Summary table of HIV treatment regimens
- Africa (30)
- Asia (9)
- Latin America & Caribbean (20)
- North America (1)
- Oceania (2)
- Russia & Eastern Europe(2)
- Infants and children (#)
- Adults and adolescents (#)
Country | Clients/Year Issued |
Criteria For Starting ARV Treatment |
First Line Regimen |
Second Line Regimen |
Third Line Regimen |
---|---|---|---|---|---|
Algeria |
Adults and adolescents 2010 |
All patients with any of the following clinical symptoms:
All patients with:
In the following situations:
|
AZT
|
Change the combination from 2 NRTIs and 1 NNRTI to 2 NRTIs and 1 PI; or Change at least 2 of the first-line drugs TDF or TDF |
Substitute 1 of the following drugs for each of at least 2 of the second-line drugs: DRV or ETV or RAL or ddI |
Algeria |
Infants and children 2010 |
All children < 2 years Immunological criteria:
Clinical criteria:
|
Infants: AZT or AZT |
Change the combination from 2 NRTIs and 1 PI/r to 2 NRTIs and 1 NNRTI; or Change at least 2 of the first-line drugs TDF |
______ |
Argentina |
Adults and adolescents 2012 |
All patients with:
Patients with the following conditions should also be initiated on ART:
Treatment recommended if CD4 count is > 350/mm3 and |
ABC TDF AZT Can replace EFV or NVP with ATV/r or LPV/r or FPV/r or SQV/r |
If failed on 2 NRTIs + NNRTI switch to: 2 new NRTIs or 2 new NRTIs |
If failed on 2 NRTIs + PI/r or 1–2 NRTIs + PI/r + NNRTI switch to: 1–2 NRTIs
|
Argentina |
Infants and children 2009 |
All children < 2 years Children 2–5 years with:
Children > 5 years with:
Treatment recommended if CD4 count is > 350/mm3 and < 500/mm3. |
Children < 3 years: AZT or ABC Children > 3 years: AZT ABC or TDF (only in children > 12 years at Tanner stage 4 or 5) |
If failed on 2 NRTIs + NNRTI switch to: 2 new NRTIs If failed on 2 NRTIs + PI/r switch to: 2 NRTIs* 2 NRTIs* or 2 NRTIs* *based on resistance testing |
Refer to pg. 118 of the guidelines. |
Bangladesh |
Adults and adolescents 2011 |
All patients with:
|
AZT or TDF |
TDF or AZT
|
______ |
Bangladesh |
Infants and children 2011 |
All children < 2 years Children 25–59 months with:
Children > 5 years with:
|
Infants group 1 (not exposed to ARVs or unknown exposure): Preferred: AZT Alternative: ABC Infants group 2 (exposed to maternal or infant NVP or other NNRTIs used for maternal treatment or PMTCT): Preferred: AZT Alternative: AZT Children 12–24 months group 1 (exposed to maternal or infant NVP or other NNRTIs used for maternal treatment or PMTCT): Preferred: AZT Alternative: AZT Children 12–24 months group 2 (not exposed to NNRTIs): Preferred: AZT Alternative: ABC 3 years and older: Preferred: AZT Alternative: ABC |
Infants and children < 24 months group 1 (not exposed to ARVs or unknown exposure): ABC or AZT Infants and children < 24 months group 2 (exposed to maternal or infant NVP or other NNRTIs used for maternal treatment or PMTCT): AZT Children > 24 months: ABC or AZT |
______ |
Bhutan |
Infants and children 2008 |
Children < 18 months of age with:
Children 18 months to 5 years of age with:
Children > 5 years or age with:
|
AZT |
d4T |
______ |
Bolivia |
Adults and adolescents 2009 |
All patients with:
|
AZT or d4T* or AZT *Use only in cases of AZT toxicity when there are no other options |
3TC or AZT or TDF |
______ |
Botswana |
Adults and adolescents 2012 |
All patients with:
* Adolescents who are Tanner stages 4 and 5 should be treated according to the adult ARV guidelines |
TDF |
AZT |
Resistance specialist required |
Botswana |
Infants and children 2012 |
All infants and children < 24 months Children > 24 months with:
* Adolescents who are Tanner stages 1, 2, and 3 should be treated according to the pediatric ARV guidelines with close clinical monitoring |
Children < 3 years who did not receive sdNVP: AZT Children < 3 years who received sdNVP: AZT (consult HIV pediatric specialist if child is ≤ 1 month) Children > 3 years: AZT |
If failed on AZT + 3TC + NNRTI switch to: ABC |
______ |
Brazil |
Adults and adolescents 2008 |
All patients with:
|
AZT |
ddI or TDF |
______ |
Brazil |
Infants and children 2009 |
All infants (< 12 months) Children 12–36 months with:
Children 36–60 months with:
Children > 5 years with:
* Except LIP, thrombocytopenia, pulmonary tuberculosis, persistent fever and single episode of pneumonia |
Children and adolescents < 40 lbs: Preferred NRTI combination: AZT or ABC Alternative NRTI combination: AZT Preferred third drug: NVP*; EFV† Alternative third drug: LPV/r Alternative PIs: ATV/r or FPV‡ or FPV/r§ or NFV Children and adolescents ≥ 40 lbs: Preferred NRTI combination: AZT or ABC or TDF Alternative NRTI combinations: AZT Preferred third drug: NVP*; EFV† Alternative third drug: LPV/r Alternative PIs: ATV/r or FPV‡ or FPV/r§ or NRV * for children < 3 years |
Preferred NRTI combinations: If failed on AZT or d4T + 3TC switch to: ABC If failed on ABC + 3TC switch to: AZT Alternative NRTI combinations: If failed on AZT or d4T + 3TC switch to: ABC If failed on ABC + 3TC switch to: AZT Preferred third drug for 2–6 years: LPV/r or TPV/r Preferred third drug for > 6 years: LPV/r or TPV/r or FPV/r or DRV/r or ATV/r* or T20 or RAL *for children >16 years |
In cases of resistance in 3 drug classes (e.g., NRTI, NNRTI, and PI), the decision must be individualized, based on genotypic testing and recent patient medical history. If new classes of medicines are not available, assess off-label use of available drugs or inclusion in a clinical trial. |
Burundi |
Adults and adolescents 2010 |
All patients with:
|
AZT or TDF |
If failed on AZT + 3TC + NVP or EFV switch to: ABC If failed on TDF + FTC + NVP or EFV switch to: ABC or ABC |
Any change to third-line treatment should be decided by an expert panel. Choice of drugs would include a new NNRTI, an integrase inhibitor and a new PI/r (e.g., ETV, RAL, or DRV/r). |
Burundi |
Infants and children 2010 |
All infants and children < 24 months Children ≥ 24 to < 59 months with:
Children > 59 months with:
|
Children < 3 years: AZT Children > 3 years: AZT |
ABC |
Any change to third-line treatment should be decided by an expert panel. Choice of drugs would include a new NNRTI, an integrase inhibitor and a new PI/r (e.g., ETV, RAL, or DRV/r). |
Cambodia |
Adults and adolescents 2007 |
Patients must fulfill psychosocial criteria to initiate ART. All patients with:
|
d4T |
TDF or ddI |
_______ |
Cambodia |
Infants and children 2011 |
All infants and children < 24 months of age Children ≥ 24 to 59 months with:
Children ≥ 5 years with:
|
Children < 12 months with infant daily NVP exposure: AZT or d4T Children < 3 years or < 10 kg: AZT or d4T Children ≥ 3 years or > 10 kg: AZT or d4T |
If failed on AZT or d4T + 3TC + NVP (or EFV) switch to: ABC If failed on ABC + 3TC + NVP (or EFV) switch to: AZT Children ≥ 12 years or Tanner stage > 4 who failed on AZT or d4T + 3TC + NVP switch to: TDF If failed on PI-based regimen: Refer to specialist. After genotype analysis, it is usually recommended that patient remains on original regimen with renewed focus on adherence and dosing. |
______ |
Cameroon |
Adults and adolescents No Date |
All patients with:
|
AZT AZT d4T or d4T |
______ |
______ |
Cameroon |
Infants and children No Date |
Children < 3 years or weighing < 10 kg: AZT AZT Children ≥ 3 years and weighing 10–35 kg: AZT Children weighing > 35 kg: d4T or AZT |
______ |
______ |
|
Cape Verde |
Adults and adolescents 2004 |
All patients with:
|
d4T For pregnant women: AZT In patients with TB: d4T For HIV 2: AZT or d4T |
AZT or (d4T + ddI)* For HIV 2: d4T * Consider medium- and long-term side effects and decide whether to replace this combination with TDF. |
______ |
Cape Verde |
Infants and children 2004 |
All children with:
|
Children < 3 years or weighing < 10 kg: AZT Children ≥ 3 years and weighing > 10 kg: AZT For HIV 2: AZT |
d4T |
Genotyping |
Chile |
Adults and adolescents 2010 |
All patients with:
|
AZT ABC or TDF *Alternatives for third drug: ATV/r or FPV/r or LPV/r |
Switch regimen to 3 fully active drugs. PI/r should replace the first-line NNRTI. |
______ |
Chile |
Infants and children 2010 |
All children with:
|
Preferred NRTI combinations: AZT ddI or ABC Alternative NRTI combinations: AZT or ABC NNRTIs NVP (for children < 3 and as an alternative for those ≥ 3 who cannot swallow tablets); PIs Preferred: LPV/r Alternatives: FPV/r (for children ≥ 6); Postpubertal adolescents: NRTIs: PI/r: IDV/r or FVP/r or SQV/r or ATV/r |
If the first-line regimen was NNRTI-based, change to a PI-based regimen. If the first-line regimen was PI-based, change to a NNRTI-based regimen or an alternative PI reinforced with a low dose of RTV. In the case of a new NNRTI-based regimen, it is important to choose a new combination of NRTIs. A resistance test is essential in order to select a combination of NRTIs that the virus is susceptible to. In cases where there are no dual NRTI combinations that the virus is susceptible to, a regimen of 3 distinct classes of ARVs (i.e., NRTI + NNRTI + PI/r) may be indicated. |
______ |
Colombia |
Adults and adolescents 2010 |
All patients with:
Consider treating patients with:
|
Preferred: AZT * In cases where EFV or NVP cannot be used, replace with one of the following PIs: LPV/r or SQV/r or ATV/r or FPV/r |
If failed on AZT* or d4T + 3TC + EFV or NVP switch to: ABC If failed on AZT* or d4T + 3TC + PI switch to: ABC *AZT is preferred over d4T |
Perform genotypic testing on patients with a second or third treatment failure. Always confirm virological failure and a viral load > 1,000 copies/mL before ordering a genotypic test. |
Comoros |
Adults and adolescents 2007 |
All patients with:
|
TDF |
ddI |
______ |
Comoros |
Infants and children 2007 |
All patients with:
|
Children ≤ 3 years or ≤ 10 kg: AZT Children > 3 years and > 10 kg: AZT |
ddI |
______ |
Côte d Ivoire |
Adults and adolescents 2005 |
All patients with:
|
d4T or AZT |
ABC or TDF |
Refer to specialized |
Côte d Ivoire |
Infants and children 2005 |
Children < 18 months with:
Children > 18 months with:
|
d4T or AZT
|
ABC |
Refer to specialized |
Cuba |
Adults and adolescents 2009 |
All patients with CD4 count < 350/mm3 Patients with special conditions, including:
|
AZT or d4T |
Refer to the guidelines for further guidance (pg. 18). |
______ |
Democratic Republic of Congo |
Adults and adolescents 2005 |
All patients with:
|
d4T or AZT |
ABC |
______ |
Democratic Republic of Congo |
Infants and children 2005 |
Children < 18 months of age with:
Children > 18 months of age with:
|
Children < 3 years of age: AZT Children > 3 years of age: d4T |
ABC |
______ |
Djibouti |
Adults and adolescents 2008 |
All patients with:
|
AZT or d4T Alternative: AZT or AZT or d4T |
ddI or TDF TDF or EFV or NVP ± ddI |
______ |
Dominican Republic |
Adults and adolescents 2004 |
All patients with:
|
AZT |
AZT |
Use of four or more ARVs. See guidelines for further guidance (pg. 64-67). |
Dominican Republic |
Infants and children 2004 |
Children < 18 months of age with:
Children > 18 months and < 13 years of age with:
|
Children weighing < 10 kg: Children weighing > 10 kg: |
AZT |
______ |
Ecuador |
Adults and adolescents 2007 |
All patients with:
|
AZT or ddI or ABC or d4T AZT or d4T AZT TDF |
Refer to the guidelines for further guidance (pg. 42-43) |
______ |
El Salvador |
Adults and adolescents 2005 |
Evaluate the following:
|
AZT |
d4T (for those with anemia) or AZT |
______ |
El Salvador |
Infants and children 2005 |
All children should get a psychosocial evaluation approved by the institutional committee. Infants (< 12 months of age) of infected mothers independent of immunological state and viral load, especially those with:
Children 1 to 3 years of age with:
Children 3 to 13 years of age with:
|
AZT AZT or d4T
|
AZT or d4T |
Patients must visit |
Ethiopia |
Adults and adolescents 2008 |
All patients with:
|
d4T or AZT + or ABC
|
ABC AZT TDF ABC or EFV or NVP
|
______ |
Ethiopia |
Infants and children 2008 |
All infants (< 12 months) Children from 1–5 years with:
Children > 5 years with:
|
d4T or AZT |
ABC |
______ |
Ghana |
Adults and adolescents 2005 |
All patients with:
For pregnant women where CD4 count > 350/mm3, initiate ARV prophylaxis at 28 weeks for the purpose of PMTCT. |
Preferred drugs, first option: AZT Preferred drugs, second option: AZT Alternative drugs, first option: d4T Alternative drugs, second option: d4T |
ABC |
______ |
Ghana |
Infants and children 2005 |
Children < 18 months with:
Children > 18 months with:
|
d4T or AZT |
ABC |
______ |
Guatemala |
Adults and adolescents 2012 |
All patients with:
|
First option: TDF Second option: AZT Third option: ABC
Adolescents: Follow pediatric dosing for Tanner stages 1 and 2. Use individualized dosing for Tanner stage 3. Follow adult dosing for Tanner stages 4 and 5.
|
If failed on first option switch to: ABC ABC or AZT If failed on second option switch to: ABC or ABC If failed on third option switch to: ddI TDF + 3TC + LPV/r or SQV/r; or AZT + ddI + LPV/r or SQV/r
|
Genotypic testing is required. Consult the recommendations of the Committee on Drug Resistance (Comité de Farmacorresistencia). Patients should continue on second-line treatment until third-line treatment is available. Patients should be referred to one of the following clinics for treatment before returning to their home clinic:
|
Guatemala |
Infants and children 2012 |
All infants (< 12 months) Children 1–5 years with:
Children 6–12 years with:
|
Children < 3 years or < 10 kg: First option: AZT Second option: ABC Third option: d4T Children > 3 years or > 10 kg: First option: AZT Second option: ABC Third option: d4T
|
If failed on first or third option (with EFV or NVP) switch to: ABC If failed on first or third option (with LPV/r) switch to: ABC If failed on second option (with EFV or NVP) switch to: AZT or TDF (if > 16 years) If failed on second option (with LPV/r) switch to: AZT or TDF (if > 16 years)
|
Genotypic testing is required. Consult the recommendations of the National Committee on Drug Resistance (Comité de Farmacorresistencia). |
Guinea |
Adults and adolescents 2011 |
All patients with:
Treatment of patients with CD4 counts between 350 and 500/mm3 should be discussed with regard to:
|
AZT TDF or AZT |
If failed on AZT + 3TC + NVP or EFV switch to: ABC or TDF If failed on TDF + FTC + EFV switch to: ABC If failed on AZT + 3TC + LPV/r switch to: ABC
|
Discuss with multidisciplinary team and refer to specialist center. Review treatment history and send for genotypic testing. 2 NRTI
|
Guinea |
Infants and children 2011 |
Infants ≤ 11 months with:
Children 12–35 months with:
Children 36–59 months with:
Children > 5 years with:
|
Children < 3 years or < 10 kg: Preferred: AZT Alternative: d4T Children > 3 years and > 10 kg: Preferred: AZT Alternatives: d4T or ABC |
If failed on AZT or d4T + 3TC + NVP or EFV switch to: ddI or ddI If failed on AZT or d4T + 3TC + ABC switch to: ddI In children < 18 months who failed on AZT or d4T + 3TC + PI/r switch to: ddI or ddI
|
______ |
Guyana |
Adults and adolescents 2011 |
All patients with:
Consider starting treatment in patients with CD4 count 351–500/mm3 if patient is highly motivated or there are other risk factors (e.g., hepatitis B, renal failure, cardiovascular disease). |
Preferred: TDF Alternatives: AZT or ABC
|
If failed on one of the following: TDF + FTC + EFV or NVP; AZT + 3TC + NVP or EFV; d4T + 3TC + NVP or EFV, switch to: TDF If failed on ABC + 3TC + NVP or EFV switch to: AZT If failed on any NRTI-only regimen switch to: TDF or TDF If failed on any PI regimen switch to: TDF
|
It is recommended that clinicians continue the use of second-line regimens while contacting an HIV treatment specialist or the NCTC. |
Guyana |
Infants and children 2011 |
All children < 2 years Children 2–5 years with:
Children > 5 years with:
Can offer antiretroviral therapy to all children above initiation thresholds after conducting a thorough adherence assessment. |
Preferred: ABC Alternatives: d4T or AZT
|
If failed on ABC + 3TC + NVP or EFV switch to: AZT If failed on AZT or d4T + 3TC + NVP or EFV switch to: Preferred: TDF Alternative: TDF If failed on AZT + 3TC + ABC switch to: TDF or TDF If failed on PI regimen: Switch NRTI backbone and continue PI
|
It is recommended that clinicians continue the use of second-line regimens while contacting an HIV treatment specialist or the NCTC. |
Haiti |
Adults and adolescents 2008 |
All patients with:
Those with a CD4 count > 200/mm3 but < 350/mm3 may be considered for treatment. |
TDF or AZT or d4T |
AZT or TDF |
______ |
Haiti |
Infants and children 2006 |
Infants ≤ 11 months with WHO pediatric clinical stage 3 or 4 irrespective of CD4% Children 12–35 months with:
Children 36–59 months with:
Children ≥ 5 years with:
|
AZT d4T or ABC |
If failed on a regimen containing AZT or d4T switch to: ddI If failed on a regimen containing ABC switch to: ddI If failed on regimen containing 3 NRTIs switch to: ddI
|
Third-line ART can sometimes be provided in centers where viral load, genotype, and phenotype testing are available. Regimens consisting of 5 or more drugs (including 2 PIs), the use of T20, and remaining on the current regimen until other ARVs are available are some of approaches that have been used. In these cases, management is difficult and requires a doctor from a tertiary hospital with sufficient experience in pediatric HIV treatment.
|
India |
Infants and children 2006 |
Clinical Markers Infants < 12 months with:
Children > 12 months with:
Immunological Markers Infants < 11 months with:
Children 12–35 months with:
Children 36–59 months with:
Children > 5 years with:
|
d4T or AZT
|
If failed on AZT or d4T + 3TC + NVP or EFV switch to: ddI If failed on ABC or 3TC + NVP or EFV switch to: ddI If failed on AZT or d4T + 3TC + ABC switch to: ddI
|
______ |
India |
Adults and adolescents 2007 |
All patients with:
Those with a CD4 count > 200/mm3 but < 350/mm3 at WHO clinical stage 3 may be considered for treatment. |
d4T or AZT
|
ABC |
______ |
Kenya |
Adults and adolescents 2011 |
All patients with:
|
TDF or AZT |
AZT or TDF * The national therapeutic committee should be consulted for patients who initiated a PI-based regimen as their first-line regimen and subsequently fail treatment. |
Maintain the patient on the failing regimen until a full third-line regimen is available as recommended by the national TWG. Third-line regimens should contain at least 2 fully active drugs for durable, potent virologic suppression. Third-line regimen choice must be guided by resistance testing. Possible third-line agents: DRV, RAL, 3TC, and TDF (recycling drugs); ETV. |
Kenya |
Infants and children 2011 |
All children ≤ 24 months Children 25–59 months with:
Children 5–12 years with:
|
Children not previously exposed to NVP (< 3 years or < 10 kg): Preferred: ABC Alternative: AZT Children not previously exposed to NVP (> 3 years or > 10 kg): Preferred: ABC Alternative: AZT Children previously exposed to NVP: ABC or AZT |
Children not previously exposed to NVP (if failed on a regimen containing ABC) switch to: AZT Children not previously exposed to NVP (if failed on a regimen containing AZT) switch to: ABC Children previously exposed to NVP: Discuss with national ARV therapeutics TWG.
|
Children experiencing treatment failure on second-line therapy should be managed in consultation with senior clinicians experienced in HIV treatment. A framework is being developed by NASCOP to facilitate effective management of patients failing second-line therapy.
|
Lesotho |
Adults and adolescents 2007 |
All patients with:
|
AZT TDF or d4T
|
If failed on AZT or d4T + 3TC + NVP or EFV switch to: TDF If failed on TDF + 3TC + NVP or EFV switch to: ddI ddI or AZT
|
______ |
Lesotho |
Infants and children 2007 |
All infants < 12 months with:
Children 12–35 months with:
Children 36–59 months with:
Children ≥ 5 years with:
An infant or child who has been diagnosed using presumptive criteria can also be initiated on HAART. |
Children < 3 or < 10 kg: AZT or d4T Children > 3 and > 10 kg: AZT or d4T
|
ddI |
______ |
Liberia |
Adults and adolescents 2007 |
All patients with:
|
AZT TDF or d4T |
TDF or AZT or ABC
|
_______ |
Liberia |
Infants and children 2007 |
All infants and children with:
Infants < 11 months with:
Children 12–35 months with:
Children 36–59 months with:
Children ≥ 5 years with:
|
Children < 3 kg: AZT Children > 3 kg: d4T
|
ABC |
______ |
Malawi |
Adults and adolescents 2011 |
All patients with:
|
d4T AZT or TDF |
TDF or AZT |
______ |
Malawi |
Infants and children 2011 |
All infants and children < 24 months. Children ≥ 24 months to < 5 years with:
Children ≥ 5 years with:
|
AZT |
ABC |
______ |
Mauritania |
Adults and adolescents 2005 |
All patients with:
|
d4T or AZT |
ABC |
______ |
Mauritania |
Infants and children 2005 |
Children < 18 months with:
Children ≥ 18 months with:
|
Children ≤ 3 years: AZT Children ≥ 3 years: d4T |
If failed on d4T or AZT + 3TC + NVP or EFV switch to: Preferred: TDF or ABC Alternative: ABC |
______ |
Mexico |
Adults and adolescents 2012 |
All patients with:
|
Preferred NRTI backbone: TDF Alternative NRTI backbones: ABC or AZT Preferred third drug: EFV Alternative third drugs: ATV/r or LPV/r or FPV/r or SQV/r
|
NRTI backbone (if failed on TDF + FTC) switch to: TDF NRTI backbone (if failed on ABC + 3TC or FTC) switch to: TDF NRTI backbone (if failed on AZT + 3TC) switch to: TDF Third drug (if failed on EFV or NVP or ATV/r) switch to: LPV/r Third drug (if failed on LPV/r): Consult the institutional committee for review
|
Patient should be sent to referral center for expert review. Resistance testing (genotypic or phenotypic) is necessary in addition to thorough review of patient’s treatment history. Use at least 2, preferably 3, active ARVs. The following drugs can be used in third-line regimens and are available in Mexico. The institutional committee must authorize the prescription of these drugs: PIs: DRV, TPV NNRTI: ETV Integrase inhibitor: RAL CCR5 inhibitor: MVC Fusion inhibitor: T20
|
Mexico |
Infants and children 2012 |
All infants < 12 months Children ≥ 1 to < 5 years with:
Children > 5 years with:
|
NRTI backbones: ABC AZT or ddI Third drug for children < 3 years: LPV/r Third drug for children > 3 years: LPV/r Alternative third drugs if > 6 years: ATV/r or FPV/r
|
2 new NRTIs If failed on EFV or NVP, switch to: ETV If failed on a PI switch to: NNRTI
|
The following drugs can be used in third-line regimens and are available in Mexico. The institutional committee must authorize the prescription of these drugs: PIs: DRV, TPV NNRTI: ETV Integrase inhibitor: RAL CCR5 inhibitor: MVC Fusion inhibitor: T20
|
Mozambique |
Adults and adolescents 2010 |
All patients with:
|
AZT |
If failed on AZT or d4T + 3TC + NVP or EFV switch to: TDF TDF ABC or TDF
|
______ |
Myanmar |
Adults and adolescents 2011 |
All patients with:
|
AZT TDF
|
If failed on d4T or AZT switch to: TDF If failed on TDF switch to: AZT
|
Refer to page 29 of guidelines. |
Namibia |
Adults and adolescents 2010 |
All patients with:
|
Preferred: TDF Alternative: AZT * EFV should be used instead of NVP in women with CD4 > 350/mm3 or in men with CD4 > 400/mm3.
|
AZT Note that ABC and ddI can be considered as backup options in case of AZT or TDF toxicity or contraindication.
|
Third-line regimens are complicated and should only be implemented following the recommendation and close supervision of an HIV specialist. |
Namibia |
Infants and children 2010 |
All children < 24 months Children 24–59 months with:
Children ≥ 5 years with:
|
Children < 24 months with known prior exposure to NVP: d4T Children < 24 months without (or with unknown) prior exposure to NVP and children ≥ 24 months, but < 14 kg: d4T Children ≥ 24 months and ≥ 14 kg and Tanner stage 1–3: AZT Children ≥ 24 months and ≥ 14 kg and Tanner stage ≥ 4: TDF + 3TC + NVP
|
Children in Tanner stages 1–3 on NNRTI-based first-line regimen switch to: ABC Children in Tanner stages 1–3 on PI-based first-line regimen switch to: ABC Children in Tanner stages 4 or 5 on NNRTI-based first-line regimen switch to: TDF* Children in Tanner stages 4 or 5 on PI-based first-line regimen switch to: TDF* * If the first-line regimen included TDF, seek advice of an HIV specialist.
|
An HIV specialist can give approval for resistance testing for a child failing a second-line regimen and should be consulted for further management of the child. |
Nepal |
Adults and adolescents 2009 |
All patients with:
|
AZT or TDF
|
If failed on AZT or d4T + 3TC + NVP or EFV switch to: TDF If failed on TDF + 3TC + NVP or EFV switch to: ddI
|
______ |
Nepal |
Infants and children 2009 |
All infants < 12 months Children 12–35 months with:
Children 36–59 months with:
Children > 5 years with:
|
Children < 3 years or < 10 kg: AZT Children > 3 years and > 10 kg: AZT Anemic children: d4T
|
______ |
______ |
Nicaragua |
Adults and adolescents 2009 |
All patients with:
|
CD4 count > 200/mm3: AZT or TDF CD4 count < 200/mm3: AZT or TDF |
CD4 count > 200/mm3 switch to: ABC or ddI CD4 count < 200/mm3 switch to: ABC or ddI or ABC or ddI |
______ |
Niger |
Adults and adolescents 2009 |
All patients with:
|
AZT For patients infected with HIV-2 or HIV-1 and HIV-2: AZT |
ABC |
Available alternative ARVs: ATV or SQV or DRV or RAL or ETV |
Nigeria |
Adults and adolescents 2010 |
All patients with:
Consider treatment in patients with CD4 count > 350/mm3 if:
|
AZT or TDF |
If failed on d4T or AZT switch to: TDF If failed on TDF switch to: AZT |
Genotype or phenotype resistance testing is not readily available. Conduct a comprehensive evaluation to ascertain the cause of failure. Recommended salvage therapy: DRV/r + RAL with an optimized background of NRTIs including 3TC or FTC. If salvage regimen is unavailable, continue patient on optimized second-line regimen |
Nigeria |
Infants and children 2010 |
All children < 24 months Children 24–59 months with:
Children ≥ 5 years with:
|
Children < 2 years with no prior NNRTI exposure: Preferred: AZT Alternatives: ABC AZT or d4T Children < 12 months with prior NNRTI exposure: Preferred: AZT Alternatives: ABC or AZT Children 12 months to 2 years with NNRTI exposure: Preferred: AZT Alternatives: AZT ABC or d4T Children 2–3 years, regardless of NNRTI exposure: Preferred: AZT Alternatives: ABC AZT or d4T Children > 3 years: Preferred: AZT Alternatives: AZT AZT d4T or ABC |
If failed on AZT + 3TC + NVP switch to: ABC or d4T If failed on ABC + 3TC + NVP switch to: AZT d4T or ddI If failed on AZT + 3TC + ABC switch to: ddI TDF or ddI If failed on d4T + 3TC + NVP switch to: ABC ddI or AZT If failed on AZT + 3TC + LPV/r switch to: ABC or ddI If failed on ABC + 3TC + LPV/r switch to: AZT or AZT If failed on AZT or d4T + 3TC + EFV switch to: ABC If failed on TDF + 3TC or FTC + EFV or NVP switch to: AZT d4T ABC or ABC |
Children with such needs should be referred to higher levels of care or ART specialists if necessary. When salvage treatment is unavailable, a failing second-line regimen may be continued because there is evidence of some benefit despite the emergence of resistance mutations. |
Pakistan |
Adults and adolescents 2005 |
If CD4 testing is available:
If CD4 testing is not available:
|
AZT |
TDF or ABC |
______ |
Panama |
Adults and adolescents 2011 |
All patients with:
|
Preferred: TDF Alternative: AZT For pregnant women: AZT or SQV/r Alternative: AZT
|
If failed on TDF + 3TC or FTC + EFV switch to: AZT If failed on AZT + 3TC + EFV switch to: TDF If failed on a PI-based first-line regimen, refer to an infectious disease specialist.
|
Virologic failure does not always warrant a change in triple therapy. If a regimen change is necessary, it should be done as soon as possible to avoid greater resistance. Patient adherence must be evaluated. The new regimen should have at least 2 (preferably 3) different active drugs such as RAL or MVC or DRV or EFV.
|
Panama |
Infants and children 2011 |
All children < 2 years Children 2 to < 5 years with:
Consider treatment in children 2 to < 5 years with:
Children ≥ 5 years with:
Consider treatment in children ≥ 5 years with:
|
Children < 3 years: AZT Children ≥ 3 years: AZT
|
Children < 3 years switch to: AZT Children ≥ 3 years switch to: AZT
|
______ |
Papua New Guinea |
Adults and adolescents 2009 |
All patients with:
|
AZT or d4T
|
If failed on AZT + 3TC + NVP or EFV switch to: TDF or ddI If failed on d4T + 3TC + NVP switch to: TDF If failed on d4T + 3TC + EFV switch to: ddI If failed on d4T + 3TC + EFV switch to: TDF
|
______ |
Papua New Guinea |
Infants and children 2009 |
All infants < 12 months Children 12–35 months with:
Children 36–59 months with:
Children ≥ 5 years with:
|
Children < 3 years or < 10 kg: AZT Children > 3 years and > 10 kg: AZT Alternative: Replace AZT with d4T in the above regimens.
|
If failed on AZT or d4T + 3TC + NVP or EFV switch to: ddI If failed on AZT or d4T + 3TC + ABC switch to: ddI
|
______ |
Paraguay |
Adults and adolescents 2011 |
All patients with:
Consider treatment in patients with CD4 count > 350/mm3 and:
ART should be initiated independent of CD4 count in cases of:
|
AZT AZT d4T FTC TDF or ABC |
AZT d4T AZT FTC d4T or ABC
|
If not used in first- or second-line regimen switch to: AZT AZT or AZT
|
Peru |
Adults and adolescents 2004 |
All patients with:
|
AZT or d4T |
2 new NRTIs |
______ |
Peru |
Infants and children 2009 |
Children < 12 months with:
Consider treatment in children < 12 months with:
Children > 12 months with:
Consider treatment in children > 12 months with:
For adolescents > Tanner stage 3 and/or > 40 kg, treat as adults. |
Preferred: 2 NRTIs Alternative: 2 NRTIs Preferred NRTI backbone: AZT Alternative NRTI backbones: d4T ABC ABC TDF* or TDF* NNRTIs: In children < 3 years: NVP In children > 3 years: EFV or NVP PIs: LPV/r or NFV * Use in adolescents.
|
If failed on regimen of 2 NRTIs + 1 NNRTI switch to: 2 new NRTIs or 1 new NRTI If failed on regimen of 2 NRTIs + PI/r switch to: 2 new NRTIs 1 new NRTI or 2 new NRTIs If failed on AZT + 3TC + NVP or EFV switch to: Children < 6 years: ABC Children > 6 years: TDF
|
The following drugs may be indicated after consultation with the committee of experts: ATV or SQV or DRV or MVC or AMP or FPV
|
Philippines |
Adults and adolescents 2009 |
All patients with:
Those with a CD4 count > 200/mm3 but < 350/mm3 at WHO clinical stage 3 may be considered for treatment. |
AZT or d4T |
AZT or TDF |
______ |
Russia |
Adults and adolescents 2007 |
All patients with:
The Ministry of Health of the Russian Federation also recommends treatment if:
|
2 NRTIs NRTI backbones: AZT ABC PZT d4T TDF or ABC NNRTIs: Preferred: EFV Alternative: NVP PIs: LPV/r or IDV/r or SQV/r or FPV/r or ATV/r, ATV, or NFV
|
Some of the ARVs used in second-line regimens are ATV, ATV/r, DRV, and TPV. Refer to page 38 of the guidelines for further information. |
______ |
Rwanda |
Adults and adolescents 2007 |
All patients with:
|
d4T or TDF or AZT |
ABC or AZT or d4T |
______ |
Rwanda |
Infants and children 2007 |
Infants < 11 months with:
Children 12–35 months with:
Children 36–59 months with:
Children > 5 years with:
|
d4T or AZT |
ddI |
______ |
Senegal |
Adults and adolescents No Date |
All patients with:
|
The choice of first line regimen should be individualized based on potential advantages and disadvantages specific to each patient. Refer to the guidelines for further guidance. |
The choice of second line regimen should be individualized based on potential advantages and disadvantages specific to each patient. Refer to the guidelines for further guidance. |
______ |
Sierra Leone |
Adults and adolescents 2006 |
All patients with:
|
Preferred: AZT or d4T Alternative: AZT
|
2 new NRTIs + Preferred: AZT Alternative: AZT
|
______ |
Sierra Leone |
Infants and children 2007 |
All children with:
If virological testing is not available to confirm HIV infection, HIV antibody–positive infants and children < 18 months who have clinically diagnosed presumed severe HIV disease should be considered for ART. |
Children < 3 years or < 10 kg: AZT or d4T Children > 3 years and > 10 kg: AZT or d4T
|
If failed on AZT + 3TC backbone switch to: d4t If failed on d4T + 3TC backbone switch to: AZT If failed on EFV or NVP switch to: Switch third drug to LPV/r If failed on LPV/r switch to: Switch third drug to EFV or NVP |
______ |
South Africa |
Adults and adolescents 2010 |
All patients with:
|
TDF |
AZT |
______ |
South Africa |
Infants and children 2010 |
All infants (< 12 months) Children 12 months to 5 years with:
Children > 5 years with:
|
Children < 3 years of age or weighing < 10kg: ABC Children > 3 years and weighing > 10kg: ABC |
______ |
______ |
Swaziland |
Infants and children 2006 |
All children with:
|
d4T or AZT |
ABC |
______ |
Swaziland |
Adults and adolescents 2010 |
All patients with:
|
Preferred NRTI backbone: TDF Alternative: AZT or d4 Preferred NNRTI: EFV Alternative: NVP |
ABC * Use SQV/r or ATV/r or IDV/r in patients who cannot tolerate LPV/r. |
______ |
Tanzania |
Adults and adolescents 2009 |
All patients with:
|
AZT Alternatives to AZT: d4T or TDF Alternative to 3TC: FTC |
If failed on AZT or d4t switch to: TDF If initiated on TDF due to intolerance to AZT or d4T switch to: ABC |
ART regimen should be continued until patient is no longer receiving clinical benefits from treatment. If the patient is at WHO clinical stage 4 while on second-line regimen, expert opinion should be sought regarding stopping ART and instituting palliative care. |
Tanzania |
Infants and children 2009 |
All infants < 12 months Children 12–18 months with:
Children > 18 months with:
|
Children < 3 years: AZT ABC or d4T Children > 3 years: AZT ABC or d4T Children who have received NVP or 3TC as MTCT prophylaxis should be given a second-line PI-based regimen. If second-line regimen is unavailable, these children should be given an available first-line regimen. |
ddI |
______ |
Thailand |
Adults and adolescents 2010 |
All patients with:
* But discontinue after delivery for those women with a pretreatment CD4 count of ≥ 350/mm3 |
Preferred: AZT or TDF Alternatives: ABC d4T* or ddI * d4T should be replaced by another NRTI after 6–12 months.
If patient cannot tolerate NNRTIs, replace with: Preferred: LPV/r Alternative: ATV/r or DRV/r or SQV/r |
If first regimen was NNRTI-based switch to: PI/r If first regimen was PI/r-based switch to: Active PI/r Active PI/r NNRTI |
At least 2 new active ARVs, such as DRV/r or ETV or RAL Refer to expert consultation or appropriate clinical trial in cases where these drugs are not available. While waiting for new drugs, a holding regimen consisting of 3TC and other NRTIs may be considered. |
Thailand |
Infants and children 2010 |
All infants (< 12 months) Children 1–5 years with:
Children > 5 years with:
|
Children < 3 years: Preferred: AZT Alternative: d4T Children > 3 years: Preferred: AZT Alternative: AZT or d4T Adolescents (weight > 40kg or Tanner stage 4): TDF |
2 NRTIs Select NRTIs guided by genotype of RT gene. Refer to Figure 1 on page 510 of the guidelines for specific second-line regimens recommended for different scenarios. |
To design a salvage regimen, use at least 2 active drugs plus a recycled NRTI. Access to new drugs such as DRV, MVC, ETV, and RAL may be needed. Expert consultation is recommended. Refer to page 511 of the guidelines for further information. |
Togo |
Adults and adolescents 2010 |
All patients with:
|
AZT |
If failed on AZT or ABC or d4T switch to: TDF If failed on TDF switch to: AZT or ABC |
______ |
Uganda |
Adults and adolescents 2009 |
All patients with:
|
Preferred: AZT Alternative, first option: TDF Alternative, second option: d4T
|
If failed on AZT + 3TC + NVP or EFV switch to: ABC or TDF If failed on TDF + 3TC or FTC + NVP or EFV switch to: AZT ABC or AZT If failed on d4T + 3TC + NVP or EFV switch to: ABC or TDF
|
______ |
Uganda |
Infants and children 2009 |
All infants (< 12 months) Children 12–35 months with CD4% ≤ 20% (CD4 count ≤ 750/mm3) Children 36–59 months with CD4% ≤ 20% (CD4 count ≤ 350/mm3) Children ≥ 5 years with CD4% ≤ 15% (CD4 count ≤ 250/mm3)
|
Infants < 12 months initiating ART with previous exposure to NVP or EFV: d4T Children < 5 years: d4T Children ≥ 5 years initiating or being switched from d4T-containing regimens: AZT
|
If failed on d4T + 3TC + NVP or EFV switch to: ABC TDF or AZT If failed on AZT + 3TC + NVP or EFV switch to: ABC or TDF If failed on d4T + 3TC + LPV/r switch to: ABC
|
______ |
Ukraine |
Adults and adolescents 2006 |
All patients with:
Consider treatment if CD4 count > 200/mm3 and < 350/mm3 and WHO clinical stage 1 or 2. |
Preferred: AZT or TDF* Alternative: AZT Preferred PI-based regimens: AZT or TDF* Alternative PI-based regimen: AZT * TDF and FTC require registration in Ukraine.
|
If failed on AZT + 3TC + EFV or NVP switch to: ddI or TDF If failed on TDF + FTC or 3TC + EFV or NVP switch to: ddI If failed on AZT + 3TC + LPV/r switch to: ddI or TDF If failed on TDF + FTC + LPV/r switch to: ddI If failed on AZT + 3TC + NFV switch to: AZT
|
Considerations for salvage regimens:
|
Ukraine |
Infants and children 2007 |
Infants ≤ 11 months:
Children 12–35 months:
Children 36–59 months:
Children ≥ 5 years:
* TB, LIP, OHL, or thrombocytopenia |
Preferred NRTI backbones: AZT d4T AZT or ddI Alternative NRTI backbones: ABC ABC or d4T NNRTIs: Children < 3 years: NVP Children ≥ 3 years: EFV PIs: LPV/r or NFV
|
If failed on AZT or d4T + 3TC + NVP or EFV switch to: ddI If failed on ABC + 3TC + NVP or EFV switch to: ddI If failed on AZT or d4T + 3TC + LPV/r or NFV switch to: ddI If failed on ABC + 3TC + LPV/r or NFV switch to: ddI If failed on AZT or d4T + 3TC + ABC switch to: ddI
|
This requires consultation with an experienced professional. Strategic approaches include:
|
United States |
Adults and adolescents 2012 |
All patients with:
|
Preferred: EFV or ATV/r or DRV/r or RAL
|
Patient’s treatment history and former and current resistance test results should be used to identify at least 2 (preferably 3) fully active agents to combine with an optimized background ARV regimen. Refer to the guidelines for further guidance (pg. H-1). |
Refer to pg. H-1 of the guidelines. |
United States |
Infants and children 2010 |
All infants (< 12 months) Children ≥ 1 with:
|
Children < 3 years: Preferred: ABC or ddI or AZT Alternative: AZT Children > 3 years: Preferred: ABC or ddI or AZT or TDF* Alternative: AZT Children ≥ 6 years: Preferred: ABC or ddI or AZT or TDF* Alternative: AZT * TDF for Tanner stage 4 or postpubertal adolescents only
|
If failed on 2 NRTIs + NNRTI switch to: 2 NRTIs If failed on 2 NRTIs + PI switch to: 2 NRTIs 2 NRTIs or NRTI(s) If failed on 3 NRTIs switch to: 2 NRTIs or NRTI(s)
|
Refer to guidelines for further information (pg. 130–136). |
Uruguay |
Adults and adolescents 2006 |
All patients with:
|
AZT or d4T |
2 NRTIs 2 NRTIs or 1 NRTI |
______ |
Venezuela |
Adults and adolescents 2012 |
All patients with:
Treat patients with special considerations such as:
|
TDF or ABC or AZT or ddI or TDF or ABC or AZT or ddI
|
If failed on TDF + 3TC backbone switch to: AZT ddI or ddI If failed on ABC + 3TC backbone switch to: TDF or AZT If failed on AZT + 3TC backbone switch to: ABC or TDF If failed on ddI + 3TC backbone switch to: TDF or TDF If failed on AZT + ddI backbone switch to: TDF or ABC If failed on d4T + ddI backbone switch to: TDF ABC or TDF If failed on AZT + ABC + 3TC switch to: PI/r If failed on d4T + 3TC backbone switch to: TDF or ABC If failed on d4T or AZT + ABC backbone switch to: TDF If failed on NNRTI-based regimen, switch to PI/r switch to: ATV/r or FPV/r or LPV/r or SQV/r If failed on PI/r-based regimen switch to NNRTI: EFV or NVP
|
Available third-line drugs: DRV, ETV, RAL, T20 Include 2 active ARVs in a 3-drug regimen.
|
Venezuela |
Infants and children 2012 |
All infants < 12 months Children 1 to < 5 years with:
Consider treatment in asymptomatic children 1 to < 5 years with CD4% ≥ 25% and viral load ≥ 100,000 copies/mL. Children > 5 years with:
Consider treatment in asymptomatic children > 5 years with CD4 count ≥ 350/mm3 and viral load ≥ 100,000 copies/mL. |
Children < 3 years: ABC or AZT or ddI Children ≥ 3 years and > 10 kg: ABC or AZT or ddI or TDF * Can substitute LPV/r or ATV/r for EFV if > 6 years † 3TC only in adolescents at Tanner stages 4 or 5
|
If failed on 2 NRTIs + NNRTI switch to: 2 NRTIs If failed on 2 NRTIs + PI/r switch to: 2 NRTIs or NRTI
|
Refer to CONARESAR for further guidance. For more information, see pg. 37 of the guidelines. |
Vietnam |
Adults and adolescents 2009 |
All patients with:
|
Preferred: AZT or d4T Alternatives: AZT or d4T For patients who cannot use AZT or d4T: TDF For patients who cannot use NVP or EFV: AZT
|
If failed on d4T or AZT + 3TC + NVP or EFV switch to: TDF or ddI If failed on TDF + 3TC + NVP or EFV switch to: ddI or AZT If failed on AZT or d4T + 3TC + TDF or ABC switch to: EFV or NVP * ATV/r can be used as an alternative for LPV/r.
|
______ |
Vietnam |
Infants and children 2009 |
All infants < 12 months Children > 12 months with:
* See pg. 97 of guidelines for pediatric immunological staging. |
Preferred regimen for non-NVP-exposed children: AZT For NVP-exposed infants < 12 months: Preferred: AZT Alternatives: d4T or ABC * If LPV/r is not available, use NVP.
|
If failed on AZT or d4T + 3TC + NVP or EFV switch to: ddI If failed on AZT or d4T + 3TC + ABC switch to: ddI or ddI If failed on ABC + 3TC + NVP or EFV switch to: AZT or d4T * ATV/r can be used as an alternative for LPV/r.
|
______ |
Zambia |
Adults and adolescents 2007 |
All patients with:
|
TDF |
AZT or d4T |
______ |
Zambia |
Infants and children 2010 |
All children < 2 years Children ≥ 2 and < 5 years with:
Children ≥ 5 years with:
|
Infants and children < 24 months with no previous NNRTI exposure: 2 NRTIs Infants and children < 24 months with previous NNRTI exposure (e.g., from PMTCT): 2 NRTIs Children ≥ 24 months and < 3 years: 2 NRTIs Children > 3 years: 2 NRTIs Preferential order of NRTI backbone: AZT + 3TC ABC + 3TC d4T + 3TC
|
If failed on AZT or d4T + 3TC + NVP or EFV switch to: ABC In children > 12 years switch to: TDF If failed on ABC + 3TC + NVP or EFV switch to: AZT If failed on AZT or d4T + 3TC + LPV/r switch to: ABC If failed on ABC + 3TC + LPV/r switch to: AZT
|
Considerations:
For further information on the failure of second-line regimens, refer to page 73 of the guidelines. |
Zimbabwe |
Adults and adolescents 2010 |
All patients with:
|
Preferred: TDF Alternative: AZT
|
Preferred: AZT If failed on regimen containing AZT or d4T switch to: TDF Alternative: ABC * 3TC may be replaced with FTC † ATV/r is an alternative PI
|
______ |
Zimbabwe |
Infants and children 2010 |
All infants < 12 months Children ≥ 1 and < 5 years with:
Children ≥ 5 years with:
|
For NVP-exposed infants: Preferred: AZT Alternative: d4T For non-NVP-exposed infants and children: Preferred: AZT Alternative: d4T
|
If failed on regimen with PI switch to: Preferred: ABC Alternative: ABC If failed on regimen with NVP switch to: Preferred: ABC Alternative: ABC
|
______ |