7.2.1 First-line ART for adults
Consolidated ARV guidelines, June 2013
The 2010 WHO ART guidelines (2) recommended that ART in treatment-naive adults should initially consist of an NNRTI (either NVP or EFV) plus two NRTIs, one of which should be 3TC (or FTC) and the other AZT or TDF.
The guidelines emphasized the importance of avoiding d4T as a preferred option in first-line regimens because of its well-known mitochondrial toxicity, using regimens that are potentially less toxic and more suitable for most people, preferably as fixed-dose combinations given the clinical, operational and programmatic benefits. The recommended regimens had better toxicity profiles than d4T but were considered comparable in terms of efficacy, since there was no evidence that AZT is virologically superior to d4T, AZT superior to TDF, TDF superior to d4T or ABC, or EFV superior to NVP.
The phasing out of d4T as a preferred option in first-line ART has been variable. Some countries have made rapid and substantial progress, whereas others have taken a gradual approach, such as avoiding d4T only for people starting ART or not using d4T in pregnant women (Web Annex)
WHO (119 120) promotes a more affordable and efficient approach to treatment, including simpler, single-pill, once-daily ART regimens. The 2013 guidelines promote further simplification of ART delivery by reducing the number of preferred first-line regimens and focusing on regimens that may be used across a range of populations.