• Sexual
• Perinatal
• Blood (Pareneteral, occupational exposures, blood products)

• Entry into human body
• Attachment to receptors
• Internalization (integration) of HIV virion
• Production and release of new virions

1.  Antibody Tests

• Rapid HIV Test kit
• ELISA
• Western Blot

2.  Antibody Window Repeat Testing

• 6 weeks
• 6 months
• 1 yr

3.  Antigen Tests

• HIV DNA PCR
• HIV Viral Load

4.  CD4 Count

• Tests viral genes for mutations of drug resistance
• Takes 1-2 weeks

• Tests virus ability to replicate in presence of meds
• Takes 2-3 weeks
• Harder to interpret than genotype testing
• More expensive than genotype testing

• Acute HIV infection
• Chronic HIV infection
• Virologic failure
• Pregnant Patients

• AIDS defining illness
• HIV-associated nephropathy
• Pregnancy
• Coinfection Hep B Virus when HBV being treated
• If asymptomatic , therapy is based on CD4 counts and viral titers, risks and benefits of therapy, and patient willingness to begin treatment

Risks:

• Drug adverse effects, so decreased QOL
• Risk of drug resistance
• Limitation of future drug options

Benefits:

• Control easier to achieve and maintain
• Delay immunocompromise
• Lower risk of resistance
• Reduction of HIV transmission

Risks:

• Risk of irreversible immunocompromise
• Increased difficulty in suppressing viral replication
• Increased risk of HIV transmission

Benefits:

• Avoid adverse effects, so better QOL
• Delays drug resistance
• Preserves future drug options

• Maximal and durable suppression of viral load
• Restoration or preservation of immune function
• Improvement in quality of life
• Reduction of HIV-related morbidity and mortality

• Never Monotherapy
• Avoid Sequential Monotherapy

• 2 NRTI + NNRTI
• 2NRTI + Protease Inhibitor (boosted with Ritonavir)
• 2NRTI + Integrase Inhibitor

Advantages

• Saves Protease Inhibitor and Raltegravir for future 
• Low pill burden
• Less lipid SE

Disadvantages

• NNRTI resistance in therapy naive patients
• Low genetic barrier for development of resistance: Cross-Resistance among NNRTIs
• Skin rash
• Drug interactions

Advantages

• Saves NNRTI for future
• Higher genetic barrier for resistance
• Protease Inhibitor resistance uncommon with failure (boosted PIs)

Disadvantages

• Compromise future Protease Inhibitor regimens
• Metabolic complications (dyslipidemia, insulin resistance, hepatotoxicity)
• GI adverse effects
• Drug interactions (Ritonavir, esp)
• Higher pill burden

Advantages

• Saves PI and NNRTI for future
• Fewer drug related AEs and lipid changes than Efavirenz
• Virologic response non-inferior to Efavirenz
• No food effect
• Fewer drug interactions than PI or NNRTI

Disadvantages

• Less long term experience in ART-naive 
• Lower genetic barrier for development of resistance than boosted Protease Inhibitor
• No data with NRTIs other than Tenofovir/Emtricitabine in ART-naive patients
• BID dosing required

• Atazanavir (PI)/Ritonavir (PI) + Tenofovir (NRTI)/Emtricitabine (NRTI)

• Darunavir (PI)/Ritonavir (PI) + Tenofovir (NRTI)/Emtricitabine (NRTI)

Lopinavir (PI)/Ritonavir (PI) + Zidovudine (NRTI)/Lamivudine (NRTI)

BID

• Obtain CD4 and HIV RNA titers before starting
• HIV RNA level < 400 after 24 weeks
• HIV RNA level < 50 after 48 weeks
• Persistent low-level viremia
• Check HIV RNA titers in 2-8 weeks after initiation or after a change in antiretroviral therapy, then q 3-4 months
• Always confirm rising titer with 2nd test
• Check CD4 counts every 3-6 months based on HIV RNA titers

• 2 mg/kg/dose PO q6hr

OR

• 1.5 mg/kg/dose IV q6hr

• HIV DNA PCR
• CBC with differential
• Urine CMV
• RPR