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Key Clinical Updates in Choosing an Antiretroviral Treatment Regimen

Lenacapavir is FDA-approved in combination with oral antiretrovirals with residual activity for patients with multidrug-resistant HIV, based on the results of the CAPELLA study. Lenacapavir is a first-in-class capsid inhibitor that is very potent and can be given as a single subcutaneous injection every 26 weeks after two oral loading doses.

Segal-Maurer S et al; CAPELLA Study Investigators. N Engl J Med. [PMID: 35544387]

Treatment for HIV infection can be broadly divided into the following categories: (1) prophylaxis for opportunistic infections, malignancies, and other complications of HIV infection; (2) treatment of opportunistic infections, malignancies, and other complications of HIV infection; and (3) treatment of the HIV infection itself with ART.

A. Prophylaxis for Complications of HIV Infection

In general, decisions about prophylaxis of opportunistic infections are based on the CD4 count, recent HIV viral load, and a history of having had the infection in the past. Studies have shown that in patients with robust improvements in immune function—as measured by increases in CD4 counts above the levels that are used to initiate treatment—or prolonged virologic suppression in the setting of poor immunologic response, prophylactic regimens can safely be discontinued.

Because people with advanced HIV infection are susceptible to a number of opportunistic pathogens, the use of agents with activity against more than one pathogen is preferable. It has been shown, for example, that trimethoprim-sulfamethoxazole confers protection against toxoplasmosis in individuals receiving this medication for Pneumocystis prophylaxis.

1. Prophylaxis against Pneumocystis pneumonia

Patients with CD4 counts below 200 cells/mcL, a CD4 lymphocyte percentage below 14%, or oral candidiasis should be offered primary prophylaxis for Pneumocystis pneumonia. Patients with a history of Pneumocystis pneumonia should receive secondary prophylaxis until their viral load is undetectable and they have maintained a CD4 count of 200 cells/mcL or more while receiving ART for longer than 3 months. Regimens for Pneumocystis prophylaxis are given in Table 33–6.

Table 33–6.Pneumocystis jirovecii prophylaxis, in order of preference.

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