Approach to HIV Part 2 – Treatment demystified (NEET PG, NEET SS, MRCP)

Welcome back to Medicine Beyond Harrison. In Part 1, we established the diagnosis. Now, in Part 2, we move to the core of management: Antiretroviral Therapy (ART). Gone are the days of complex, toxic regimens. The era of Dolutegravir (DTG) and the "Test and Treat" policy has revolutionized HIV care. However, with potent drugs come critical responsibilities: managing drug-drug interactions (especially with Rifampicin), understanding the definition of Treatment Failure, and knowing exactly when to start Post-Exposure Prophylaxis (PEP). 📝 Topics Covered in This Video: Baseline Workup: Differentiating "Essential" labs from "Physician-Directed" investigations. ART Initiation: Why TLD (Tenofovir + Lamivudine + Dolutegravir) is the gold standard and the pharmacology behind Triple Therapy. Dolutegravir (DTG) Pearls: Managing interactions with Metformin, Antacids, and Anti-epileptics. TB-HIV Co-infection: The critical rule of starting ART within 2 weeks and double-dosing DTG with Rifampicin. Monitoring: The shift from CD4 monitoring to Viral Load monitoring. Prophylaxis: Indications for Cotrimoxazole (CPT) and TB Preventive Therapy (TPT). Post-Exposure Prophylaxis (PEP): The 72-hour window and the 28-day regimen. Primary: HIV Treatment Guidelines 2024, Antiretroviral Therapy, Dolutegravir Side Effects, TLD Regimen, Post Exposure Prophylaxis HIV. Clinical: TB HIV Co-infection treatment, Cotrimoxazole Prophylaxis, HIV Viral Load Monitoring, Immune Reconstitution Inflammatory Syndrome (IRIS), Tenofovir Nephrotoxicity. Exams: NEET SS Medicine, INI SS, MRCP PACES, Harrison's Internal Medicine, USMLE Step 2 CK Pharmacology. References & Further Reading Harrison's Principles of Internal Medicine, 21st Ed: Chapter on Human Immunodeficiency Virus (Treatment). NACO Guidelines (2021/2023): Antiretroviral Therapy for Adults and Adolescents. WHO Consolidated Guidelines: HIV Prevention, Testing, Treatment, Service Delivery and Monitoring. BHIVA Guidelines: Treatment of HIV-1-positive adults with antiretroviral therapy. Rapid Review Questions (Exam-Style) Question 1 (Pharmacology/Interactions): A 35-year-old male on a TLD regimen (Tenofovir/Lamivudine/Dolutegravir) for HIV is diagnosed with Pulmonary Tuberculosis. You initiate standard ATT containing Rifampicin. What adjustment to the ART regimen is mandatory? A. Switch Dolutegravir to Efavirenz. B. Increase Dolutegravir to 50 mg Twice Daily. C. Stop ART until the intensive phase of ATT is over. D. No dose adjustment is required. Answer: B. Rifampicin is a potent inducer of UGT1A1 and CYP3A4, reducing Dolutegravir concentrations. To maintain therapeutic levels, DTG must be increased to 50mg BID during TB treatment and for 2 weeks after stopping Rifampicin. Question 2 (Prophylaxis): A patient on ART has a rising CD4 count. Currently, it is 420 cells/mm³. He has been on Cotrimoxazole Preventive Therapy (CPT). When can you safely discontinue CPT? A. Immediately, as CD4 is more than 200. B. When CD4 more than 350 on two occasions, 6 months apart. C. CPT is lifelong regardless of CD4 count. D. When the Viral Load becomes undetectable. Answer: B. According to WHO/NACO guidelines, CPT can be stopped when the CD4 count is more than 350 cells/mm³ on two consecutive visits spaced 6 months apart, indicating sustained immune recovery. 💡 Teacher’s Insight (The "Extra Step") Engagement Strategy: The "Pinned Comment" Pin this comment to drive home a critical clinical point that often traps students: 🧠 Clinical Pearl / Exam Trap: The "Paradox" of Treatment: You start a patient on ART. Two weeks later, they come back with high fever and a massive enlargement of cervical lymph nodes. Is this Treatment Failure? NO. This is likely IRIS (Immune Reconstitution Inflammatory Syndrome). The immune system has "woken up" and is attacking a latent infection (usually TB or Crypto). The Golden Rule: Do NOT stop ART. Treat the opportunistic infection and add steroids if the reaction is life-threatening. Have you managed a case of IRIS? How did you distinguish it from failure? Let me know below! 👇