2025 Step & Shelf Update: New HIV Treatment

HIV is a top-10 high-yield topic for Step & Shelf exams, and there's a new first-line treatment you need to know in 2025. Here's the simplified guideline:

What's IN

• Integrase inhibitor-based regimens are now the clear first-line choice for most patients starting HIV therapy.
• These typically combine:
• One integrase inhibitor (e.g., bictegravir or dolutegravir)
• Two nucleoside reverse transcriptase inhibitors (NRTIs, e.g., tenofovir + emtricitabine)
• In some cases, a simplified two-drug integrase-based regimen (dolutegravir + lamivudine) is acceptable, but avoid if:
• Very high viral load (>500,000 copies/mL)
• Hepatitis B coinfection
• Starting therapy before resistance test results are available

What's OUT

Regimens based on:

• Protease inhibitors (e.g., atazanavir)
• Non-nucleoside reverse transcriptase inhibitors (NNRTIs, e.g., efavirenz)
• Older integrase inhibitors (raltegravir, elvitegravir)

These are out due to:

• Higher risk of resistance
• More side effects and drug interactions
• Higher pill burden and less convenience

Bottom line: When in doubt, pick an integrase inhibitor-based regimen for first-line HIV treatment questions!

P.S. HIV treatment is super nuanced. Tons of caveats (e.g. standard integrase inhibitor-based regimens are risky in patients who have taken long-acting cabotegravir as PrEP). If you need extra practice, Ora has over 500 HIV questions so you can study the details until you feel confident!