Start ART as soon as practical after diagnosis, almost regardless of CD4 count. Initiation and PBS prescribing sit with an HIV specialist (S100 prescriber); the GP's role is to identify, support and co-manage. This sheet reflects the current ASHM/US DHHS hierarchy — Triumeq is no longer first-line preferred.
When to start
- Newly diagnosed: start as soon as practical after diagnosis, regardless of CD4 count, once the patient is ready.
- CD4 <200: urgent specialist referral — high risk of opportunistic infection while untreated.
- AIDS-defining illness: urgent specialist co-management; timing of ART relative to the acute illness is specialist-led.
- Pregnancy: urgent specialist referral regardless of gestation — ART reduces mother-to-child transmission substantially.
- HIV with active TB: specialist-led timing to manage IRIS risk and drug interactions between regimens.
Pre-ART checks with specialist
- Resistance genotype before regimen selection.
- HLA-B*5701 status if abacavir is being considered.
- Hepatitis B status — affects regimen choice and stop-risk on discontinuation.
- IRIS risk assessment, especially with low CD4 or active TB.
- Pregnancy status, contraception, mental health and adherence support needs.
Preferred first-line regimens
- Biktarvy (bictegravir/TAF/FTC): a commonly preferred single-tablet 3-drug regimen; high barrier to resistance.
- DTG-based 3-drug: dolutegravir + TAF or TDF + FTC/3TC — a preferred option, high barrier to resistance.
- Dovato (dolutegravir/3TC, 2-drug): a preferred option for selected patients — avoid if HIV RNA >500,000, HBV co-infection, or before genotype results.
- Triumeq (dolutegravir/abacavir/3TC): no longer first-line preferred under current guidance — reserve for selected scenarios (e.g. established tolerance, HLA-B*5701-negative).
- Cabenuva (long-acting injectable cabotegravir/rilpivirine): a specialist-initiated maintenance option once stable and virally suppressed.
PBS, access & helpline. ART is PBS Section 100-prescribed by an HIV specialist; GP shared care continues once stable. Confirm current PBS listings and authority requirements at pbs.gov.au. ASHM helpline 1800 022 226 for clinician support.
Safety
- Triumeq has moved from preferred to a reserved/selected-scenario option under current guidance — confirm regimen choice against the specialist's current local protocol.
- Don't start abacavir-containing regimens without a known HLA-B*5701-negative result.
- Check hepatitis B status before starting or stopping any TDF/TAF/3TC-containing regimen — abrupt cessation can flare HBV.
Red flags / refer
- Any newly diagnosed patient → HIV specialist referral for ART initiation, as soon as practical.
- CD4 <200, an AIDS-defining illness, pregnancy, or HIV with active TB → urgent specialist referral.
- Adherence difficulty, virological failure, or treatment side-effects on an existing regimen → specialist review.
ID-02 v1.0 · Reviewed Jun 2026 · Review Jun 2027
For health-professional use. Framework: ASHM Antiretroviral Guidelines, US DHHS Adult ARV Guidelines. Companion sheet: ID-02B ART Workup & Monitoring. Doses are a guide only — confirm current dosing with the specialist.
