All Wales HIV guidelines routinely exclude single tablet regimens as first-line ART

3 July 2026. Related: Other news.

Simon Collins, HIV i-Base

In May 2026, new HIV prescribing guidelines were published “to support consistency across Wales in the evidence-based and prudent prescribing of ART for HIV-1”.

This aims of this 13-page document include:

• To support doctors and other health professionals to deliver good prescribing practice.
• To optimise treatment to suppress viral load (to <82 IU/mL, equivalent to <50 copies/mL).
• To minimise the risk of side effects.
• To improve health-related quality of life.
• To support a uniform approach to the prescribing of ART throughout Wales.

The guidelines are broadly based on summarising and deferring to the full 220-page BHIVA guidelines (2025 update). [2]

However, there are significant differences to BHIVA on the recommendations for first-line ART (Table 1 in Wales guidelines) by limiting preferred options to just two – both using triple drug combinations and both requiring two pills rather than one daily pill.

1. Dolutegravir + TDF/emtricitabine.
2. Dolutegravir/lamivudine + TDF.

Easier options using single tablet regimens (STR) are only recommended “If single tablet regimen is necessary” due to kidney function (eGFR <60 min/mL), bone disease (confirmed osteoporosis or severe osteopenia) or active HBV.

Dolutegravir/lamivudine (Dovato) is not routinely recommended as first-line ART, even though this would enable use of an STR that is currently also recommended as first-line ART in BHIVA guidelines until adherence is established on a three-drug combination. This technically implies that dolutegravir + emtricitabine would be recommended. Although dolutegravir/lamivudine is a suitable option “if HBsAg negative” this should perhaps also emphasise the importance of protection from HBV vaccination.

Switch options (due to kidney, bone or cardiovascular concerns) are either dolutegravir/lamivudine (Dovato), bictegravir/emtricitabine/TAF (Biktarvy) or injectable ART which includes individualised off-label use in people with detectable viral load.

comment

Although these guidelines are designed to provide consistency in prescribing in Wales, based on BHIVA guidelines, the focus on ‘prudent’ prescribing has led to important differences in access, with neither Dovato nor Biktarvy routinely recommended as first-line ART.

It is a shame that the advantages of single tablet regimens are not recognised two decades after these were established (after the approval of Atripla).

The panel encourages feedback to these guidelines using the following link.
https://forms.office.com/pages/responsepage.aspx?id=uChWuyjjgkCoVkM8ntyPrm76xzM_UjRLmsly2F6XgHRUQVRTNVNCTTFVM1VBVVlJMElBOUVOMkhVUi4u&route=shorturl

References

1. All Wales Medicines Strategy Group. All Wales HIV-1 antiretroviral therapy prescribing guidelines. May 2026.
   https://awttc.nhs.wales/medicines-optimisation-and-safety/medicines-optimisation-guidance-resources-and-data/prescribing-guidance/all-wales-hiv-1-antiretroviral-therapy-prescribing-guidelines/ (webpage)
   https://awttc.nhs.wales/files/guidelines-and-pils/all-wales-hiv-1-antiretroviral-therapy-prescribing-guidelines-with-survey-pdf/?ts=1783091463235 (PDF)
2. BHIVA. BHIVA guidelines on antiretroviral treatment for adults living with HIV-1 2022 (2025 interim update).
   https://bhiva.org/clinical-guideline/hiv-1-treatment-guidelines