Box 10.7: Key implementation considerations for programme managers: phasing out d4T

Consolidated ARV guidelines, June 2013

Choose a suitable alternative. WHO recommends TDF as the preferred alternative to d4T in firstline regimens. TDF is also more likely to be effective than AZT among people who have developed resistance while on d4T.

Design a costed phase-out plan. The overall operational plan for phasing out d4T should be fully costed and should consider any additional investment in laboratory strengthening and capacitybuilding that may be required to support implementation.

Identify priorities for implementation. Because of programme constraints, not all countries may be able to promptly switch everyone receiving d4T to new regimens. Priorities should be clearly defined and agreed with all relevant stakeholders.

Avoid treatment disruption. Although new d4T orders should be discontinued, adequate and timely forecasting and procurement of the preferred alternative drug are critical to avoid stock-outs and treatment interruption.

Review and compare prices. Substantial reductions in the price of both TDF and its preferred companion drug EFV have been observed in recent years. Countries are encouraged to ensure they are procuring these drugs at the best possible price. WHO’s Global Price Reporting Mechanism may be a useful source of price information (23).

Manage stockpiles. Options include reserving stocks for back-up situations for individuals who may require d4T in the absence of alternative choices.

Train and educate both clinic staff and people receiving ART. Clinic staff should be trained and prepared to carry out the transition and to educate ART patients about their new regimens.

Phase out d4T among children when alternatives are available. WHO’s recommendation to phase out the use of d4T applies equally to both adults and children. However, considering the limited availability of age-appropriate NRTI formulations, d4T may be used in special circumstances, especially in settings where formulations of abacavir for children are not available (see sections 7.2.3: First-line ART for children younger than three years of age, and 7.2.4: First-line ART for children three years and older (including adolescents)).