Protocol · WHO HIV guidelines
HIV: testing and starting ART
Everyone diagnosed with HIV should start antiretroviral therapy (ART), whatever the CD4 count or stage, and the sooner the better. The first visit decides a lot: confirm the diagnosis properly, look for TB and advanced disease, and help the person start, ideally the same day.
- Based on WHO HIV guidelines
- For doctors, clinical officers, nurses and lay counsellors
- Reviewed October 2026
1Who / when
- Offer an HIV test to: anyone with an STI, TB (presumptive or confirmed), hepatitis, symptoms suggesting HIV, recent exposure; pregnant women; key populations; partners and children of people with HIV.
- Retest at least yearly people with ongoing risk; all sexually active people in high-burden settings.
- Infants of mothers with HIV: virological (NAT) testing per the national infant algorithm, not antibody tests.
2Red flags: refer now
- Severe headache, neck stiffness, confusion or fits (possible cryptococcal or TB meningitis).
- Seriously ill: breathing over 30 per minute, temperature over 39 °C, pulse over 120 per minute, or unable to walk unaided.
- Severe breathlessness, severe wasting, or severe dehydration.
- Child under 5 with any danger sign or severe classification.
Meningitis: refer firstDo not start ART the same day if meningitis is possible: ART is delayed 4 to 6 weeks after starting treatment for cryptococcal meningitis. Refer for lumbar puncture.
3Assess
Confirm the diagnosis
- Use the national testing algorithm. WHO encourages three consecutive reactive tests to give a positive diagnosis.
- Retest everyone newly diagnosed before starting ART, with the same algorithm. Do not retest people already on ART.
At the first visit
- TB screen: current cough, fever, weight loss or night sweats. Any one: test for TB (rapid molecular test; urine LAM if seriously ill or advanced HIV).
- WHO stage, weight, pregnancy and contraception, other medicines, mental health.
- CD4 count where available, to find advanced HIV disease.
- CD4 below 100 (consider below 200): cryptococcal antigen screen before ART.
- Readiness: does the person want to start today, and what support do they need?
4Classify
| Finding | Classify as | Action |
|---|---|---|
| Signs of meningitis, or seriously ill | Severe illness | Refer urgently; do not start ART today |
| CD4 below 200, WHO stage 3 or 4, or any child under 5 | Advanced HIV disease | Advanced disease package (TB, cryptococcal screening, co-trimoxazole); prioritise rapid ART |
| TB diagnosed | HIV with TB | Start TB treatment first; ART within 2 weeks |
| Confirmed HIV, no TB symptoms, well | HIV, ready for ART | Start ART the same day if ready, or within 7 days |
5Treat
- Start ART for everyone with HIV, at any CD4 count or stage, including pregnant and breastfeeding women.
- Rapid start: within 7 days of diagnosis; the same day for people who are ready. Encourage, never coerce.
- First line: dolutegravir (DTG) with two NRTIs. For adults and adolescents usually tenofovir (TDF) + lamivudine (3TC) + DTG as one daily tablet. Children: DTG-based regimens with approved paediatric dosing.
- Alternative where DTG is not suitable: efavirenz 400 mg with an NRTI backbone, or per national guideline.
- Co-trimoxazole prophylaxis for adults with WHO stage 3 or 4 or CD4 350 or less, for all children with HIV, and for everyone with TB; in high malaria or bacterial-infection settings give it regardless of CD4.
- TB preventive treatment when active TB is ruled out.
- Refer partners and children for testing (index testing).
6Follow-up
- Review early after starting, per national schedule: adherence, side effects, TB symptoms, immune reconstitution illness.
- Viral load at 6 months, at 12 months, then every 12 months.
- Viral load above 1000 copies/mL: adherence support, then repeat in 3 to 6 months; still above 1000 means treatment failure: refer or switch per national guideline.
- When stable and suppressed, offer longer refills and less frequent visits per national differentiated-care model.
7Counsel
- ART is lifelong, once a day. Missing doses lets the virus come back and become resistant.
- An undetectable viral load on ART means no risk of passing HIV to sexual partners; at or below 1000 copies/mL the risk is almost zero.
- Discuss disclosure, partner testing, condoms, family planning and safe breastfeeding on ART.
- Come back at once for headache, fever, cough, breathlessness, yellow eyes or rash.
HIV is treatable. If you take one tablet every day, the virus goes down until the test cannot find it, you stay well, and you cannot pass it to your partner through sex.
8When to refer
- Urgently: possible meningitis, seriously ill, severe breathlessness, or a child with danger signs.
- Positive cryptococcal antigen screen (needs lumbar puncture and antifungal treatment).
- Discordant or inconclusive test results.
- Two viral loads above 1000 copies/mL despite good adherence.
- Severe side effects: rash with fever or mouth sores, jaundice, severe abdominal pain.
9Sources
- World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. 2021.
- World Health Organization. Consolidated guidelines on HIV testing services. 2019. Three-test strategy and retesting before ART, as reproduced in the 2021 consolidated guidelines.
- World Health Organization. The role of HIV viral suppression in improving individual health and reducing transmission: policy brief. 2023.
- World Health Organization. WHO consolidated guidelines on tuberculosis. Module 3: diagnosis, third edition. 2024. Advanced HIV disease and 'seriously ill' definitions; urine LF-LAM.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.