Prognosis

Untreated, HIV leads to death on average 8–10 years after infection.

Progression varies among individuals: Some patients may die within a few years while others can remain asymptomatic for decades.

• Untreated individuals with advanced HIV infection usually die within a few years (median survival is 12–18 months).

  • Some untreated individuals show only slow progression and can remain asymptomatic for more than 20 years.

  • In rare cases, untreated individuals have no detectable viremia and continue to have high CD4 counts for long periods.

The average life expectancy of HIV-infected individuals who receive adequate antiretroviral treatment is approaching that of noninfected individuals of the same age. [63][64]

Individuals with HIV infection on adequate antiretroviral therapy are more likely to develop chronic comorbidities (e.g., cardiovascular disease, diabetes, cancer) than healthy individuals

Adequate antiretroviral treatment

Viral set point and CD4 count

Exposure to opportunistic pathogens

Individual genetic properties

HIV species and subtype

Preexisting conditions

Definition: the use of ART to prevent infection in individuals at high risk of contracting HIV

Eligibility

• Negative HIV test result and no signs or symptoms of acute HIV infection

• Normal renal function test

• Fulfillment of at least one indication criterion

Indications

• Men who have sex with men

  • Any anal sex without condoms in the past 6 months

  • A bacterial STI (e.g., syphilis, chlamydia, or gonorrhea) diagnosed or reported in the past 6 months

• Heterosexual men and women

  • Sexually active with an HIV-positive partner

  • Inconsistent or no condom use during sexual activity with one or more sexual partners of unknown HIV status

  • A bacterial STI in the past 6 months

• Individuals who inject drugs with high-risk needle behavior (e.g., sharing needles or equipment) or with an HIV-positive injection partner

Timing: prior to the exposure to HIV and continued for a month after the exposure [69]

Regimens

• Preferred regimen: emtricitabine PLUS tenofovir disoproxil (may be given as a single tablet of truvada)

• Alternative (not for patients at risk via receptive vaginal sex): emtricitabine PLUS tenofovir alafenamide (may be given as a single tablet of descovy) [70][71]

Follow-up

• Every 3 months

  • Testing: HIV screen, STI screening, pregnancy test if indicated

  • Assessment and counseling: medication adherence, side effects, risk behaviors

• Every 6 months: Check renal function.

• Every 12 months: Assess the need for continuing HIV PrEP.

Definition: a short course of ART taken by patients after a potential exposure to HIV

Indications

• Injury with HIV-contaminated instruments or needles

• Contamination of open wounds or mucous membranes with HIV-contaminated fluids

• Unprotected sexual activity with a known or potentially HIV-infected person

Timing: Initiate as soon as possible (ideally within 1–2 hours of exposure)

Drugs: a three-drug regimen is recommended (similar to ART). Typically, this includes a nucleoside/nucleotide combination NRTI plus an integrase inhibitor, e.g. : [17]

• Tenofovir disoproxil PLUS emtricitabine (may be given as a single combined tablet of truvada)

• PLUS one of the following:

  • Dolutegravir

  • Raltegravir

Further management

• For occupational exposure, follow the procedure for health care personnel exposures (see “Infection Prevention and Control”).

• Counsel patients to use barrier contraception, avoid donation of blood, semen, or tissue, and, if possible, avoid pregnancy and breastfeeding throughout the 6-month follow-up period.

• Ensure patients are educated about the adverse effects of medications and that they have appointments booked for testing