NACO HIV Testing to ART Initiation Pathway
From the positive test to the first prescription, following NACO
How to use this tool: Enter the demographics, WHO stage and baseline investigations. The tool returns the NACO pathway from a reactive test through to the first prescription. Start ART rapidly in everyone testing positive, preferably within 7 days, unless a specific opportunistic infection needs stabilising first. Adults and adolescents only, from 10 years and 30 kg. The confirmatory testing algorithm, paediatric dosing and second-line switching are not covered here.
1. Patient Demographics & Vitals
2. Clinical & Laboratory Parameters
3. Disease Staging (for AHD Assessment)
Illness Scripts: Acute Retroviral Syndrome Differentials
1. Clinical Pearls & Caveats
Acute HIV infection often presents as a mononucleosis-like illness 2 to 4 weeks after exposure. Fever, pharyngitis and a rash with mucocutaneous ulcers together are the presentation to recognise, and the antibody test may still be negative at that point.
| Acute HIV Syndrome | Infectious Mononucleosis (EBV) | Secondary Syphilis |
|---|---|---|
| Fever, non-exudative pharyngitis, generalised tender lymphadenopathy. | Exudative pharyngitis, profound fatigue, atypical lymphocytes. | Maculopapular rash (involving palms/soles), condylomata lata. |
| Maculopapular rash (trunk/face). Mucocutaneous ulcers (highly specific). | Hepatosplenomegaly. Rash typically after Ampicillin administration. | Painless lymphadenopathy. History of painless chancre. |
| High HIV RNA Viral Load. Antibody tests may be negative (window period). | Positive Monospot (heterophile antibody). EBV VCA IgM positive. | Positive VDRL/RPR (non-treponemal) and TPHA (treponemal). |
Immune Reconstitution Inflammatory Syndrome (IRIS): Starting ART in patients with undiagnosed or partially treated opportunistic infections can trigger paradoxical inflammatory worsening. Delay ART by: 4 to 6 weeks for Cryptococcal Meningitis; 2 to 8 weeks for TB Meningitis. Do NOT delay ART for pulmonary TB without CNS involvement.
Rifampicin Interaction: Rifampicin is a potent CYP3A4/UGT1A1 inducer and lowers DTG trough levels by approximately 54%. Add an extra DTG 50mg dose 12 hours after the TLd combination tablet. Without it, DTG levels are sub-therapeutic, and what follows is virological failure and then integrase inhibitor resistance.
Abacavir (ABC) Hypersensitivity: ABC can cause a potentially fatal multi-organ hypersensitivity reaction, strongly associated with HLA-B*5701. Suspect it if the patient develops fever, rash, GI symptoms, or respiratory distress within the first 6 weeks. Stop ABC immediately and never rechallenge. Rechallenging after confirmed HSR carries a risk of fatal anaphylaxis.
DTG and Weight Gain: Dolutegravir-based regimens are associated with excess weight gain, particularly in women and patients of African descent. Monitor metabolic parameters (fasting glucose, lipid profile) at baseline and during follow-up.
2. Baseline Monitoring Schedule
| Investigation | Timing | Rationale |
|---|---|---|
| HIV Viral Load | At 6 months, then annually | Confirm virological suppression (< 1000 copies/mL) |
| CD4 Count | At baseline, 6 months, then as needed | Monitor immune recovery; guide OI prophylaxis |
| Serum Creatinine / CrCl | Baseline, 3 months, then 6-monthly (if on TDF) | TDF nephrotoxicity surveillance |
| CBC with differential | Baseline, 4 weeks, 3 months (if on AZT) | AZT-induced anaemia and neutropenia |
| HBsAg | Baseline | HBV coinfection guides backbone selection |
| ALT / AST | Baseline, then as indicated | Hepatotoxicity monitoring |
Abbreviations: ABC (Abacavir) · AHD (Advanced HIV Disease) · AIDS (Acquired Immunodeficiency Syndrome) · ALT (Alanine Aminotransferase) · ART (Antiretroviral Therapy) · AST (Aspartate Aminotransferase) · AZT (Zidovudine) · BD (Twice Daily) · CBC (Complete Blood Count) · CD4 (Cluster of Differentiation 4) · CNS (Central Nervous System) · CrAg (Cryptococcal Antigen) · CrCl (Creatinine Clearance) · CYP3A4/UGT1A1 (Cytochrome P450 3A4 / Uridine Diphosphate Glucuronosyltransferase 1A1) · DTG (Dolutegravir) · EBV (Epstein-Barr Virus) · FDC (Fixed-Dose Combination) · GI (Gastrointestinal) · Hb (Haemoglobin) · HBsAg (Hepatitis B Surface Antigen) · HBV (Hepatitis B Virus) · HIV (Human Immunodeficiency Virus) · HLA-B*5701 (Human Leucocyte Antigen B, Allele 5701) · HSR (Hypersensitivity Reaction) · IgM (Immunoglobulin M) · IRIS (Immune Reconstitution Inflammatory Syndrome) · LAM (Lipoarabinomannan) · LP (Lumbar Puncture) · NACO (National AIDS Control Organisation) · OD (Once Daily) · OI (Opportunistic Infection) · RNA (Ribonucleic Acid) · SBAR (Situation, Background, Assessment, Recommendation) · TAF (Tenofovir Alafenamide) · TB (Tuberculosis) · TB-LAM (Tuberculosis Lipoarabinomannan Assay) · TDF (Tenofovir Disoproxil Fumarate) · TLd (Tenofovir + Lamivudine + Dolutegravir) · TMP-SMX (Trimethoprim-Sulfamethoxazole) · TPHA (Treponema pallidum Haemagglutination Assay) · VCA (Viral Capsid Antigen) · VDRL/RPR (Venereal Disease Research Laboratory / Rapid Plasma Reagin) · WBC (White Blood Cell) · WHO (World Health Organization) · 3TC (Lamivudine)
Algorithm References & Evidence Base
- National AIDS Control Organisation (NACO). National Guidelines for HIV Care and Treatment. Ministry of Health and Family Welfare, Government of India; 2021.
- World Health Organization (WHO). Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. 2021.
- World Health Organization. WHO updated recommendations on HIV clinical management: recommendations for a public health approach. Geneva: WHO; 7 January 2026. [First substantial revision since 2021. DRV/r becomes the preferred boosted PI; supports reuse of TDF and ABC in subsequent regimens; long-acting injectable ART and oral two-drug regimens in defined circumstances; revised vertical transmission and TB preventive treatment guidance. NACO remains the operative source for Indian practice.]
- Venter WDF, Moorhouse M, et al. Dolutegravir plus two different prodrugs of tenofovir to treat HIV. N Engl J Med. 2019;381(9):803-815.
- NACO. National Technical Guidelines on Anti-Retroviral Treatment. October 2018 (Updated 2021).
How to Cite This Tool
AMA Style: Umakanth S. NACO HIV Testing to ART Initiation Pathway. MEDiscuss. Published 2026. Accessed .
Vancouver Style: Umakanth S. NACO HIV Testing to ART Initiation Pathway [Internet]. MEDiscuss.org; 2026 [cited ]. Available from:
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Category Therapeutic & Management PathwaysPathway
Specialties Internal Medicine, Infectious Diseases
Written and maintained by Dr Shashikiran Umakanth.
Last revised: 8 August 2026
Last revised: 8 August 2026