## Clinical Context This patient presents with advanced HIV disease (CD4 < 100 cells/μL) with active opportunistic infections (oral candidiasis, chronic diarrhea). Immediate ART initiation is the standard of care. ## Management Algorithm ```mermaid flowchart TD A[HIV+ with CD4 < 100]:::outcome --> B{Active OI present?}:::decision B -->|Yes| C[Baseline investigations:<br/>CD4, VL, resistance test]:::action C --> D[Start ART immediately<br/>within 2 weeks]:::action D --> E[Concurrent OI prophylaxis<br/>TMP-SMX, fluconazole, MAC]:::action E --> F[Monitor for IRIS]:::outcome B -->|No| G[Can defer ART 2 weeks<br/>for TB exclusion]:::action ``` ## Key Point: **In CD4 < 50 cells/μL with active OI, ART should be initiated within 2 weeks of diagnosis.** Delaying therapy increases mortality risk. ## High-Yield: - **Timing of ART in advanced disease:** Start immediately (within 2 weeks) if CD4 < 50 or active OI present. - **Baseline before ART:** CD4 count, viral load, resistance testing, TB screening, hepatitis B/C status. - **Concurrent prophylaxis:** TMP-SMX for PCP/toxo, fluconazole for candida, azithromycin for MAC (all when CD4 < 50). ## Clinical Pearl: **IRIS risk is highest in the first 2–4 weeks after ART initiation in patients with CD4 < 50.** This is managed with continued ART (do NOT stop) and corticosteroids if severe. IRIS is NOT a reason to delay ART. ## Warning: ~~Genotypic resistance testing delays ART initiation~~ — it should be done at baseline (before ART) but results do not delay starting therapy. Initial regimen is chosen empirically based on local resistance patterns and patient factors. [cite:Harrison 21e Ch 197, Park 26e Ch 8]
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