Starting Antiretroviral Therapy: Building the Regimen Around the Patient

A husband is diagnosed with HIV in 2013 with a CD4 count of 330 and started on an older three-drug regimen. His wife tests positive too, but under the guidelines of the time she is simply monitored rather than treated, since treatment decisions then hinged on CD4 count. Twelve years later, her CD4 count has fallen from 960 to 670, and she is still waiting to be offered therapy. The case is a useful marker of how much antiretroviral policy has moved in a decade, and of what a modern regimen actually looks like.

Treat Everyone, Regardless of CD4 Count

Since 2015, and adopted a couple of years later in Indian settings, the guiding principle in HIV care has been to treat every diagnosed patient immediately, irrespective of CD4 count. The wife in this case should have started therapy years earlier under the older guidance; under current guidance, the answer to whether she should start now is an unambiguous yes.

The Backbone of a Modern Regimen

The workhorse combination today is two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) plus one integrase strand transfer inhibitor. In practice, this usually means tenofovir with lamivudine or emtricitabine, paired with dolutegravir or bictegravir, and increasingly delivered as a single pill taken once a day with minimal food restrictions. This is a marked shift from the older regimens built around zidovudine, lamivudine and nevirapine, which carried a heavier side-effect load and a stricter dosing schedule.

Why the Same Regimen Doesn't Suit Every Patient

A 52-year-old woman, recently widowed after her HIV-positive husband died of cardiac complications, illustrates why regimen choice is a whole-patient decision rather than a fixed protocol. She was osteopenic and post-menopausal, asthmatic on long-term inhaled steroids, hypertensive and obese, with a haemoglobin of 9.9, a CD4 count of 398 and a high viral load. Tenofovir disoproxil fumarate (TDF), the default NRTI backbone for most patients, carries two well-known risks: further bone density loss and reduced kidney function. In a patient already at high risk on both fronts, that trade-off has to be weighed directly rather than defaulted into. Regimen selection has to account for the patient's other conditions, including psychiatric medication that can interact with antiretrovirals, pill burden and how many times a day the patient can realistically dose, and each drug's own resistance barrier, not just which combination is theoretically most potent.

Where TAF Fits as an Alternative

Tenofovir alafenamide (TAF), a newer formulation, avoids the bone and kidney toxicity associated with TDF, which makes it a better fit for patients like the 52-year-old case above. Its trade-off runs the other way: TAF is associated with lipid disturbances and a higher BMI over time, so it isn't a universal upgrade, only a different set of risks to weigh against the same patient's actual profile.