66.3 Chronic HIV Infection Management & Primary Care Integration

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

66.3 Chronic HIV Infection Management & Primary Care Integration

Key Takeaways Explain This Topic AI

Antiretroviral therapy (ART) is recommended for ALL individuals with HIV regardless of CD4+ T-cell count immediately upon diagnosis; 'Undetectable = Untransmittable' (U=U) confirms that patients with sustained viral load <200 copies/mL have zero risk of sexually transmitting HIV.

Preferred first-line initial ART regimens are anchored by a second-generation Integrase Strand Transfer Inhibitor (INSTI) with a high barrier to resistance: bictegravir/tenofovir alafenamide/emtricitabine (Biktarvy single-tablet daily) or dolutegravir with 2 NRTIs; the 2-drug regimen dolutegravir/lamivudine (Dovato) is approved ONLY if baseline HIV RNA is <500,000 copies/mL, HBV surface antigen is negative, and no resistance mutations exist.

Primary prophylaxis against Pneumocystis jirovecii pneumonia (PJP) is mandated when CD4 count <200 cells/μL (or CD4% <14%) using TMP-SMX (1 DS tablet daily; provides cross-prophylaxis against Toxoplasma gondii); prophylaxis is safely discontinued once CD4 >200 cells/μL for ≥3 consecutive months on ART.

Primary prophylaxis against Mycobacterium avium complex (MAC) with azithromycin is NO LONGER recommended for patients with CD4 <50 cells/μL if they are immediately initiating effective ART, per updated DHHS/CDC guidelines.

Per the landmark REPRIEVE trial, statin therapy (e.g., pitavastatin 4 mg daily or atorvastatin) is indicated to reduce major adverse cardiovascular events (MACE) in individuals with HIV aged 40–75 with low-to-moderate ASCVD risk due to chronic heightened arterial inflammation; live attenuated vaccines (MMR, Varicella) are strictly contraindicated when CD4 <200 cells/μL.

Last updated: September 2026

Antiretroviral Therapy (ART): Principles & Modern Regimens

Advances in antiretroviral therapy (ART) have transformed HIV from a fatal progressive immunodeficiency into a manageable, chronic medical condition. Modern primary care integration requires family physicians to manage both viral suppression and long-term cardiometabolic, oncologic, and infectious comorbidities.

Universal Initiation & The U=U Paradigm

DHHS / WHO Recommendation : ART is recommended for all HIV-infected individuals, regardless of their CD4+ T-cell count , as soon as possible following diagnosis (including same-day "rapid start" ART), to decrease morbidity and mortality and prevent transmission.

Undetectable = Untransmittable (U=U) : Large-scale multicenter prospective studies (PARTNER 1, PARTNER 2, and Opposites Attract) proved conclusively that individuals with HIV who maintain a sustained plasma viral load of < 200 copies/mL <200\text{ copies/mL} < 200 copies/mL (undetectable) on ART have ZERO risk of sexually transmitting HIV to their HIV-negative sexual partners. This paradigm eliminates stigma and promotes lifelong treatment adherence.

First-Line Antiretroviral Regimens

First-line initial regimens for ART-naive adults consist of a second-generation Integrase Strand Transfer Inhibitor (INSTI) with a high barrier to genetic resistance, combined with two Nucleoside Reverse Transcriptase Inhibitors (NRTIs) , or a specific approved two-drug regimen : FIRST-LINE INITIAL ART REGIMENS (DHHS GUIDELINES)

Regimen Formulation Components & Class Composition Dosing & Clinical Advantages

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Biktarvy • Bictegravir (50 mg INSTI) • Single tablet once daily with or without food.

(Single-Tablet Regimen) • Tenofovir Alafenamide (TAF 25 mg NRTI) • Extremely high barrier to resistance;

Emtricitabine (FTC 200 mg NRTI) excellent renal and bone safety profile.

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Triumeq • Dolutegravir (50 mg INSTI) • Single tablet once daily.

(Single-Tablet Regimen) • Abacavir (ABC 600 mg NRTI) • MANDATORY HLA-B*5701 SCREENING PRIOR

Lamivudine (3TC 300 mg NRTI) TO USE (prevents fatal hypersensitivity!).
Contraindicated if patient has HBV coinfection.

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Tivicay + Descovy or Truvada • Dolutegravir (50 mg INSTI) • Two tablets once daily.

(Multi-Tablet Regimen) • PLUS [TAF 25 mg / FTC 200 mg] (Descovy) • Rapid viral suppression; minimal CYP interactions;

OR [TDF 300 mg / FTC 200 mg] (Truvada) high resistance barrier.

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Dovato • Dolutegravir (50 mg INSTI) • Single tablet once daily (TWO-DRUG REGIMEN).

(Approved 2-Drug Regimen) • Lamivudine (3TC 300 mg NRTI) • STRICT RESTRICTIONS: Baseline viral load
must be < 500,000 copies/mL, no HBV coinfection,

and no prior M184V/I resistance mutations.

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Critical Pharmacological & Organ-Specific Considerations

Tenofovir Alafenamide (TAF) vs. Tenofovir Disoproxil Fumarate (TDF) :

TDF (Older Formulation) : High plasma circulating tenofovir concentrations cause proximal renal tubular dysfunction ( Fanconi syndrome : hypophosphatemia, proteinuria, glycosuria, acute kidney injury) and progressive accelerated bone mineral density loss / osteomalacia .

TAF (Newer Formulation) : A targeted prodrug that is taken up intracellularly into lymphoid cells and peripheral blood mononuclear cells before hydrolyzing into active tenofovir diphosphate. Plasma circulating tenofovir levels are 90% lower , resulting in significantly less renal tubular toxicity and minimal bone mineral density impact. However, TAF is associated with greater weight gain and mild lipid elevations compared to TDF.

Abacavir & The HLA-B*5701 Hypersensitivity Reaction :

Patients possessing the HLA-B*5701 allele (present in 5–8% of Caucasians) have an extreme risk of a life-threatening, multi-system hypersensitivity reaction (fever, rash, nausea, vomiting, dyspnea, hypotension).

Mandatory Rule : Every patient must be screened for HLA-B*5701 before initiating abacavir . If positive, abacavir is permanently contraindicated and documented as an allergy. Never rechallenge a patient suspected of abacavir hypersensitivity, as re-exposure can be rapidly fatal.

Coadministration with Polyvalent Cations :

Integrase inhibitors (bictegravir, dolutegravir) chelate divalent/trivalent cations ( M g 2 + , A l 3 + , C a 2 + , F e 2 + Mg^{2+}, Al^{3+}, Ca^{2+}, Fe^{2+} M g 2 + , A l 3 + , C a 2 + , F e 2 + ). Antacids, sucralfate, calcium, or iron supplements bind INSTIs in the gastrointestinal tract, dropping absorption by > 70 % >70\% > 70% . INSTIs must be taken at least 2 hours before or 6 hours after cation-containing antacids/supplements.

Laboratory Monitoring Schedule

Baseline Evaluation : Plasma HIV-1 RNA viral load, CD4+ T-lymphocyte count, HIV genotype/resistance test (reverse transcriptase and protease, ± integrase), complete blood count, comprehensive metabolic panel (BUN, creatinine, eGFR, LFTs), fasting lipid profile, HbA1c, urinalysis with urine protein/creatinine ratio, HLA-B*5701 screen, Hepatitis A/B/C serologies, syphilis testing (RPR/VDRL), gonorrhea/chlamydia NAAT, and baseline IGRA/tuberculin skin test.

Longitudinal Monitoring :

Plasma HIV RNA and CD4 count: Check 2 to 4 weeks after ART initiation/modification, then every 3 to 6 months until virologically suppressed ( < 50 copies/mL <50\text{ copies/mL} < 50 copies/mL ). Once suppressed for > 1 – 2 >1–2 > 1–2 years with CD4 > 300 – 500 cells/ μ L >300–500\text{ cells/}\mu\text{L} > 300–500 cells/ μ L , viral load can be monitored every 6 months , and routine CD4 monitoring may be optional.

Opportunistic Infection (OI) Prophylaxis Protocol

Opportunistic infections correlate directly with the degree of cell-mediated immunosuppression quantified by the absolute CD4+ T-cell count : OPPORTUNISTIC INFECTION PROPHYLAXIS PROTOCOL (DHHS / CDC)

CD4+ Threshold Target Pathogen First-Line Prophylactic Regimen Alternative Regimens & Stopping Criteria

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CD4 < 200 cells/μL Pneumocystis jirovecii • TMP-SMX (Bactrim) 1 Double-Strength • Alternatives (Sulfa allergy / G6PD):

(or CD4% < 14% or Pneumonia (PJP) (DS) tablet PO once daily - Dapsone 100 mg daily (check G6PD!)
oral thrush) • Co-protects against Toxoplasma gondii - Atovaquone 1500 mg daily with meals

- Aerosolized Pentamidine 300 mg monthly.

• DISCONTINUATION: Stop when CD4 > 200

for ≥ 3 consecutive months on ART.

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CD4 < 100 cells/μL Toxoplasma gondii Encephalitis • TMP-SMX 1 DS tablet PO once daily • Alternative: Dapsone 50 mg daily +

(and positive (Cerebral mass lesions, seizures) (same regimen as PJP prophylaxis) Pyrimethamine 50 mg/week + Leucovorin 25 mg/wk,

Toxoplasma IgG) or Atovaquone 1500 mg daily.

• DISCONTINUATION: Stop when CD4 > 200

for ≥ 3 consecutive months on ART.

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CD4 < 50 cells/μL Mycobacterium avium Complex (MAC) • ROUTINE PRIMARY PROPHYLAXIS IS NO • Primary prophylaxis with Azithromycin

(Disseminated fever, drenching LONGER RECOMMENDED in patients who 1200 mg weekly is RESERVED ONLY for
night sweats, severe anemia, IMMEDIATELY INITIATE ART. patients NOT on effective ART or with

hepatosplenomegaly) persistent viremia.

• Stop when effective ART is initiated.

Immune Reconstitution Inflammatory Syndrome (IRIS)

When ART is initiated in a patient with severe baseline immunosuppression (typically CD4 < 100 cells/ μ L <100\text{ cells/}\mu\text{L} < 100 cells/ μ L ), rapid immune recovery and proliferation of pathogen-specific CD4 memory cells can trigger an exuberant, dysregulated hyperinflammatory response termed IRIS :

Paradoxical IRIS : Exaggerated, paradoxical clinical worsening of a treated opportunistic infection (e.g., patient being treated for pulmonary tuberculosis suddenly develops high fevers, expanding infiltrates, and massive lymphadenopathy despite microbiological cure).

Unmasking IRIS : Sudden, aggressive clinical presentation of a previously occult, subclinical, undiagnosed opportunistic pathogen (e.g., undiagnosed cryptococcal meningitis erupting with intracranial hypertension and cranial nerve palsies 2 weeks after ART start).

Management Principles :

DO NOT STOP ART in most cases: Maintain antiretroviral therapy to ensure long-term immune restoration.

Treat the underlying opportunistic infection aggressively with specific antimicrobials.

For severe, life-threatening inflammation (e.g., CNS IRIS, tracheal compression, severe hypoxemic respiratory failure): Administer systemic corticosteroids ( prednisone 0.5 to 1.0 mg/kg/day tapered over 2 to 6 weeks).

Exception / Timing Nuance : In acute cryptococcal meningitis , ART must be delayed for 2 to 6 weeks after initiating antifungal therapy (amphotericin B + flucytosine) because early ART initiation in cryptococcal CNS disease dramatically increases mortality from fatal cerebral edema.

Primary Care Health Maintenance & Comorbidity Management

Because effective ART achieves normal life expectancies, individuals living with chronic HIV face non-AIDS chronic diseases driven by persistent low-grade immune activation, systemic inflammation, and antiretroviral metabolic effects.

Cardiovascular Disease & The REPRIEVE Trial Guidelines

Patients with HIV experience a 1.5- to 2-fold increased relative risk of atherosclerotic cardiovascular disease (ASCVD) compared to uninfected controls, even after adjusting for traditional risk factors.

The Landmark REPRIEVE Trial (2023) : Randomized over 7,700 individuals with HIV aged 40–75 with low-to-moderate 10-year ASCVD risk (median risk ~4.5%) to pitavastatin 4 mg daily versus placebo. Statin therapy resulted in a 35% relative reduction in major adverse cardiovascular events (MACE) and an 11% reduction in all-cause mortality.

Updated Primary Care Guidelines : Clinicians should recommend moderate-intensity statin therapy (e.g., pitavastatin 4 mg daily, atorvastatin 20 mg daily, or rosuvastatin 10 mg daily ) for all individuals with HIV aged 40 to 75 years with low-to-moderate ASCVD risk ( < 20 % <20\% < 20% ), independent of baseline LDL levels.

Drug Interaction Alert : Simvastatin and lovastatin are STRICTLY CONTRAINDICATED with protease inhibitors (atazanavir, darunavir) and cobicistat/ritonavir boosters because CYP3A4 inhibition increases statin levels > 20 >20 > 20 -fold, precipitating fatal rhabdomyolysis.

Cancer Screening Protocol in Chronic HIV CANCER SCREENING RECOMMENDATIONS IN HIV

Malignancy Target Population & Screening Protocol Clinical Rationale & Notes

Cervical Cancer • Begin cervical Pap smear at diagnosis or onset of • Markedly increased incidence of
sexual activity (no later than age 21). HPV persistence, CIN II/III,

• Screen annually for 3 consecutive normal results; and invasive cervical carcinoma.

then co-testing (cytology + HPV) every 3 years. • AIDS-defining malignancy.

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Anal Cancer • Consider Anal Cytology (Anal Pap) every 1–3 years for: • ANCHOR Trial demonstrated that
Men who have sex with men (MSM) treating biopsy-proven high-grade
Transgender women squamous intraepithelial lesions (HSIL)

- Women with history of cervical/vulvar HSIL with ablation reduces anal cancer by 57%.

• Abnormal anal cytology warrants High-Resolution Anoscopy (HRA).

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Breast & Colorectal • Follow standard average-risk guidelines: • Same as general population.

Malignancies - Screening mammography starting at age 40 (USPSTF).

- Colorectal cancer screening from age 45 to 75.

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Hepatocellular Carcinoma • Hepatic ultrasound ± serum alpha-fetoprotein (AFP) • Accelerated progression from

every 6 months in patients with cirrhosis or chronic HBV/HCV. chronic hepatitis to cirrhosis in HIV.

Comprehensive Immunization Guidelines in Chronic HIV

Immunizations must be proactively updated, with strict precautions regarding live vaccines:

Pneumococcal Conjugate Vaccine : Single dose of PCV20 (Prevnar 20) alone, OR PCV15 followed by PPSV23 (Pneumovax 23) ≥ 8 \ge 8 ≥ 8 weeks later.

Hepatitis B Virus (HBV) : Double-dose recombinant hepatitis B vaccine series (40 mcg at 0, 1, and 6 months) OR the 2-dose CpG-adjuvanted vaccine ( Heplisav-B 20 mcg at 0 and 1 month). Check post-vaccination surface antibody (anti-HBs) titers 1–2 months after series completion; target anti-HBs ≥ 10 mIU/mL \ge 10\text{ mIU/mL} ≥ 10 mIU/mL .

Meningococcal Conjugate (MenACWY) : 2-dose primary series administered 8 weeks apart, with a booster dose every 5 years throughout life.

Recombinant Zoster Vaccine (Shingrix) : 2 doses separated by 2 to 6 months for all adults aged ≥ 19 \ge 19 ≥ 19 years with HIV, regardless of prior zoster history or CD4 count.

Human Papillomavirus (HPV) : 3-dose series (0, 1–2, and 6 months) of recombinant 9-valent HPV vaccine through age 45 years .

Annual Influenza & COVID-19 : Routine seasonal intramuscular inactivated influenza vaccine and updated COVID-19 mRNA vaccines.

[!CRITICAL] Live Attenuated Vaccine Prohibition Live attenuated vaccines (MMR, Varicella, Yellow Fever, oral typhoid, intranasal live influenza) are STRICTLY CONTRAINDICATED in any individual with HIV whose CD4+ T-cell count is < 200 cells/ μ L < 200\text{ cells/}\mu\text{L} < 200 cells/ μ L (or CD4 percentage < 14 % <14\% < 14% ) . Administration of live replication-competent virus in this immunocompromised window can cause uncontrolled, fatal vaccine-strain disseminated infection.

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