7.2.1 First-line ART for adults

Consolidated ARV guidelines, June 2013

Rationale and supporting evidence: The move to TDF + 3TC (or FTC) + EFV as the preferred first-line option

A systematic review comparing six regimens showed moderate-quality evidence indicating that a once-daily combination of TDF + 3TC (or FTC) + EFV is less frequently associated with severe adverse events and has a better virological and treatment response compared with other once- or twice-daily regimens (Web Annex). An additional systematic review showed people receiving NVP are twice as likely as those receiving EFV to discontinue treatment because of adverse events (121).

The Guideline Development Group also reviewed a published meta-analysis and a further updated analysis (122, 123) that showed no increased risk of birth defects with EFV compared with other ARV drugs used during the first trimester of pregnancy (122). 3TC and FTC are pharmacologically comparable (123). TDF + 3TC (or FTC) + EFV offers good potential for harmonizing treatment across different populations: TDF/FTC or TDF/3TC are the preferred NRTI backbone for people coinfected with HIV and HBV and can be used among people coinfected with TB and among pregnant women. EFV is the preferred NNRTI for people with HIV and TB (pharmacological compatibility with TB drugs) and HIV and HBV coinfection (less risk of hepatic toxicity) and can be used among pregnant women, including those in the first trimester.

If TDF + 3TC (or FTC) + EFV cannot be used, other once- or twice-daily NNRTI-containing regimens (AZT + 3TC + EFV, AZT + 3TC + NVP, and TDF + 3TC (or FTC) + NVP) can be used as alternative first-line regimens in ART-naive people. Despite being considered equivalent options, they have potential disadvantages compared with preferred regimens. Use of other drugs such as ABC and boosted PIs are acceptable as potential backup options in special situations but are not recommended as preferred alternatives, considering the principles of optimizing ARV drugs.