7.5.1 Second-line ART for adults and adolescents
Consolidated ARV guidelines, June 2013
Clinical considerations and key research gaps
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.