroperitoneal adenopathy: MAC, lymphoma

›Bowel wall thickening: CMV colitis, MAC enteritis, lymphoma

Ultrasound

›Point-of-care ultrasound (POCUS) applications

›Cardiac POCUS

›HIV cardiomyopathy: dilated chambers, reduced ejection fraction

›Pericardial effusion: TB pericarditis, KS, lymphoma

›IVC assessment for volume status and fluid responsiveness

›Lung POCUS

›B-line pattern: interstitial pattern supports PCP or heart failure

›Consolidation with air bronchograms: bacterial pneumonia

›Pleural effusion: TB, KS, bacterial empyema

›Abdominal POCUS

›Hepatosplenomegaly rapid assessment

›Free fluid or ascites: lymphoma, TB peritonitis

›Ophthalmologic ultrasound

›B-scan ultrasound for posterior segment if direct fundoscopy limited

›Retinal detachment complicating CMV retinitis

07Disposition/dispo34

Admission indications

›Mandatory hospitalization criteria

›Active OI requiring IV therapy

›PCP with SpO2 <92% or PaO2 <70 mmHg — respiratory failure risk

›Cryptococcal meningitis — IV antifungal initiation and pressure management

›CMV end-organ disease: retinitis, colitis, pneumonitis — IV ganciclovir

›Disseminated MAC at CD4 <50 with systemic illness

›Bacterial sepsis or septic shock

›Neurologic compromise

›Altered mental status, seizure, focal deficits

›LP required for diagnosis

›Hemodynamic instability

›Septic shock: IV antibiotics, vasopressors

›Inability to tolerate oral medications

›CD4 <200 with community-acquired pneumonia — hospitalize regardless of PSI score

›Severe IRIS with clinical deterioration

ICU level care indications

›Critical care triggers

›Respiratory failure requiring mechanical ventilation

›Severe PCP unresponsive to HFNC

›Septic shock requiring vasopressors

›Status epilepticus or acute brain herniation

›Rapidly rising intracranial pressure in cryptococcal meningitis

Discharge criteria

›Safe discharge conditions

›Uncomplicated acute retroviral syndrome with mild symptoms

›Able to tolerate oral ART

›Confirmed linkage to HIV care within 48–72 hours

08Treatment/t88

Antiretroviral therapy — acute HIV

›Timing of ART initiation

›Same-day or within 7 days of diagnosis: guideline recommendation

›DHHS and IAS-USA 2024 guidelines support rapid start

›Baseline labs drawn first but do not delay ART for results

›Benefits of early ART in acute infection

›Reduces viral reservoir seeding

›Preserves CD4 count and immune function

›Reduces transmission risk (U=U principle once viral suppression achieved)

›Preferred initial ART regimens (standard)

›Bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC; Biktarvy)

›Single tablet once daily

›High barrier to resistance; preferred by DHHS 2024

›Avoid in pregnancy — limited safety data in first trimester

›Dolutegravir + TAF/FTC (or TDF/FTC)

›Dolutegravir 50 mg once daily + TAF/FTC or TDF/FTC

›Alternative: DTG/3TC (Dovato) — only if HIV RNA <500,000 copies/mL, no HBV, labs available

›Do NOT use NNRTIs (efavirenz, rilpivirine) for rapid start

›NNRTI resistance mutations common and results pending at initiation

›Do NOT use abacavir without HLA-B*5701 testing

›Hypersensitivity reaction risk

›Prior cabotegravir PrEP (CAB-LA) exposure

›InSTI resistance possible due to long-acting pharmacokinetics

›Preferred regimen: boosted darunavir (DRV/r or DRV/c) + TAF/FTC

›Darunavir 800 mg + ritonavir 100 mg once daily (or cobicistat 150 mg)

›Pending integrase genotype resistance result

›Do NOT use standard InSTI-based regimen until genotype confirms sensitivity

OI-specific treatments

›PCP (Pneumocystis jirovecii pneumonia)

›First-line treatment

›TMP-SMX: 15–20 mg/kg/day TMP component IV or orally divided every 6–8 hours

›Duration: 21 days total

›Switch to oral once clinically improving (typically day 5–7)

›Adjunctive corticosteroids for severe PCP (PaO2 <70 mmHg or A-a gradient >35 mmHg)

›Prednisone 40 mg orally twice daily days 1–5

›Prednisone 40 mg once daily days 6–10

›Prednisone 20 mg once daily days 11–21

›ART timing in PCP: start within 2 weeks of PCP therapy initiation

›Cryptococcal meningitis

›Induction phase (2 weeks minimum)

›Liposomal amphotericin B 3–4 mg/kg/day IV + flucytosine 25 mg/kg orally four times daily

›Alternative: amphotericin B deoxycholate 0.7–1 mg/kg/day IV if liposomal unavailable

›Consolidation phase

›Fluconazole 400 mg orally once daily x8 weeks

›Maintenance phase

›Fluconazole 200 mg orally once daily until CD4 >200 for >=6 months on ART

›Elevated ICP management

›Therapeutic LP for opening pressure >250 mm H2O; target <200 mm H2O

›Daily LPs until pressure controlled

›Lumbar drain or VP shunt if refractory

›ART timing in cryptococcal meningitis: DELAY ART 4–6 weeks after antifungal initiation

›Early ART increases mortality (COAT trial evidence)

›CNS toxoplasmosis

›Empiric treatment when CD4 <100 and ring-enhancing lesions present

›Pyrimethamine 200 mg loading dose then 50–75 mg orally once daily

›Sulfadiazine 1000–1500 mg orally four times daily

›Leucovorin 10–25 mg orally once daily (prevents pyrimethamine bone marrow toxicity)

›Duration: 6 weeks acute, then secondary prophylaxis

›Response assessment: clinical and radiographic improvement at 2 weeks

›Failure to improve suggests PCNSL or alternative diagnosis — consider brain biopsy

›ART timing in toxoplasmosis: start within 2 weeks of OI therapy

›Disseminated MAC

›Clarithromycin 500 mg orally twice daily + ethambutol 15 mg/kg orally once daily

›Addition of rifabutin 300 mg orally once daily for severe disease

›ART within 2 weeks of MAC therapy initiation

›CMV retinitis

›Sight-threatening or zone 1 lesions

›Intravitreal ganciclovir or foscarnet injection (immediate ophthalmology management)

›Systemic therapy (concurrent with intravitreal)

›Valganciclovir 900 mg orally twice daily x21 days induction

›Valganciclovir 900 mg orally once daily maintenance until CD4 >100 for >=6 months

›IV ganciclovir 5 mg/kg every 12 hours if oral not tolerated

OI prophylaxis

›Primary prophylaxis thresholds

›CD4 <200: TMP-SMX DS 1 tablet orally once daily (PCP prophylaxis)

›Also covers Toxoplasma if Toxoplasma IgG positive at CD4 <100

›Alternative if sulfa allergy: dapsone 100 mg orally once daily or atovaquone 1500 mg once daily

›CD4 <50: azithromycin 1200 mg orally once weekly (MAC prophylaxis)

›Only if ART not being initiated immediately

›Discontinue once CD4 >100 on ART x3 months

›Isoniazid preventive therapy (IPT): 300 mg orally once daily x9 months if LTBI positive

›Immunizations to complete or update

›Pneumococcal: PCV20 or PCV15 + PPSV23

›Influenza: annual inactivated vaccine

›Hepatitis A and B series if non-immune

›HPV series if age-appropriate and not completed

IRIS management

›Identify and confirm IRIS

›Do not stop ART unless life-threatening

›NSAIDs for mild-moderate IRIS: ibuprofen 400–600 mg orally three times daily

›Corticosteroids for severe IRIS: prednisone 1 mg/kg/day x5–10 days then taper

›Exception: do not use corticosteroids in PML-IRIS (worsens outcomes)

09Special Populations/sp66

Pregnancy

›HIV in pregnancy: testing and urgency

›Universal HIV testing at first prenatal visit, third trimester, and delivery

›Acute HIV in pregnancy: immediate ART initiation

›Risk of perinatal transmission highest during acute infection (high viremia)

›Preferred ART in pregnancy (DHHS Perinatal Guidelines 2025)

›Dolutegravir (50 mg once daily) + TDF/FTC or TAF/FTC — preferred across all trimesters

›Neural tube defect risk with periconceptional DTG: 0.1–0.2%, counseling required

›Avoid cobicistat-boosted regimens in 2nd and 3rd trimester

›Avoid efavirenz in first trimester

›Perinatal transmission prevention

›Goal: HIV RNA <200 copies/mL by delivery

›IV zidovudine infusion during labor for mothers with HIV RNA >=400 copies/mL near delivery

›Zidovudine 2 mg/kg IV over 1 hour then 1 mg/kg/hour until delivery

›Neonatal prophylaxis: zidovudine 4 mg/kg orally twice daily x4 weeks

›High-risk neonates: triple ARV prophylaxis

›Avoid breastfeeding in resource-adequate settings

›OI treatment modifications in pregnancy

›TMP-SMX: safe for PCP treatment in pregnancy; avoid high-dose folate antagonist risk with leucovorin supplementation

›Amphotericin B: safe in pregnancy (preferred for cryptococcal meningitis)

›Fluconazole: avoid first trimester (teratogenic at high doses); short-course lower doses with caution

›Pyrimethamine: teratogenic in first trimester; delay toxoplasmosis treatment or use alternatives if possible

Geriatric

›Aging with HIV

›Prevalence: >50% of persons living with HIV in the US are now aged >=50

›Accelerated aging phenotype on ART

›Increased cardiovascular disease, osteoporosis, neurocognitive decline, frailty

›Metabolic syndrome from ART and HIV-related inflammation

›ART selection considerations in older adults

›Prefer TAF over TDF: lower bone and renal toxicity

›eGFR monitoring every 6 months

›DEXA scan screening for osteoporosis

›Avoid QTc-prolonging regimens: dofetilide, sotalol interactions with cobicistat

›Polypharmacy risk: cobicistat and ritonavir are potent CYP3A4 inhibitors

›Statins, antihypertensives, anticoagulants commonly affected

›Use an HIV drug interaction checker (hivdruginteractions.org) for every new medication

›OI presentation differences in elderly

›Atypical presentations of PCP: subacute dyspnea, minimal hypoxia at rest

›CMV reactivation more common with advancing age independent of CD4

›Higher baseline mortality for sepsis from OIs vs younger adults

›Geriatric-specific monitoring

›Annual frailty and falls assessment

›Cognitive screening with MoCA annually if CD4 nadir <200

›Bone density monitoring q1–2 years

Pediatrics

›Pediatric HIV epidemiology

›Perinatal transmission: primary route in children <13 years

›Adolescent acquisition: same routes as adults; MSM, IDU, sexual contact

›CDC/HRSA pediatric HIV guidelines updated 2024

›Testing in neonates and infants

›HIV DNA PCR (not antibody test) at 14–21 days, 1–2 months, and 4–6 months

›Maternal antibodies persist until 18 months — antibody tests unreliable

›If positive at any timepoint: immediate ART and confirmatory testing

›Preferred ART regimens in children (weight-based dosing; DHHS Pediatric Guidelines 2024)

›Neonates (birth to 4 weeks)

›Zidovudine + nevirapine + 3TC

›Infants 4 weeks to 3 years

›Lopinavir/ritonavir solution + ZDV/3TC or ABC/3TC

›Children >=2 years and >=10 kg

›Dolutegravir + ABC/3TC (if HLA-B*5701 negative)

›BIC/TAF/FTC approved >=25 kg

›Adolescents (Tanner IV or V)

›Adult dosing applies once adult pubertal development reached

›OI prophylaxis in children

›TMP-SMX prophylaxis starting at 4–6 weeks of age in HIV-exposed neonates (pending test results)

›PCP threshold: CD4 <200 or CD4% <15% for prophylaxis

›Immunizations in HIV-infected children

›Live vaccines (MMR, varicella): safe if CD4% >=15%; avoid if CD4% <15%

›Pneumococcal, Hib, meningococcal: complete series as scheduled

10Background/b63

Epidemiology

›Global and US HIV burden

›Approximately 39 million people living with HIV globally as of 2023 (UNAIDS)

›United States: approximately 1.2 million people living with HIV

›Approximately 13% unaware of diagnosis

›Approximately 36,000 new HIV infections per year in the US

›Gay and bisexual men account for approximately 70% of new diagnoses

›Black/African American individuals disproportionately affected: 42% of new diagnoses

›Emergency department HIV prevalence: approximately 0.5–1.5% in high-prevalence ED settings

›Routine opt-out ED screening detects acute HIV in 0.08–0.14% of screened patients (White et al., 2018)

›Acute retroviral syndrome

›40–90% of acutely infected individuals develop symptomatic acute HIV

›Median time from exposure to symptoms: 2–4 weeks

›Peak viremia correlates with symptom peak and maximum infectivity

›Natural history: symptoms resolve within 1–3 weeks even without treatment

›Mortality and morbidity

›AIDS-related mortality in US: approximately 6,000–7,000 per year

›With effective ART: near-normal life expectancy achievable

›Sepsis mortality in HIV-positive patients approximately 2x higher than HIV-negative (Deinhardt-Emmer et al., 2025)

Pathophysiology

›Acute HIV infection mechanism

›HIV-1 primarily infects CD4+ T lymphocytes, macrophages, and dendritic cells via gp120–CD4/CCR5 binding

›CCR5-tropic virus predominates in early transmission

›Massive CD4 T-cell depletion in gut-associated lymphoid tissue (GALT) within days

›Peak viremia during acute infection: typically 10^6 copies/mL

›High viraemia drives transmission risk (estimated 26x higher than in chronic infection)

›Set-point viral load established after immune response — predicts rate of progression

›Immunologic progression to AIDS

›Chronic immune activation: persistent inflammation despite viremia control

›Microbial translocation from damaged gut epithelium

›Systemic inflammation accelerates non-AIDS comorbidities (CVD, neurocognition)

›Progressive CD4 decline without ART: average 50–100 cells/uL/year

›AIDS: CD4 <200 cells/uL or AIDS-defining condition

›OI risk correlates inversely with CD4 count

›HIV reservoir establishment during acute infection

›Integrated proviral DNA in resting CD4 cells: major obstacle to cure

›OI pathogenesis

›PCP: Pneumocystis jirovecii, an atypical fungus, causes alveolar damage

›Impaired alveolar macrophage function at CD4 <200

›Cryptococcus neoformans: polysaccharide capsule impairs phagocytosis

›CNS tropism via phagocytic "Trojan horse" mechanism

›CMV reactivation: lifelong latent infection reactivates when T-cell immunity lost

›Toxoplasma gondii: reactivation of latent cysts in brain parenchyma

Therapeutic Considerations

›ART mechanism and resistance

›InSTI (integrase strand transfer inhibitors): bictegravir, dolutegravir, raltegravir

›Block HIV DNA integration into host genome

›High genetic barrier to resistance: dolutegravir and bictegravir preferred

›NRTI (nucleoside reverse transcriptase inhibitors): TDF, TAF, FTC, 3TC, ABC, ZDV

›Chain termination of viral DNA synthesis

›TAF preferred over TDF for renal and bone safety

›NNRTI (non-nucleoside reverse transcriptase inhibitors): efavirenz, rilpivirine, doravirine

›Low genetic barrier to resistance — not for rapid start

›PI (protease inhibitors): darunavir, atazanavir (require pharmacokinetic booster)

›High barrier to resistance but significant drug interactions via CYP3A4

›ART timing for OIs

›Early ART (within 2 weeks) recommended for most OIs

›Reduces AIDS progression and mortality for most OIs

›Delayed ART for cryptococcal meningitis (4–6 weeks) and TB meningitis (2–4 weeks)

›Early ART drives paradoxical IRIS with increased intracranial pressure and mortality

›Drug interaction framework

›Cobicistat and ritonavir: potent CYP3A4 inhibitors

›Significant interactions: rifampin (contraindicated), statins, midazolam, PPIs

›Rifampin: potent CYP3A4 inducer — contraindicated with most boosted PIs and cobicistat

›Use with InSTI requires DTG 50 mg twice daily dose doubling

›Methadone: minimal interaction with InSTI-based regimens

11Patient Discharge Instructions/pdi36

copy discharge instructions

›What is HIV and what happens now

›HIV (Human Immunodeficiency Virus) attacks your immune system over time

›With medication (ART — antiretroviral therapy), most people with HIV live a long, healthy life

›The virus is NOT curable but is very controllable with daily medication

›You were diagnosed with HIV today — this is a medical condition you can manage

›Taking your medication every day is the single most important thing you can do

›Your medication

›Take your HIV medication (antiretroviral therapy) every day as prescribed

›Never stop or skip doses without talking to your HIV doctor first

›Stopping medication can allow the virus to become resistant and harder to treat

›If you have side effects (nausea, headache, fatigue), they usually improve after 1–2 weeks

›Contact your HIV clinic or pharmacist before stopping the medication

›Follow-up appointments

›HIV clinic appointment: within 1–2 weeks — this is critical

›Blood tests (viral load and CD4 count) will be repeated at this visit

›If you cannot get an HIV clinic appointment: return to the emergency department

›Take your prescription immediately to the pharmacy — do not wait

›Protecting others and yourself

›HIV can be transmitted to sexual partners — use condoms until you are virally suppressed

›"Undetectable = Untransmittable" (U=U): once your viral load is undetectable for 6 months, transmission risk is negligible

›Do not share needles, syringes, or drug equipment

›Tell sexual partners you have been exposed — they can be tested and start PEP if needed (within 72 hours of exposure)

›HIV is NOT transmitted by casual contact: hugging, sharing food, toilets, or coughing

›Return to the emergency department immediately if

›Severe headache with stiff neck or sensitivity to light

›Vision changes, floaters, or sudden vision loss

›Confusion, memory problems, or weakness on one side of the body

12References/r34

Guidelines and key sources

›DHHS Antiretroviral Therapy Guidelines 2024

›Gulick RM, Pau AK, Agwu A, et al. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV. Office of AIDS Research Advisory Council, 2024

›clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf

›HIVMA/IDSA Primary Care Guidance 2024

›Horberg M, Thompson M, Agwu A, et al. Primary Care Guidance for Providers of Care for Persons With HIV: 2024 Update. Clin Infect Dis, 2024

›doi.org/10.1093/cid/ciae479

›IAS-USA Panel 2024 Antiretroviral Recommendations

›Gandhi RT, Landovitz RJ, Sax PE, et al. Antiretroviral Drugs for Treatment and Prevention of HIV in Adults: 2024 Recommendations. JAMA, 2025

›jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2024.24543

›OI Prevention and Treatment Guidelines 2025

›Benson C, Brooks J, Dhanireddy S, et al. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents With HIV. IDSA/OARAC, 2025

›clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-oi/guidelines-adult-adolescent-oi.pdf

›DHHS Perinatal HIV Guidelines 2025

›Badell ML, Best BM, Brooks KM, et al. Recommendations for Use of Antiretroviral Drugs During Pregnancy. OARAC, 2025

›clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/perinatal-hiv/guidelines-perinatal.pdf

Emergency medicine evidence

›ED-based HIV screening studies

›White DAE, Giordano TP, Pasalar S, et al. Acute HIV Discovered During Routine HIV Screening With HIV Antigen-Antibody Combination Tests in 9 US Emergency Departments. Ann Emerg Med, 2018

›PMID: 29310870

›Acute HIV clinical features

›Robb ML, Eller LA, Kibuuka H, et al. Prospective Study of Acute HIV-1 Infection in Adults in East Africa and Thailand. N Engl J Med, 2016

›NEJM doi: 10.1056/NEJMoa1508952

›Crowell TA, Colby DJ, Pinyakorn S, et al. Acute Retroviral Syndrome Is Associated With High Viral Burden, CD4 Depletion, and Immune Activation. Clin Infect Dis, 2018; PMID: 29228130

›Immunocompromised host pneumonia

›Cheng GS, Crothers K, Aliberti S, et al. Immunocompromised Host Pneumonia: Definitions and Diagnostic Criteria: ATS Workshop Report. Ann Am Thorac Soc, 2023

›PMC9993146

›Sepsis in immunocompromised patients

Evidence & Review

Evidence & Review