7.5.1 Second-line ART for adults and adolescents

Consolidated ARV guidelines, June 2013

Clinical considerations and key research gaps

Clinical considerations

Clinical and programmatic simplification can be promoted in the sequencing from first- to second-line ART. If AZT- or d4T-based regimens are failing, a second-line regimen with oncedaily dosing for boosted PI and NRTI components (such as TDF + 3TC (or FTC) + ATV/r) should be adopted. If a TDF-based regimen is failing, twice-daily dosing for boosted PI and NRTI components (such as AZT + 3TC + LPV/r) should be adopted.

Key research gaps

Several ongoing studies comparing various drugs and ARV classes (232–236) will provide more data on appropriate second-line regimens, including NRTI-sparing and NRTI-limiting approaches (the results are expected after 2014). Further investigation is needed of the role of DRV in second- and third-line regimens (optimal dosing in adults and children, once versus twice daily, fixed-dose combinations with other boosting agents and integrase inhibitors and sequencing strategies). Several trials are underway that are examining induction and maintenance using PI/r monotherapy in maintenance. The potential of including rifabutin as part of fixed-dose combinations for TB treatment also needs to be explored.