Treatment training manual

3.10 Treatment choices

In all countries, more than 20 drugs and formulations are approved.

However, only a few main combinations are recommended in treatment guidelines.

Guidelines for high income countries usually include more treatment options than the WHO guidelines.

This advocacy resource is mainly based on WHO guidelines which are developed for low- and middle-income countries (LMICs).

WHO guidleines are for “population-based” care. This means they are developed to tackle HIV on a population level – usually because of the high numbers of people that need treatment with limited resources. This is a slightly different approach to high-income guidelines that emphasise “individualised care”.

First-line therapy in WHO guidelines

Most guidelines recommend that first-line treatment is a combination of two nukes (NRTIs) plus a non-nuke (NNRTI).

The next update of the WHO guidelines (2016) on which drugs to use are expected to be published in January 2016.
http://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en

The main recommendations are included in a summary document released in November 2015.
http://www.who.int/hiv/pub/arv/policy-brief-arv-2015/en

The recommendation for first-line therapy is a fixed dose combination (FDC).

  • tenofovir DF + 3TC (or FTC) + efavirenz

If this combination is not available or cannot be used, one of the following options is recommended:

  • AZT + 3TC + efavirenz 600mg (or nevirapine)
  • tenofovir DF + 3TC (or FTC) + dolutegravir
  • tenofovir DF + 3TC (or FTC) + efavirenz 400 mg
  • tenofovir DF + 3TC (or FTC) + nevirapine

Fixed dose combinations (FDCs) are where all three drugs in these combinations are supplied in one pill. Generic manufacturers produce FDCs but they are only available in some countries.

Second-line therapy in WHO guidelines

Most guidelines recommend changing to three new drugs for second-line therapy. This usually means that people who started on an NNRTI- or integrase inhibitor-based combination with two nukes will change to  a PI-based combination (usually with two nukes).

The WHO 2016 guidelines recommend a boosted protease inhibitor (PI/r) plus two nucleoside analogues (nukes) for second-line therapy. It recommended atazanavir/r and lopinaivr/r are the preferred boosted PI’s for second-line.

The following sequence of second-line NRTI options is recommended for second-line ART:

  • After failure on a tenofovir DF + 3TC (or FTC)–based first-line regimen, use AZT + 3TC.
  • After failure on an AZT or d4T + 3TC–based first-line regimen, use tenofovir DF + 3TC (or FTC).
  • Use of NRTI backbones as a fixed-dose combination is preferred.
  • Heat-stable fixed-dose combinations of ATV/r and LPV/r are the preferred boosted PI options.

In US, UK, European and other Western guidelines there are a wider choice of drugs and drug classes to use in second-line therapy.

Last updated: 1 January 2016.