HIV/AIDS Management for NEET PG — Complete Guide 2026

Version 1.0 — Published April 2026

HIV is a retrovirus that causes progressive destruction of CD4+ T-lymphocytes, leading to AIDS if untreated — and its management is a flagship NEET PG topic because it integrates medicine, pharmacology, microbiology, and community medicine. The student who masters opportunistic infections by CD4 count, NACO TLD regimen, and ART side effects has covered the foundation for 3–4 marks across papers. Pair this guide with daily MCQ practice on the Medicine subject hub, cross-reference the high-yield medicine topics overview, and revise high-yield microbiology topics for virology fundamentals.

Pathophysiology — CD4 depletion and viral load

HIV is a single-stranded enveloped RNA retrovirus of the Lentivirus genus, with two species (HIV-1 worldwide, HIV-2 mainly in West Africa) and a well-characterised entry mechanism.

Viral entry sequence:

1. gp120 on viral envelope binds CD4 on helper T cell / macrophage / dendritic cell
2. Conformational change exposes co-receptor binding site
3. Binding to CCR5 (macrophage-tropic R5 virus — early disease) or CXCR4 (T-cell-tropic X4 virus — late disease)
4. gp41 mediates fusion of viral + cell membranes
5. Release of viral RNA + reverse transcriptase + integrase into cytoplasm

Post-entry steps (ART drug targets): 6. Reverse transcription of viral RNA → proviral DNA (NRTI / NNRTI target) 7. Nuclear translocation; integration into host genome (INSTI target) 8. Transcription + translation of viral proteins (long polyprotein) 9. Protease cleaves polyprotein into mature structural proteins (PI target) 10. Viral assembly and budding → new virions

CCR5 delta-32 mutation: 1% of Northern Europeans are homozygous and resistant to R5-HIV (source of the "Berlin patient" cure via CCR5-negative stem cell transplant).

Natural history without ART:

• Acute HIV (2–4 weeks post-infection): flu-like illness, pharyngitis, rash, lymphadenopathy (mononucleosis-like). Very high viral load (10^6–10^7 copies/mL).
• Clinical latency (median 8–10 years): viral set point established. Gradual CD4 decline ~50–80 cells/μL per year.
• AIDS: CD4 <200 cells/μL or AIDS-defining illness.
• Median survival from AIDS without ART: 1–3 years.

With modern ART, life expectancy approaches normal in patients who start early and maintain virologic suppression.

WHO clinical staging of HIV

WHO clinical staging is a standardised framework that stages HIV disease by clinical findings alone — essential where CD4 testing is unavailable.

AIDS diagnosis (any of the following):

• CD4 <200 cells/μL (or <15%)
• WHO stage 4 clinical condition
• Clinical AIDS per CDC 1993 definition

Acute retroviral syndrome (ARS) hallmarks:

• Fever (96%)
• Lymphadenopathy (74%)
• Pharyngitis (70%)
• Maculopapular rash on trunk (70%)
• Myalgia / arthralgia (50%)
• Mucocutaneous ulcers

ARS is often misdiagnosed as mononucleosis. Diagnosis requires HIV RNA PCR or p24 antigen — ELISA may be negative in window period.

Diagnostic tests — ELISA, Western blot, PCR

HIV diagnosis in adults uses a multi-test strategy because a single test cannot meet both sensitivity and specificity standards required for a lifelong diagnosis.

India (NACO) 3-test strategy:

• Test 1: ELISA or rapid test (highest sensitivity)
• Test 2: Different ELISA or rapid test (different antigen / principle)
• Test 3: Third ELISA or rapid test (if the first two disagree)
• Two concordant positives → HIV-positive reported
• Discordant → repeat after 4–6 weeks or do HIV RNA PCR

Western blot positivity (CDC criteria): Bands of >=2 of gp160 / gp120, gp41, p24.

Neonatal / infant diagnosis (<18 months):

• Maternal IgG antibodies cross placenta — ELISA can stay positive till 15–18 months
• Use HIV DNA PCR or HIV RNA PCR at:
  • 48 hours of birth (rule out in-utero transmission)
  • 2 weeks
  • 6 weeks
  • 4–6 months
• Two positive PCRs confirm infection; two negative PCRs after 4 months with no breastfeeding rule out

Viral load monitoring:

• Baseline before ART
• 6 months after ART start, then every 6–12 months
• Virologic failure: two consecutive VL >1000 copies/mL after 6 months on ART with confirmed adherence
• Undetectable = virologically suppressed (<50 copies/mL; U=U — Undetectable equals Untransmittable)

Opportunistic infections by CD4 count

Opportunistic infections in HIV follow a predictable CD4-stratified sequence, and this table is the single highest-yield HIV content for NEET PG.

Opportunistic infection highlights:

Pneumocystis jirovecii pneumonia (PJP):

• Bilateral perihilar "bat-wing" interstitial infiltrates on CXR
• Dry cough, progressive dyspnoea, desaturation on exertion
• Elevated LDH; induced sputum or BAL for PCR / silver stain (Grocott)
• Treatment: TMP-SMX (cotrimoxazole) 15–20 mg/kg/day of TMP for 21 days
• Add prednisolone if PaO2 <70 mmHg or A-a gradient >35 mmHg
• Prophylaxis: cotrimoxazole 960 mg daily at CD4 <200

Toxoplasma encephalitis:

• Ring-enhancing lesions in basal ganglia on MRI with mass effect
• Positive toxoplasma IgG in >95% of cases
• Treatment: pyrimethamine + sulfadiazine + leucovorin × 6 weeks
• Prophylaxis: cotrimoxazole at CD4 <100 with positive IgG

Cryptococcal meningitis:

• Subacute headache, fever, altered sensorium
• CSF: elevated opening pressure, mononuclear pleocytosis, positive India ink, cryptococcal antigen (CrAg)
• Treatment: amphotericin B + flucytosine × 2 weeks (induction), then fluconazole 400 mg × 8 weeks (consolidation), then fluconazole 200 mg (maintenance)
• Repeated therapeutic LPs to manage elevated ICP

CMV retinitis:

• Painless vision loss; fundus: pizza-pie retinopathy (haemorrhage + exudate along vessels)
• Treatment: IV ganciclovir or oral valganciclovir; intravitreal ganciclovir for sight-threatening disease

Kaposi sarcoma (HHV-8):

• Violaceous plaques and nodules on skin, oral cavity, GI tract, lungs
• Treatment: ART alone often induces regression; liposomal doxorubicin for advanced disease

Progressive multifocal leukoencephalopathy (JC virus):

• Subacute progressive neurological deficits
• MRI: non-enhancing white matter lesions (no mass effect)
• CSF PCR for JC virus
• No specific antiviral — ART for immune reconstitution

ART regimens — NACO first-line and beyond

ART combines 3 drugs from different classes to achieve durable viral suppression, and India's NACO programme now uses TLD as universal first-line.

Drug classes:

NACO first-line (2021+): TLD

• Tenofovir 300 mg + Lamivudine 300 mg + Dolutegravir 50 mg
• Once daily, single fixed-dose combination (Trivenz, Tridarda brand names)
• Why DTG replaced EFV:
  • Higher virologic suppression rate (SINGLE, FLAMINGO trials)
  • Very high genetic barrier to resistance
  • Better tolerability (less CNS toxicity than EFV)
  • Safe in pregnancy (latest WHO, Tsepamo updates — original neural tube defect signal not confirmed)

Alternative first-line when TLD contraindicated:

• TLE: TDF + 3TC + Efavirenz (historic standard)
• AZT + 3TC + DTG: if renal disease contraindicates TDF
• TAF + FTC + DTG: newer prodrug of tenofovir (less renal and bone toxicity)

When to start ART (NACO 2017+):

• All HIV-positive individuals regardless of CD4 — "treat all" strategy since 2017
• Same-day ART initiation encouraged if patient is ready and ruled out for TBM / cryptococcal meningitis (risk of IRIS)

Second-line ART: If TLD fails → switch NRTI backbone (AZT + 3TC) + boosted PI (LPV/r or ATV/r).

Third-line / salvage: Darunavir/ritonavir + dolutegravir (if not previously used) + additional active agents (etravirine, maraviroc, enfuvirtide) based on genotypic resistance testing.

ART side effects — drug-specific profiles

ART side effects are drug-specific, detectable with routine monitoring, and frequently tested as single-best-answer items.

Tenofovir (TDF):

• Proximal renal tubular dysfunction → Fanconi syndrome (glycosuria, phosphaturia, aminoaciduria)
• Acute kidney injury
• Decreased bone mineral density; osteoporosis / osteomalacia
• Monitor creatinine, eGFR, urine protein at baseline and every 6 months
• TAF (tenofovir alafenamide) has less renal and bone toxicity

Zidovudine (AZT):

• Macrocytic anaemia (dose-related; MCV rises predictably)
• Neutropenia
• Myopathy (mitochondrial toxicity); myositis
• Lipoatrophy (facial and limb fat wasting)
• Lactic acidosis (rare, severe)

Abacavir (ABC):

• Hypersensitivity reaction — fever, rash, GI upset, dyspnoea within 6 weeks of start
• Strongly linked to HLA-B*5701 — test before prescribing; do not re-challenge
• Cardiovascular risk (observational; debated)

Efavirenz (EFV):

• CNS — vivid dreams, dizziness, insomnia, depression, suicidal ideation (take at bedtime to reduce)
• Symptoms peak at 2–4 weeks, often improve
• Teratogenic — first-trimester neural tube defects (historical signal)
• Rash; hepatitis
• Gynecomastia
• False-positive cannabis on urine drug screen

Nevirapine (NVP):

• Rash — Stevens-Johnson syndrome / TEN
• Severe hepatitis (higher risk in women with CD4 >250 and men with CD4 >400; avoid starting in these groups)
• Lead-in dose (200 mg once daily for 14 days, then 200 mg BD) to minimise rash / hepatitis

Protease inhibitors (boosted with ritonavir):

• Metabolic syndrome — dyslipidaemia, insulin resistance, central fat accumulation
• GI upset (diarrhoea common with LPV/r)
• Hepatitis; nephrolithiasis (indinavir — obsolete)
• Many drug interactions (ritonavir is a potent CYP3A4 inhibitor)
• Atazanavir: unconjugated hyperbilirubinaemia (benign Gilbert-like)

Dolutegravir (DTG):

• Weight gain (more than EFV-based regimens)
• Insomnia, headache (mild)
• Rare: hepatotoxicity, hypersensitivity
• Drug interactions: decrease metformin dose; take 2 hours before / 6 hours after antacids (chelation)

Maraviroc: Requires tropism assay (effective only against R5-tropic virus).

Opportunistic infection prophylaxis

Opportunistic infection prophylaxis is added based on CD4 count and endemic exposure, and stopping criteria require sustained immune reconstitution on ART.

IRIS (Immune Reconstitution Inflammatory Syndrome):

• Paradoxical worsening of pre-existing OI or unmasking of latent OI after ART start
• Most common with TB, cryptococcus, CMV, hepatitis
• Timing: weeks to months after ART start, especially if baseline CD4 was very low
• Management: continue ART; treat the underlying OI; add steroids if severe (especially TB-IRIS, PJP-IRIS)
• Mitigation: start OI therapy first, defer ART by 2 weeks in cryptococcal meningitis and 8 weeks in TBM

PEP, PrEP, and PPTCT

Post-exposure prophylaxis, pre-exposure prophylaxis, and prevention of parent-to-child transmission are the three preventive pillars — each has specific regimens and timing.

Post-exposure prophylaxis (PEP)

Indications:

• Occupational: percutaneous, mucosal, or non-intact skin exposure to HIV-positive or unknown-source blood / body fluid
• Non-occupational: unprotected intercourse with HIV-positive partner, sexual assault, needle sharing

Timing: Start within 72 hours (ideally within 2 hours); no benefit after 72 hours.

Regimen (NACO / WHO 2021): TDF 300 mg + 3TC 300 mg + DTG 50 mg (or raltegravir 400 mg BD), once daily × 28 days.

Baseline + follow-up testing:

• At time 0: HIV, HBV, HCV, STI screen, pregnancy test
• Follow-up HIV: 6 weeks, 3 months, 6 months
• Use 4th-gen ELISA (shorter window) to allow earlier reassurance

Efficacy: ~80–90% reduction in transmission risk if started within 72 hours with full 28-day adherence.

Pre-exposure prophylaxis (PrEP)

Indications:

• Serodiscordant couples (HIV-negative partner)
• Men who have sex with men with multiple partners
• Transgender women, sex workers, injection drug users
• Repeated PEP users

Regimen:

• Oral daily TDF + FTC (Truvada / Taf-Emt) OR TDF alone
• Alternative: event-based "2-1-1" dosing for MSM (2 tablets 2–24 h before, 1 at 24 h after, 1 at 48 h after)
• Long-acting injectable cabotegravir every 8 weeks — highly effective in HPTN 083 and 084; not yet widespread in India

Efficacy: >99% reduction in HIV acquisition with high adherence.

Baseline + monitoring:

• HIV test before starting and every 3 months
• HBV serology at baseline (TDF active against HBV — ensure status)
• eGFR baseline and every 6–12 months
• STI screen every 3–6 months

PPTCT — prevention of parent-to-child transmission

PPTCT is the set of interventions that reduce HIV transmission from mother to infant during pregnancy, delivery, or breastfeeding.

India PPTCT components (NACO):

1. Universal antenatal HIV testing at first antenatal visit (opt-out)
2. Lifelong ART (Option B+) for all HIV-positive pregnant women from time of diagnosis — regardless of CD4 or stage. Regimen: TLD.
3. Safe delivery: vaginal delivery acceptable if viral load <1000 copies/mL at delivery; elective LSCS at 38 weeks if VL >1000
4. Infant ART prophylaxis: nevirapine daily × 6–12 weeks (12 weeks if breastfed)
5. Infant feeding: exclusive breastfeeding × 6 months while mother is on ART, then mixed feeding / weaning. Avoid mixed feeding in first 6 months (higher transmission than either exclusive breast or formula).
6. Early infant diagnosis (EID): HIV DNA PCR at 6 weeks (after cessation of prophylaxis) and repeat as needed till 18 months

Transmission reduction:

• Untreated: 25–40% transmission (intrapartum majority, intrauterine, breastfeeding)
• With full PPTCT: <2% transmission (and <1% in high-income countries)

Sources and references

1. National AIDS Control Organisation (NACO), Ministry of Health & Family Welfare, Government of India — National Guidelines for HIV Care and Treatment (2021 edition) including ART Technical Guidelines and PPTCT guidelines.
2. WHO Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring: Recommendations for a Public Health Approach (2021 update).
3. Harrison's Principles of Internal Medicine, 21st Edition (Loscalzo et al., 2022) — Chapter on HIV infection and AIDS.
4. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents — Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV (2023 update).
5. Havlir DV et al. Opportunistic infections in the era of antiretroviral therapy. New England Journal of Medicine 2011; 365:1922-1931.
6. INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. New England Journal of Medicine 2015; 373:795-807 — evidence base for "treat all".

Frequently asked questions

How many HIV questions appear in NEET PG?

HIV/AIDS contributes 3-4 direct questions per NEET PG paper across medicine, pharmacology, microbiology, and community medicine. Opportunistic infections by CD4 count, NACO TLD first-line regimen, ART side effects, and PEP protocol are the most tested subtopics based on 2019-2025 pattern analysis.

What is the first-line ART regimen in India?

Under NACO guidelines (2021 update), the first-line regimen for all adults and adolescents is TLD — tenofovir 300 mg plus lamivudine 300 mg plus dolutegravir 50 mg, given as a single once-daily fixed-dose combination. Dolutegravir replaced efavirenz as the preferred third agent because of higher virologic suppression, higher genetic barrier to resistance, and better tolerability.

Which opportunistic infection occurs at CD4 less than 200?

At CD4 less than 200 cells per microlitre, the hallmark opportunistic infection is Pneumocystis jirovecii pneumonia (PJP), which presents with progressive dyspnoea, dry cough, and a chest X-ray showing bilateral perihilar interstitial infiltrates. Prophylaxis with cotrimoxazole (TMP-SMX) 960 mg once daily is started at CD4 less than 200 and continued until CD4 is sustained above 200 for 6 months on ART.

What is the CD4 cutoff for toxoplasma prophylaxis?

Toxoplasma encephalitis prophylaxis is initiated at CD4 less than 100 cells per microlitre in patients with positive toxoplasma IgG serology. Cotrimoxazole 960 mg daily provides dual prophylaxis against both PJP and toxoplasma. Patients present with ring-enhancing lesions on MRI brain with predilection for basal ganglia.

What is the CD4 threshold for CMV and MAC prophylaxis?

CMV and MAC (Mycobacterium avium complex) become threats at CD4 less than 50 cells per microlitre. CMV retinitis presents with painless vision loss and pizza-pie fundus appearance — treatment is IV ganciclovir or oral valganciclovir. MAC causes disseminated infection with fever, weight loss, and hepatosplenomegaly — prophylaxis with azithromycin 1200 mg weekly is recommended only if CD4 stays below 50 and ART has failed.

What are the classes of antiretroviral drugs?

ART drug classes are NRTIs (nucleoside reverse transcriptase inhibitors — tenofovir, zidovudine, lamivudine, emtricitabine, abacavir), NNRTIs (efavirenz, nevirapine, rilpivirine), PIs (protease inhibitors — lopinavir/ritonavir, atazanavir/ritonavir, darunavir/ritonavir), INSTIs (integrase strand transfer inhibitors — dolutegravir, raltegravir, bictegravir), entry inhibitors (maraviroc — CCR5 antagonist), and fusion inhibitors (enfuvirtide).

What are tenofovir, efavirenz, and zidovudine side effects?

Tenofovir causes renal tubular toxicity (Fanconi syndrome) and decreased bone mineral density — monitor creatinine and eGFR before and during therapy. Efavirenz causes CNS side effects (vivid dreams, dizziness, insomnia, depression) peaking at 2-4 weeks and teratogenicity (neural tube defects — avoided in first trimester). Zidovudine causes macrocytic anaemia and myopathy.

What is the PEP regimen for occupational HIV exposure?

Post-exposure prophylaxis for HIV is indicated within 72 hours of significant percutaneous or mucosal exposure to HIV-positive or unknown-status source blood. The current recommended regimen is tenofovir plus lamivudine plus dolutegravir (or raltegravir) for 28 days. Baseline HIV test at time 0, then repeat at 6 weeks, 3 months, and 6 months. Earlier start equals higher efficacy; delay beyond 72 hours is not effective.

What is PrEP and who should receive it?

Pre-exposure prophylaxis (PrEP) is daily tenofovir plus emtricitabine (or tenofovir alone) given to HIV-negative people at high risk of HIV acquisition. Indicated for serodiscordant partners, men who have sex with men with multiple partners, injection drug users, and sex workers. Reduces HIV acquisition by approximately 99 percent if adherence is high. HIV test required before initiation and every 3 months thereafter.

How do we prevent mother-to-child transmission?

PPTCT (Prevention of Parent-to-Child Transmission) under NACO has three pillars. First: universal antenatal HIV testing and counselling. Second: lifelong ART from the time of diagnosis in pregnancy (Option B+) — TLD is the preferred regimen. Third: infant prophylaxis with nevirapine daily for 6-12 weeks and exclusive breastfeeding for 6 months while mother is on ART. This reduces vertical transmission from 25-40 percent to less than 2 percent.

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Written by: NEETPGAI Editorial Team Reviewed by: Pending SME Review Last reviewed: April 2026

This article is reviewed by qualified medical professionals for clinical accuracy and exam relevance. For corrections or updates, contact the editorial team.