Over 30 HIV drugs and formulations have been approved n the US, but not all drugs are available in every country.

Although there are many hundreds of possible combinations with these individual drugs, only a few combinations are recommended in treatment guidelines.

Guidelines in Western countries usually include more treatment options than the WHO, which this page mainly references.

First-line therapy

Most guidelines recommend that first-line treatment is a combination of:

2 nukes combined with EITHER a non-nuke OR a PI (preferably a PI boosted with ritonavir)

WHO guidelines were last updated in November 2009. Download 2009 update. PDF download (500 Kb)

This update recommends four NNRTI (non-nuke) based combinations for first-line therapy:

• AZT + 3TC + nevirapine
• AZT + 3TC + efavirenz
• tenofovir + FTC or 3TC  + nevirapine
• tenofovir + FTC or 3TC  + efavirenz

This was a major change away from the previous recommendation to use d4T (stavudine) as one of the drugs. This change was driven by the higher risk of peripheral neuropathy, lipoatrophy (fat loss) and other serious side effects with d4T, even though it is a cheaper option.

Fixed dose combinations (FDCs) are where the 3 drugs in these combinations are supplied in 1 pill. Generic manufacturers produce FDCs but they are only available in some countries.

There are advantages and disadvantages of each WHO combination.

• nevirapine-based combinations are preferred in women who are pregnant. The previous caution against using nevirapine with a CD4 count higher than 250 cells/mm³ is no longer supported in this update.
• efavirenz-based combinations should not be used by women who want to become pregnant.
• efavirenz-based combinations are preferred in people who need TB treatment at the same time.
• efavirenz-based combinations are used if people are intolerant to, or have side effects with nevirapine.
• d4T-based combinations used to be recommended because this is a very inexpensive drug – but most countries are now moving to use tenofovir or AZT instead of d4T.
• AZT-based combinations have a higher risk of causing anaemia and are not recommended if you have anaemia.

Second-line therapy

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

The WHO 2009 update recommended 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.

If d4T or AZT has been used in first-line, use tenofovir + 3TC or FTC as the nukes. If tenofovir has been used in first-line, use AZT + 3TC as the nukes.

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

WHO recommended ARVs PDF download (500 Mb)