HIV Treatment Basics: Mechanisms, 2026 Guideline Updates, and Rapid ART Start

Welcome back to another Pharmacy Times Stakeholder Summit series. In "HIV Treatment Basics: Mechanisms, 2026 Guideline Updates, and Rapid ART Start," moderator Christina Madison, PharmD is joined by Kevin Astle, PharmD, Spencer Durham, Pharm.D., FCCP, BCPS, BCIDP, Joseph Burkhart, PharmD, and Tram Nguyen, Pharm.D. to open the series on HIV.

Dr. Madison frames the discussion around three priorities: where guidelines and the standard of care stand today, which patients still need a change, and how new 2026 data should shape treatment matching. Dr. Astle begins by level-setting on antiretroviral mechanisms of action. He explains that nucleoside reverse transcriptase inhibitors, or NRTIs, were formerly the backbone of HIV regimens. With the shift in current guidelines, integrase inhibitor–based regimens have effectively become the new backbone of therapy. Non-nucleoside reverse transcriptase inhibitors and protease inhibitors still play a role in selected patients.

Dr. Durham then reviews the 2026 update to the DHHS Guidelines for the Use of antiretroviral agents in adults and adolescents with HIV. He points out that the update did not change first-line options, which have remained stable since about September 2024. Instead, the revision focused on lipid management. It aligns with new American Heart Association and American College of Cardiology guidelines that specifically address lipid management in people with HIV. First-line therapy remains an integrase inhibitor, such as bictegravir or dolutegravir, plus two NRTIs. That backbone is usually emtricitabine or lamivudine paired with a tenofovir formulation. Dr. Madison welcomes the alignment between cardiology and HIV guidance.

Dr. Burkhart addresses rapid initiation of therapy. He explains that guidelines call for starting treatment as soon as possible, ideally on the day of diagnosis or the first clinic visit. Patients should not leave the office without therapy. Early initiation suppresses the virus sooner and prevents onward transmission to others. He stresses that patients with acute HIV, in the first weeks after infection, are highly contagious, which makes same-day starts especially important. Dr. Madison adds the public health perspective. The goal is to bring everyone into care and onto treatment quickly while stopping further spread.

The next episode in this series, "First-Line HIV Therapy: Integrase Inhibitors, Exceptions, and HLA-B*5701 Testing," features Dr. Astle and Dr. Durham on why integrase inhibitors dominate initial therapy and when clinicians reach for alternatives.