Summary

The IAS-USA 2024 panel updates recommendations for antiretroviral therapy and HIV prevention in adults. ART is recommended for all individuals with HIV, with bictegravir- or dolutegravir-based InSTI regimens plus 2 NRTIs (TXF/XTC) as preferred initial therapy; DTG/3TC is the only recommended 2-drug initial option. New elements include broader statin use for ASCVD primary prevention (per REPRIEVE), doxycycline PEP for bacterial STI prevention, long-acting cabotegravir for PrEP, and integrated management of substance use disorders, weight gain, and cardiometabolic comorbidities.

Key Recommendations

Start ART as soon as possible after HIV diagnosis, ideally within 7 days or same-day, unless concomitant opportunistic infection is suspected.
Preferred initial regimens: BIC/TAF/FTC or dolutegravir plus TXF/XTC for most people with HIV.
DTG/3TC is the only recommended 2-drug initial regimen and should be avoided if HIV RNA ≥500,000 copies/mL, lamivudine/integrase resistance, HBV coinfection, pregnancy, or CD4 <200/μL.
In pregnancy, use dolutegravir + TAF/FTC (or TDF/XTC); BIC/TAF/FTC is an acceptable alternative; avoid cobicistat-containing regimens and do not initiate DTG/3TC, DTG/RPV, doravirine, or long-acting CAB/RPV during pregnancy.
Initiate ART within 2 weeks of starting OI treatment; for TB meningitis or cryptococcal meningitis, delay ART 2–4 weeks after antimicrobial start.
Define virologic failure as inability to achieve or maintain HIV RNA <200 copies/mL; isolated blips (20–200 copies/mL) do not require regimen change.
Offer long-acting injectable cabotegravir + rilpivirine for patients struggling with daily oral adherence or strong preference; avoid in chronic HBV or with documented/suspected CAB or RPV resistance.
Prescribe high-intensity statin for 10-year ASCVD risk >20% or LDL ≥190 mg/dL; moderate-intensity statin (pitavastatin 4 mg, atorvastatin 20 mg, or rosuvastatin 10 mg) for ages 40–75 with 5%–<20% risk.
Switch off abacavir-containing regimens in patients with or at high risk for cardiovascular disease when an active alternative is available.
Offer PrEP universally to sexually active individuals requesting it; options include daily TDF/FTC, daily TAF/FTC, on-demand 2-1-1 TDF/FTC (receptive anal sex in cisgender men), or long-acting injectable cabotegravir.
Recommend doxycycline 200 mg within 72 hours after condomless sex (doxyPEP) for MSM and transgender women with bacterial STI in the past year; screen STIs and syphilis quarterly.
Integrate screening and treatment of substance use disorders (buprenorphine, methadone, naltrexone for OUD; contingency management for stimulant use) with HIV prevention/treatment services.

Thresholds & Doses

Initiate ART within 7 days of HIV diagnosis (including same-day).
DTG/3TC contraindicated if HIV RNA ≥500,000 copies/mL or CD4 <200/μL.
Virologic failure defined as HIV RNA ≥200 copies/mL (blips 20–200 copies/mL not failure).
In active TB without meningitis, start ART within 2 weeks of TB treatment, especially if CD4 <50/μL.
TB meningitis: defer ART 2–4 weeks after TB treatment initiation.
Cryptococcal meningitis: start ART 2–4 weeks after antifungal therapy.
Dolutegravir dosing with rifampin-based TB regimens: 50 mg twice daily; with 3HP preventive therapy: 50 mg once daily.
Pregnancy/PrEP-exposure salvage: darunavir 600 mg + ritonavir 100 mg twice daily plus TXF/XTC.
HIV RNA monitoring: 4–6 weeks after ART start, then every 3 months until suppressed, then every 6 months (every 12 months if stable >5 years).
CD4 monitoring: every 6 months until >250/μL for 1 year, then discontinue.
CrAg screening if CD4 ≤100 cells/μL.
Statin therapy in HIV: high-intensity if 10-year ASCVD risk >20% or LDL ≥190 mg/dL (4.92 mmol/L); moderate-intensity (pitavastatin 4 mg, atorvastatin 20 mg, or rosuvastatin 10 mg) for ages 40–75 with 5%–<20% risk; moderate-intensity also recommended if <5% risk.
Weight/BMI documentation at baseline and every 6 months on InSTI- or TAF-based regimens.
Oral PrEP TDF/FTC: initiate with double dose; for rectal exposures, continue until 2 doses after last sex; for vaginal exposures, continue ≥7 days after last sex.
On-demand 2-1-1 PrEP: 2 tablets 2–24 hours before sex, then 1 tablet at 24 and 48 hours.
Long-acting cabotegravir PrEP: 600 mg (3 mL) gluteal IM; first 2 injections 4 weeks apart, then every 8 weeks; reload if ≥8 weeks late.
DoxyPEP: doxycycline 200 mg within 72 hours of condomless sex, max once daily; prescribe 30 doses (60 tablets) at a time.
PEP: 3-drug regimen for 28 days if substantial exposure within 72 hours.
REPRIEVE trial showed 36% reduction in MACE with pitavastatin 4 mg in HIV (HR 0.64, 95% CI 0.48–0.84).

Citations

Box 1 — timing of ART initiation including OI and pregnancy scenarios
Box 2 — recommended initial ART regimens and pregnancy/TB-specific regimens
Box 3 — switching ART in virologic suppression and management of virologic failure
Box 4 — weight gain, ASCVD risk, and statin recommendations
Box 5 — substance use disorder screening, harm reduction, and SUD pharmacotherapy
Box 6 — HIV/STI prevention, PrEP regimens, rapid start, and doxyPEP
Table 3 — laboratory monitoring intervals for HIV RNA, CD4, genotype, CrAg
Table 4 — biomedical HIV prevention options by exposure type (TDF/FTC, TAF/FTC, CAB-LA)