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id.hiv-initial.chronic.v1PRODUCTION
id.hiv-initial.chronic.v1

HIV — initial evaluation & rapid ART start

infectious_diseasechronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Chronic adult HIV initial evaluation + rapid ART start (DHHS 2024; START NEJM 2015; TEMPRANO NEJM 2015). Pregnancy, pediatrics, advanced disease, PEP/PrEP routed to sibling engines

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Patient inputs (15)

HBV co-infection — TDF/TAF active dual-coverage; reactivation risk if dropped (DHHS 2024)

Co-infection screening; influences DAA + ART selection (DHHS 2024; AASLD/IDSA 2024)

Differentiate antibody screen positive from active infection — Geenius / RNA confirmatory (DHHS 2024; CDC 2014 algorithm)

Treatment-naïve baseline; suppression target <50 by 6 months (DHHS 2024; IAS-USA 2024)

OI prophylaxis thresholds — PCP <200, MAC <50, toxo <100; staging (DHHS 2024 OI guidelines)

Baseline resistance testing; informs regimen if transmitted resistance (DHHS 2024; IAS-USA 2024)

Baseline before integrase / NNRTI-based regimens (DHHS 2024)

STI co-screen mandated (DHHS 2024; CDC STI guidelines 2021)

STI co-screen at all exposure sites (DHHS 2024; CDC STI guidelines 2021)

IGRA / TST + CXR; LTBI prophylaxis prevents disease (DHHS 2024; WHO 2024)

TDF nephrotoxicity / TAF preferred for eGFR <60 (DHHS 2024)

Determines regimen + perinatal counseling — dolutegravir safety reassuring per Tsepamo / IMPAACT 2010 (DHHS 2024; WHO 2024)

Adherence determinants; warm hand-off to behavioral health (DHHS 2024)

ART (especially boosted PI) cardiometabolic monitoring baseline (DHHS 2024; D:A:D study)

Baseline metabolic risk; INSTI-associated weight gain monitoring (DHHS 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningsevere_abacavir_hypersensitivity
    Fever + rash + GI / respiratory / constitutional symptoms within 6 weeks of ABC start (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaids_defining_illness_at_presentation (IDSA 2024)
    PCP, esophageal candidiasis, cryptococcal meningitis, KS, cervical cancer, CMV, lymphoma, MAC, etc. (DHHS 2024 OI guidelines)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecd4_under_200_no_prophylaxis
    CD4 <200 without PCP prophylaxis (DHHS 2024 OI guidelines)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverevirologic_failure
    Detectable VL after 6 months on ART OR rebound from suppressed (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereiris_diagnosis
    Worsening symptoms 2-12 weeks after ART start — paradoxical worsening of underlying OI or unmasking (DHHS 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_hiv
    Pregnancy in HIV+ patient (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehbv_coinfection
    HIV + HBsAg+ co-infection (DHHS 2024 — HBV/HIV co-management)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment
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Recommended regimen

HIV — first-line ART (DHHS / IAS-USA 2024)
axis: hiv_initial_art_first_line
Selected axis "HIV — first-line ART (DHHS / IAS-USA 2024)" by default fallback (first axis)
  • bictegravir-emtricitabine-tenofovir_alafenamide
    first line
    INSTI_NRTI_combination
    50/200/25 mg PO daily • PO • daily
    triggers: treatment_naive, no_specific_resistance, eGFR_>=30
    DHHS + IAS-USA 2024 — Biktarvy first-line; high barrier to resistance; no HLA-B*5701 needed; minimal DDIs
    rxcui 1996259
  • dolutegravir-lamivudine
    first line
    INSTI_NRTI_dual
    50/300 mg PO daily • PO • daily
    triggers: treatment_naive, VL_<500K, no_HBV_co_infection, no_K65R_M184V_resistance
    DHHS + IAS-USA 2024 — Dovato 2-drug regimen; not for HBV+ (3TC monotherapy on HBV)
    rxcui 2122518
  • dolutegravir-abacavir-lamivudine
    second line
    INSTI_NRTI_combination
    50/600/300 mg PO daily • PO • daily
    triggers: HLA_B5701_negative, no_high_CV_risk, eGFR_<30_alternative
    DHHS — Triumeq alternative; HLA-B*5701 must be negative (abacavir hypersensitivity) (IDSA 2024)
    rxcui 1546887
  • dolutegravir
    first line
    INSTI
    50 mg PO daily (50 BID if rifampin) • PO • daily
    triggers: use_in_pregnancy_per_Tsepamo_reassurance, building_block_with_other_NRTI
    DHHS + WHO 2024 — DTG safe in pregnancy (Tsepamo / IMPAACT 2010)
    rxcui 1433868
  • cabotegravir-rilpivirine
    second line
    INSTI_NNRTI_long_acting_injectable
    600/900 mg IM × 1 then 400/600 mg q4-8 weeks • IM • q4-8 weeks
    triggers: virologically_suppressed, adherence_difficulty, no_NNRTI_resistance
    DHHS + IAS-USA 2024 — long-acting maintenance; ATLAS / FLAIR. non_pharm: co-packaged two-ingredient long-acting injectable (Cabenuva) with no single resolving RxNorm ingredient code; prior rxcui 1486991 resolved to glucosamine at RxNav (verified 2026-05-22)

outpatient playbook — drug actions (10)

  1. 1. bictegravir/FTC/TAF
    50/200/25 mg PO daily • PO • daily
    trigger: Confirmed HIV, treatment-naive, eGFR ≥30, no contraindication; rapid-start at diagnosis encounter (DHHS 2024; RAPID Pilcher CID 2017)
    DHHS 2024 + IAS-USA 2024 first-line; high barrier to resistance; no HLA-B*5701 needed; rapid-start eligible without waiting for genotype (START NEJM 2015 PMID 26192873; TEMPRANO NEJM 2015 PMID 26193126)
  2. 2. dolutegravir + 3TC alternative (Dovato)
    DTG/3TC 50/300 mg PO daily • PO • daily
    trigger: Treatment-naive, VL <500K, no HBV co-infection, no K65R/M184V (DHHS 2024; IAS-USA 2024)
    DHHS 2024 + IAS-USA 2024 2-drug option; GEMINI-1/2 non-inferiority; not for HBV+ (3TC monotherapy on HBV)
  3. 3. TMP-SMX prophylaxis
    1 DS or 1 SS PO daily • PO • daily
    trigger: CD4 <200 (DHHS 2024 OI)
    PCP prophylaxis; also Toxo at <100 (DHHS 2024 OI guidelines). Discontinue when CD4 > 200 × 3 mo + VL suppressed.
  4. 4. azithromycin MAC prophylaxis
    1200 mg PO weekly • PO • weekly
    trigger: CD4 <50 and not on ART / VL detectable (DHHS 2024 OI)
    MAC prophylaxis. Discontinue when CD4 > 100 × 3 mo + VL suppressed (DHHS 2024 OI).
  5. 5. isoniazid LTBI
    300 mg PO daily × 9 mo (or 4 mo rifampin or 3 mo INH-rifapentine alternates) • PO • daily × 9 mo
    trigger: LTBI (positive IGRA/TST + no active TB) (DHHS 2024; WHO 2024)
    LTBI treatment prevents progression regardless of CD4 (DHHS 2024; WHO 2024)
  6. 6. HBV vaccine series
    Heplisav-B 2-dose preferred (or Engerix-B 3-dose; double-dose Engerix if low CD4 + non-response) • IM • series
    trigger: Non-immune (HBsAg- and anti-HBs <10) (ACIP 2024; DHHS 2024)
    Double-dose protocols if low CD4 (DHHS 2024; ACIP 2024)
  7. 7. pitavastatin (REPRIEVE-criteria primary prevention)
    4 mg PO daily • PO • daily
    trigger: Age 40-75, 10-year ASCVD risk 5-19%, on ART (REPRIEVE NEJM 2023 PMID 37486775)
    REPRIEVE 2023 reduced MACE 35%; pitavastatin preferred (no boosted-PI DDI); if boosted-PI present: atorvastatin 20 mg max OR rosuvastatin 10 mg max; avoid simvastatin/lovastatin (rhabdomyolysis)
  8. 8. switch TDF→TAF if eGFR < 50 or osteoporotic
    TAF 25 mg PO daily (within Biktarvy or Descovy-based regimen) • PO • daily
    trigger: eGFR < 50 OR proteinuria > 200 mg/g OR DEXA T-score < -2.5 OR FRAX 10-yr major fracture risk > 20% (DHHS 2024)
    TAF less nephrotoxicity + less bone density loss than TDF (DHHS 2024); dolutegravir creatinine artifact awareness — DTG inhibits OCT2 → creatinine ↑ ~10-15% without true GFR change
  9. 9. cabotegravir + rilpivirine LAI (Cabenuva) for adherence-challenged + suppressed
    600/900 mg IM × 1 oral lead-in, then 400/600 mg IM Q4-8 weeks (or 600/900 mg Q8W) • IM • Q4-8 weeks
    trigger: VL < 50 × ≥ 6 months on oral, no NNRTI resistance, no HBV co-infection, adherence difficulty / patient preference (ATLAS/FLAIR pooled JAIDS 2020 PMID 33136751; FLAIR NEJM 2020)
    ATLAS/FLAIR non-inferior maintenance of VL suppression; addresses adherence barriers + patient preference
  10. 10. HCV DAA treatment if HCV co-infected
    sofosbuvir/velpatasvir 400/100 mg PO daily × 12 wk OR glecaprevir/pibrentasvir 100/40 mg × 3 tabs PO daily × 8 wk (per HCV genotype; routed to id.hcv-initial.chronic.v1) • PO • daily
    trigger: HCV co-infection (anti-HCV+ with detectable HCV RNA) — AASLD/IDSA 2024
    DAA + ART DDI screen mandatory (velpatasvir + TDF requires efavirenz avoidance; glecaprevir + atazanavir contraindicated; raltegravir compatible). Routed to id.hcv-initial.chronic.v1.

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Positive HIV screen (4th-gen Ag/Ab) + confirmatory (DHHS 2024; CDC 2014 algorithm); OI presentation (PCP, candidiasis, KS) without prior diagnosis (DHHS 2024 OI guidelines); Mononucleosis-like illness with risk factors (DHHS 2024 — acute HIV).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**HIV — initial evaluation & rapid ART start** (id.hiv-initial.chronic.v1).
Phenotype framing: Acute vs chronic, controller vs progressor, transmitted-resistance candidate, OI-driven presentation (DHHS 2024)
Scope: Chronic adult HIV initial evaluation + rapid ART start (DHHS 2024; START NEJM 2015; TEMPRANO NEJM 2015). Pregnancy, pediatrics, advanced disease, PEP/PrEP routed to sibling engines

No severity triggers fired against current inputs.

Plan

Regimen axis: **HIV — first-line ART (DHHS / IAS-USA 2024)**.
1. bictegravir-emtricitabine-tenofovir_alafenamide 50/200/25 mg PO daily PO daily (INSTI_NRTI_combination, first line) — DHHS + IAS-USA 2024 — Biktarvy first-line; high barrier to resistance; no HLA-B*5701 needed; minimal DDIs
2. dolutegravir-lamivudine 50/300 mg PO daily PO daily (INSTI_NRTI_dual, first line) — DHHS + IAS-USA 2024 — Dovato 2-drug regimen; not for HBV+ (3TC monotherapy on HBV)
3. dolutegravir-abacavir-lamivudine 50/600/300 mg PO daily PO daily (INSTI_NRTI_combination, second line) — DHHS — Triumeq alternative; HLA-B*5701 must be negative (abacavir hypersensitivity) (IDSA 2024)
4. dolutegravir 50 mg PO daily (50 BID if rifampin) PO daily (INSTI, first line) — DHHS + WHO 2024 — DTG safe in pregnancy (Tsepamo / IMPAACT 2010)
5. cabotegravir-rilpivirine 600/900 mg IM × 1 then 400/600 mg q4-8 weeks IM q4-8 weeks (INSTI_NNRTI_long_acting_injectable, second line) — DHHS + IAS-USA 2024 — long-acting maintenance; ATLAS / FLAIR. non_pharm: co-packaged two-ingredient long-acting injectable (Cabenuva) with no single resolving RxNorm ingredient code; prior rxcui 1486991 resolved to glucosamine at RxNav (verified 2026-05-22)

Setting playbook (outpatient) — Confirm HIV, deliver rapid ART start, OI prophylaxis if CD4 low, vaccinate, screen STIs and TB, link to primary care + behavioural support (IDSA 2024)
6. bictegravir/FTC/TAF 50/200/25 mg PO daily PO daily — Confirmed HIV, treatment-naive, eGFR ≥30, no contraindication; rapid-start at diagnosis encounter (DHHS 2024; RAPID Pilcher CID 2017) (DHHS 2024 + IAS-USA 2024 first-line; high barrier to resistance; no HLA-B*5701 needed; rapid-start eligible without waiting for genotype (START NEJM 2015 PMID 26192873; TEMPRANO NEJM 2015 PMID 26193126))
7. dolutegravir + 3TC alternative (Dovato) DTG/3TC 50/300 mg PO daily PO daily — Treatment-naive, VL <500K, no HBV co-infection, no K65R/M184V (DHHS 2024; IAS-USA 2024) (DHHS 2024 + IAS-USA 2024 2-drug option; GEMINI-1/2 non-inferiority; not for HBV+ (3TC monotherapy on HBV))
8. TMP-SMX prophylaxis 1 DS or 1 SS PO daily PO daily — CD4 <200 (DHHS 2024 OI) (PCP prophylaxis; also Toxo at <100 (DHHS 2024 OI guidelines). Discontinue when CD4 > 200 × 3 mo + VL suppressed.)
9. azithromycin MAC prophylaxis 1200 mg PO weekly PO weekly — CD4 <50 and not on ART / VL detectable (DHHS 2024 OI) (MAC prophylaxis. Discontinue when CD4 > 100 × 3 mo + VL suppressed (DHHS 2024 OI).)
10. isoniazid LTBI 300 mg PO daily × 9 mo (or 4 mo rifampin or 3 mo INH-rifapentine alternates) PO daily × 9 mo — LTBI (positive IGRA/TST + no active TB) (DHHS 2024; WHO 2024) (LTBI treatment prevents progression regardless of CD4 (DHHS 2024; WHO 2024))
11. HBV vaccine series Heplisav-B 2-dose preferred (or Engerix-B 3-dose; double-dose Engerix if low CD4 + non-response) IM series — Non-immune (HBsAg- and anti-HBs <10) (ACIP 2024; DHHS 2024) (Double-dose protocols if low CD4 (DHHS 2024; ACIP 2024))
12. pitavastatin (REPRIEVE-criteria primary prevention) 4 mg PO daily PO daily — Age 40-75, 10-year ASCVD risk 5-19%, on ART (REPRIEVE NEJM 2023 PMID 37486775) (REPRIEVE 2023 reduced MACE 35%; pitavastatin preferred (no boosted-PI DDI); if boosted-PI present: atorvastatin 20 mg max OR rosuvastatin 10 mg max; avoid simvastatin/lovastatin (rhabdomyolysis))
13. switch TDF→TAF if eGFR < 50 or osteoporotic TAF 25 mg PO daily (within Biktarvy or Descovy-based regimen) PO daily — eGFR < 50 OR proteinuria > 200 mg/g OR DEXA T-score < -2.5 OR FRAX 10-yr major fracture risk > 20% (DHHS 2024) (TAF less nephrotoxicity + less bone density loss than TDF (DHHS 2024); dolutegravir creatinine artifact awareness — DTG inhibits OCT2 → creatinine ↑ ~10-15% without true GFR change)
14. cabotegravir + rilpivirine LAI (Cabenuva) for adherence-challenged + suppressed 600/900 mg IM × 1 oral lead-in, then 400/600 mg IM Q4-8 weeks (or 600/900 mg Q8W) IM Q4-8 weeks — VL < 50 × ≥ 6 months on oral, no NNRTI resistance, no HBV co-infection, adherence difficulty / patient preference (ATLAS/FLAIR pooled JAIDS 2020 PMID 33136751; FLAIR NEJM 2020) (ATLAS/FLAIR non-inferior maintenance of VL suppression; addresses adherence barriers + patient preference)
15. HCV DAA treatment if HCV co-infected sofosbuvir/velpatasvir 400/100 mg PO daily × 12 wk OR glecaprevir/pibrentasvir 100/40 mg × 3 tabs PO daily × 8 wk (per HCV genotype; routed to id.hcv-initial.chronic.v1) PO daily — HCV co-infection (anti-HCV+ with detectable HCV RNA) — AASLD/IDSA 2024 (DAA + ART DDI screen mandatory (velpatasvir + TDF requires efavirenz avoidance; glecaprevir + atazanavir contraindicated; raltegravir compatible). Routed to id.hcv-initial.chronic.v1.)

Non-pharmacologic actions:
- Partner notification + linkage to PrEP for HIV-negative partners (DHHS 2024; IAS-USA 2024) — TDF/FTC daily OR cabotegravir-LA Q2 mo (Apretude — HPTN 083 PMID 34379922) OR lenacapavir Q6 mo SC (PURPOSE-1 NEJM 2024 PMID 39046157, pending FDA PrEP approval)
- U=U education — sustained VL < 200 cp/mL eliminates sexual transmission risk (PARTNER NEJM 2016 PMID 27404185; PARTNER2 Lancet 2019 PMID 31056293; CDC 2018)
- Behavioral health + suicidality screening + substance use referral (psych.depression.core.v1 + psych.opioid_use_disorder.core.v1 routing); avoid efavirenz neuropsych if comorbid depression or SI
- Sexual health counselling, condoms, contraception (DHHS 2024)
- Cervical (annual cytology if HIV+) / anal cancer screening — HPV high-prevalence (DHHS 2024; IANS 2024 anal-cancer screening for MSM + HIV+ adults > 35)
- Bone health — DEXA baseline at age 50 or earlier with risk factors (low BMI, smoker, glucocorticoid, hypogonadism, family history); FRAX 10-yr risk; switch TDF → TAF if osteoporotic (DHHS 2024)
- Renal function monitoring — eGFR + UACR q6 months; switch TDF → TAF if eGFR < 50 OR proteinuria > 200 mg/g (DHHS 2024); dolutegravir creatinine artifact awareness
- Cardiovascular risk modification — lifestyle (Mediterranean diet, exercise, smoking cessation), BP control, lipid management, REPRIEVE-criteria pitavastatin (DHHS 2024; REPRIEVE NEJM 2023 PMID 37486775; D:A:D Sabin Lancet 2008)
- Nutrition + weight monitoring — INSTI-associated weight gain monitoring (DHHS 2024); particular vigilance with DTG + TAF combos in baseline-obese women
- STI screening q3-6 months in high-risk: syphilis (RPR/treponemal), GC/CT at all exposure sites (urogenital + pharyngeal + rectal triple-site), HCV antibody annually if at risk (DHHS 2024; CDC STI 2021)
- Vaccinations — PCV20 (or PCV21), HPV 9-valent (age 9-26 or shared 27-45), MenACWY + MenB (shared decision for at-risk MSM / complement deficiency), HBV (Heplisav-B preferred), Tdap, MMR + varicella ONLY if CD4 > 200 (live vaccines), influenza annual, COVID-19 per current guidance, mpox JYNNEOS 2-dose for at-risk groups, HepA 2-dose if at risk (ACIP 2024)
- DDI review at every prescription change — DTG + dofetilide contraindicated (arrhythmia); DTG + metformin (cap metformin 1000 mg/day); rifampin + DTG (double DTG to 50 mg BID OR switch to EFV-based); boosted-PI + simvastatin/lovastatin contraindicated; atazanavir + PPI avoid; rilpivirine + PPI contraindicated; integrase + cations spacing (DHHS 2024; Liverpool HIV DDI)

AVOID / contraindication checks:
- Abacavir HLA B5701 test required pre prescription (IDSA 2024)
- Dolutegravir 3TC block if HBV coinfection no HBV coverage (IDSA 2024)
- TDF renal osteo monitor eGFR and DEXA prefer TAF if eGFR<60 (IDSA 2024)
- Dolutegravir abacavir CV risk counselling D:A:D (IDSA 2024)
- Integrase cation DDI iron calcium magnesium spacing (IDSA 2024)
- Rifampin doubles DTG dose or switch (IDSA 2024)

Monitoring

Regimen monitoring:
- VL at 4-8wk then q3mo until suppressed (DHHS 2024; IAS-USA 2024)
- CD4 q6mo until >300 stable then annual (DHHS 2024)
- lipid A1c renal q6-12mo (DHHS 2024)
- genotype on virologic failure (DHHS 2024; IAS-USA 2024)
- STI screen q3-6mo in high risk (DHHS 2024; CDC STI 2021)

Setting (outpatient) monitoring:
- VL at 4-8 weeks, then q3mo until suppressed (DHHS 2024)
- CD4 q6mo until stable >300 then annually (DHHS 2024)
- Lipid + A1c q6-12 months (DHHS 2024)
- eGFR + UA q6-12 months — TDF/TAF (DHHS 2024)
- STI rescreen q3-6 months in high-risk (DHHS 2024; CDC STI 2021)
- HCV antibody annually if at risk (DHHS 2024)

Follow-up plan: Engagement support, U=U education (PARTNER NEJM 2016), partner PrEP, sexual health, mental health, comorbidity prevention (DHHS 2024)
- Close-out criterion: lifetime care plan documented

Monitoring phase: VL at 4-8 wk, then q3mo until suppressed; CD4 q6mo until >300 stable then annually; lipid/A1c/renal q6-12mo; genotype on virologic failure (DHHS 2024; IAS-USA 2024)

Disposition

Current setting: outpatient — Confirm HIV, deliver rapid ART start, OI prophylaxis if CD4 low, vaccinate, screen STIs and TB, link to primary care + behavioural support (IDSA 2024)

Disposition criteria:
- Continue outpatient ART unless OI requires admission (IDSA 2024)

Escalation triggers (move to higher acuity):
- AIDS-defining OI → admit + treat OI; defer vs start ART per OI — delay 4-6 wks for cryptococcal/TB CNS to avoid IRIS (DHHS 2024; COAT NEJM 2014)
- Severe IRIS → steroids, hospital management (DHHS 2024)
- Pregnancy → MFM + adjust regimen (DHHS 2024 perinatal; WHO 2024)
- Virologic failure with adherence good → genotype + new regimen (DHHS 2024; IAS-USA 2024)

Patient Action Plan

**HIV self-management + adherence plan (IDSA 2024)**
Personalised values: art_regimen, cd4_count (IDSA 2024), vl_status, oi_prophylaxis_active (IDSA 2024).

**Undetectable / on track (IDSA 2024)** (green):
Triggers:
- Taking ART every day
- VL undetectable
- CD4 stable or rising
- No new symptoms
- Vaccinations and STI screens up to date
Actions:
- Take ART daily at the same time — never skip doses
- Bring all medications and supplements to every visit (DDIs)
- Use condoms / prep partner if needed; U=U message — undetectable = untransmittable
- Stay current on vaccines (HBV, HPV, pneumococcal, flu, COVID, mpox)
- Keep all clinic appointments q3 months

**Side effects, missed doses, or new symptoms (IDSA 2024)** (yellow):
Triggers:
- New diarrhea, weight gain, headache, sleep issues
- Missed doses
- Started new medication / supplement
- New STI symptom or exposure
Actions:
- Continue ART unless told otherwise
- Call your provider to manage side effect or DDI
- Get tested for STIs / TB if exposed
- Resume daily dosing without doubling up missed doses
Contact provider when:
- More than 2 doses missed in a week
- New medication started
- Symptoms not improving in 24-48 h

**Severe illness — go to ED (IDSA 2024)** (red):
Triggers:
- Severe shortness of breath / chest pain
- Severe headache + fever (cryptococcus, lymphoma)
- Persistent high fever
- Sudden vision change
- Confusion / seizure
- Severe rash with fever (DRESS, abacavir hypersensitivity)
Actions:
- Go to ED immediately
- Bring your medication list including ART, OI prophylaxis, supplements
- Tell ED you are on ART and your CD4
Contact provider when:
- Always seek emergency care for these symptoms

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Fever + rash + GI / respiratory / constitutional symptoms within 6 weeks of ABC start (IDSA 2024)
- [SEVERE] PCP, esophageal candidiasis, cryptococcal meningitis, KS, cervical cancer, CMV, lymphoma, MAC, etc. (DHHS 2024 OI guidelines)
- [SEVERE] CD4 <200 without PCP prophylaxis (DHHS 2024 OI guidelines)

Citations

- DHHS Adult & Adolescent ART Guidelines (continuously updated, 2025 web edition) + IAS-USA 2024 + WHO 2024 Consolidated HIV Guidelines [PMID:36454551](https://pubmed.ncbi.nlm.nih.gov/36454551/)
- Cited evidence (PMID 33052386) [PMID:33052386](https://pubmed.ncbi.nlm.nih.gov/33052386/)
- Cited evidence (PMID 26192873) [PMID:26192873](https://pubmed.ncbi.nlm.nih.gov/26192873/)

Last reconciled with current guidelines: 2026-05-22.
References
  • DHHS Adult & Adolescent ART Guidelines (continuously updated, 2025 web edition) + IAS-USA 2024 + WHO 2024 Consolidated HIV Guidelines — PMID:36454551
  • Cited evidence (PMID 33052386) — PMID:33052386
  • Cited evidence (PMID 26192873) — PMID:26192873