7.2.1 First-line ART for adults

Consolidated ARV guidelines, June 2013

Rationale and supporting evidence: Using alternative regimens and phasing out d4T

The currently recommended alternative regimens such as AZT instead of TDF or NVP instead of EFV (Table 7.5) are comparable in therapeutic efficacy but have potential clinical and programmatic disadvantages compared with the preferred options. Individuals who are already clinically stable on an alternative regimen with no contraindications can consider continuing that regimen based on national guidance or switch to the preferred options to simplify treatment management, reduce cost, improve tolerability, enhance adherence and promote better regimen sequencing. In special circumstances, ABC and boosted PIs are acceptable but should only be used when other options are not available.

Use of d4T-containing regimens should be discontinued and restricted to cases in which other ARV drugs cannot be used, and the duration of therapy with this drug should be limited to the shortest time possible and include close monitoring. In settings in which d4T regimens are still used as a preferred option for initiating ART, a plan for phasing out d4T should be implemented, preferably towards using TDF-based first-line regimens (2,128,129). Section 10.6 (Box 10.7) further discusses the issue of phasing out d4T.