Summary table of HIV treatment regimens

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# regimens found that match the criteria
Regimen Summary Table
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:

  • CDC category C;
  • Recurrent oropharyngeal candidiasis;
  • Herpes zoster;
  • Weight loss > 10 kg;
  • Prolonged fever;
  • Prolonged diarrhea; or
  • Visceral leishmaniasis

All patients with:

  • CD4 count < 500/mm3

In the following situations:

  • Pregnant woman;
  • Discordant couple;
  • > 50 years;
  • Coinfection with hepatitis B or hepatitis C;
  • Cardiovascular risk factors;
  • Symptomatic primary infection; or
  • Viral load > 100,000 copies/mL

AZT
+
3TC
+
EFV

 

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
+
3TC
+
LPV/r

or

TDF
+
FTC (FDC)
+
LPV/r or ATV

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:

  • Children 25–59 months with CD4% < 25%; or
  • Children > 5 years with CD4% < 20% or
    25% with viral load > 100,000
    copies/mL or

Clinical criteria:

  • Children of any age with CDC category B or C; or
  • Children 24 months–5 years with CDC category B

Infants:

AZT
+
3TC
+
PI/r

or

AZT
+
3TC
+
NVP if the mother did not receive NVP during pregnancy

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
+
3TC
+
NVP or EFV

______

Argentina Adults and adolescents
2012

All patients with:

  • CD4 count <350/mm3; or
  • A history of AIDS-defining illness or clinically significant symptoms suggesting advanced disease

Patients with the following conditions should also be initiated on ART:

  • HIV-associated nephropathy;
  • Hepatitis B coinfection when HBV treatment is indicated;
  • Pregnancy; or
  • Occupational exposure or high occupational risk

Treatment recommended if CD4 count is > 350/mm3 and
< 500/mm3.

ABC
+
3TC
+
EFV or NVP;

TDF
+
FTC or 3TC
+
EFV or NVP;

or

AZT
+
3TC
+
EFV or NVP

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
+
PI/r;

or

2 new NRTIs
+
PI/r
±
NNRTI

If failed on 2 NRTIs + PI/r or 1–2 NRTIs + PI/r + NNRTI switch to:

1–2 NRTIs
+
new PI/r
±
NNRTI

 

Argentina Infants and children
2009

All children < 2 years

Children 2–5 years with:

  • AIDS-defining illness or clinically significant symptoms (CDC category B or C); or
  • CD4% < 25%

Children > 5 years with:

  • AIDS-defining illness or clinically significant symptoms (CDC category B or C); or
  • CD4 < 350/mm3

Treatment recommended if CD4 count is > 350/mm3 and < 500/mm3.

Children < 3 years:

AZT
+
3TC or FTC
+
NVP

or

ABC
+
3TC or FTC
+
NVP

Children > 3 years:

AZT
+
3TC or FTC
+
EFV;

ABC
+
3TC or FTC
+
EFV

or

TDF (only in children > 12 years at Tanner stage 4 or 5)
+
3TC or FTC
+
EFV

If failed on 2 NRTIs + NNRTI switch to:

2 new NRTIs
+
PI/r*

If failed on 2 NRTIs + PI/r switch to:

2 NRTIs*
+
NNRTI;

2 NRTIs*
+
alternative PI/r*;

or

2 NRTIs*
+
alternative PI/r*
+
NNRTI

*based on resistance testing

Refer to pg. 118 of the guidelines.

Bangladesh Adults and adolescents
2011

All patients with:

  • CD4 count ≤ 350/mm3;
  • WHO clinical stage 3 or 4 irrespective of CD4 count;
  • Active TB disease irrespective of CD4 count; or
  • HBV infection requiring treatment irrespective of CD4 count

AZT
+
3TC
+
EFV or NVP;

or

TDF
+
3TC
+
EFV or NVP (use for HIV/HBV coinfection)

TDF
+
3TC or FTC
+
LPV/r or ATV/r;

or

AZT
+
3TC or FTC
+
LPV/r or ATV/r

 

______

Bangladesh Infants and children
2011

All children < 2 years

Children 25–59 months with:

  • CD4 count ≤ 750/mm3 or CD4%
    ≤ 25%; or
  • WHO pediatric clinical stage 3 or 4 irrespective of CD4 count

Children > 5 years with:

  • CD4 count ≤ 350/mm3; or
  • WHO pediatric clinical stage 3 or 4 irrespective of CD4 count

Infants group 1 (not exposed to ARVs or unknown exposure):

Preferred:

AZT
+
3TC
+
NVP

Alternative:

ABC
+
3TC
+
NVP

Infants group 2 (exposed to maternal or infant NVP or other NNRTIs used for maternal treatment or PMTCT):

Preferred:

AZT
+
3TC
+
LPV/r

Alternative:

AZT
+
3TC
+
NVP (only when PIs are not available or not feasible)

Children 12–24 months group 1 (exposed to maternal or infant NVP or other NNRTIs used for maternal treatment or PMTCT):

Preferred:

AZT
+
3TC
+
LPV/r

Alternative:

AZT
+
3TC
+
NVP

Children 12–24 months group 2 (not exposed to NNRTIs):

Preferred:

AZT
+
3TC
+
NVP

Alternative:

ABC
+
3TC
+
NVP

3 years and older:

Preferred:

AZT
+
3TC
+
NVP or EFV

Alternative:

ABC
+
3TC
+
NVP

Infants and children < 24 months group 1 (not exposed to ARVs or unknown exposure):

ABC or AZT
+
3TC
+
LVP/r

Infants and children < 24 months group 2 (exposed to maternal or infant NVP or other NNRTIs used for maternal treatment or PMTCT):

AZT
+
3TC
+
NVP

Children > 24 months:

ABC or AZT
+
3TC
+
LVP/r

______

Bhutan Infants and children
2008

Children < 18 months of age with:

  • CD4% < 25% (1500/mm3);
  • TLC < 3400/mm3; or
  • WHO pediatric clinical stage 3 or 4

Children 18 months to 5 years of age with:

  • CD4% < 15% (500/mm3);
  • TLC < 2300/mm3; or
  • WHO pediatric clinical stage 3 or 4

Children > 5 years or age with:

  • CD4% < 15% (200/mm3);
  • TLC < 1200/mm3; or
  • WHO pediatric clinical stage 3 or 4

AZT
+
3TC
+
EFV or NVP

d4T
+
3TC
+
EFV or NVP

______

Bolivia Adults and adolescents
2009

All patients with:

  • WHO clinical stage 1, 2 or 3 with CD4 count < 500/mm3; or
  • WHO clinical stage 4

AZT or d4T*
+
3TC
+
NVP or EFV;

or

AZT
+
3TC
+
ddI

*Use only in cases of AZT toxicity when there are no other options

3TC or AZT
+
ddI
+
IDV/r or LPV/r;

or

TDF
+
3TC
+
IDV/r or LPV/r

______

Botswana Adults and adolescents
2012

All patients with:

  • CD4 count ≤ 350/mm3; or
  • WHO clinical stage 3 or 4

* Adolescents who are Tanner stages 4 and 5 should be treated according to the adult ARV guidelines

TDF
+
FTC or 3TC
+
EFV

AZT
+
3TC
+
LPV/r

Resistance specialist required

Botswana Infants and children
2012

All infants and children < 24 months

Children > 24 months with:

  • CD4% ≤ 25% or CD4 count ≤ 750/mm3; or
  • WHO pediatric clinical stage 3 or 4

* 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
+
3TC
+
NVP

Children < 3 years who received sdNVP:

AZT
+
3TC
+
LPV/r

(consult HIV pediatric specialist if child is ≤ 1 month)

Children > 3 years:

AZT
+
3TC
+
EFV

If failed on AZT + 3TC + NNRTI switch to:

ABC
+
3TC
+
LPV/r

______

Brazil Adults and adolescents
2008

All patients with:

  • CD4 count < 200/mm3;
  • A history of AIDS-defining illness or clinically significant symptoms suggesting advanced disease; or
  • CD4 count > 200/mm3 and < 350/mm3 with viral load >100,000 copies/mL

AZT
+
3TC
+
EFV or LPV/r

ddI or TDF
+
3TC
+
NVP or ATV/r

______

Brazil Infants and children
2009

All infants (< 12 months)

Children 12–36 months with:

  • CDC category B* or C;
  • CD4% < 25% or CD4 count < 750/mm3; or
  • Consider treatment if viral load > 100,000 copies/mL

Children 36–60 months with:

  • CDC category B* or C;
  • CD4% < 20% or CD4 count < 500/mm3; or
  • Consider treatment if viral load > 100,000 copies/mL

Children > 5 years with:

  • CDC category B* or C;
  • CD4% < 15% or CD4 count < 350/mm3; or
  • Consider treatment if viral load > 100,000 copies/mL

* Except LIP, thrombocytopenia, pulmonary tuberculosis, persistent fever and single episode of pneumonia

Children and adolescents < 40 lbs:

Preferred NRTI combination:

AZT or ABC
+
3TC

Alternative NRTI combination:

AZT
+
ABC or ddI

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
+
3TC

Alternative NRTI combinations:

AZT
+
ABC or ddI

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
† for children ≥ 3 years
‡ for children ≥ 2 years
§ for children > 6 years

Preferred NRTI combinations:

If failed on AZT or d4T + 3TC switch to:

ABC
+
3TC

If failed on ABC + 3TC switch to:

AZT
+
3TC

Alternative NRTI combinations:

If failed on AZT or d4T + 3TC switch to:

ABC
+
ddI

If failed on ABC + 3TC switch to:

AZT
+
ddI

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:

  • CD4 count < 350/mm3 irrespective of WHO clinical stage;
  • WHO clinical stage 3 or 4;
  • TB; or
  • Hepatitis B coinfection when HBV treatment is indicated

AZT
+
3TC
+
NVP;

or

TDF
+
FTC
+
EFV

If failed on AZT + 3TC + NVP or EFV switch to:

ABC
+
TDF
+
ATV/r or LPV/r

If failed on TDF + FTC + NVP or EFV switch to:

ABC
+
AZT
+
ATV/r or LPV/r;

or

ABC
+
ddI
+
ATV/r or LPV/r

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:

  • CD4% < 25% or CD4 count < 750 mm3; or
  • WHO pediatric clinical stage 3 or 4

Children > 59 months with:

  • CD4 count < 350 mm3; or
  • WHO pediatric clinical stage 3 or 4

Children < 3 years:

AZT
+
3TC
+
NVP

Children > 3 years:

AZT
+
3TC
+
EFV

ABC
+
ddI
+
LPV/r

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:

  • CD4 count < 250/mm3; or
  • WHO clinical stage 4 (defer ART if patient is coinfected with extra-pulmonary TB and CD4 count > 250/mm3)

d4T
+
3TC
+
NVP

TDF
+
3TC
+
LPV/r;

or

ddI
+
3TC
+
LPV/r

_______

Cambodia Infants and children
2011

All infants and children < 24 months of age

Children ≥ 24 to 59 months with:

  • CD4 percent < 25% or CD4 count < 750/mm3; or
  • WHO pediatric clinical stage 3 or 4 irrespective of CD4

Children ≥ 5 years with:

  • CD4 count < 350/mm3

Children < 12 months with infant daily NVP exposure:

AZT or d4T
+
3TC
+
LPV/r

Children < 3 years or < 10 kg:

AZT or d4T
+
3TC
+
NVP

Children ≥ 3 years or > 10 kg:

AZT or d4T
+
3TC
+
NVP (or EFV)

If failed on AZT or d4T + 3TC + NVP (or EFV) switch to:

ABC
+
3TC
+
LPV/r

If failed on ABC + 3TC + NVP (or EFV) switch to:

AZT
+
3TC
+
LPV/r

Children ≥ 12 years or Tanner stage > 4 who failed on AZT or d4T + 3TC + NVP switch to:

TDF
+
3TC (or FTC)
+
LPV/r

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:

  • WHO clinical stage 4;
  • WHO clinical stage 2 or 3 with TLC < 1200/mm3; or
  • CD4 count < 200/mm3 irrespective of clinical stage

AZT
+
3TC
+
EFV;

AZT
+
3TC
+
NVP;

d4T
+
3TC
+
NVP;

or

d4T
+
3TC
+
EFV

______

______

Cameroon Infants and children
No Date

Children < 3 years or weighing < 10 kg:

AZT
+
3TC
+
NVP (except when child has been exposed to NVP through PMTCT);

or

AZT
+
3TC
+
EFV (for children who were exposed to NVP through PMTCT)

Children ≥ 3 years and weighing 10–35 kg:

AZT
+
3TC
+
EFV or NVP

Children weighing > 35 kg:

d4T
+
3TC
+
NVP;

or

AZT
+
3TC
+
EFV

______

______

Cape Verde Adults and adolescents
2004

All patients with:

  • WHO clinical symptoms (major or minor clinical signs related to HIV infections);
  • CD4 count < 200/mm3;
  • Viral load > 30,000 RNA copies/mL (by bDNA test) or 55,000 RNA copies/mL (by PCR test); or
  • Consider treatment if CD4 > 200/mm3 and < 350/mm3

d4T
+
3TC
+
NVP

For pregnant women:

AZT
+
3TC
+
NVP

In patients with TB:

d4T
+
3TC
+
EFV

For HIV 2:

AZT
+
3TC
+
LPV/r;

or

d4T
+
3TC
+
LPV/r

AZT
+
ddI
+
NFV;

or

(d4T + ddI)*
+
NFV

For HIV 2:

d4T
+
ddI
+
LPV/r

* 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:

  • Symptoms associated with HIV infection (AIDS-defining conditions);
  • Evidence of immunosuppression (CDC categories 2 or 3); or
  • Viral load > 100,000 copies/mL

Children < 3 years or weighing < 10 kg:

AZT
+
3TC
+
NVP

Children ≥ 3 years and weighing > 10 kg:

AZT
+
3TC
+
NVP or EFV

For HIV 2:

AZT
+
3TC
+
LPV/r

d4T
+
ddI
+
LPV/r or NFV

Genotyping

Chile Adults and adolescents
2010

All patients with:

  • CDC category B with CD4 count < 350/mm3;
  • CD4 count > 200/mm3 and < 350/mm3 with two consecutive measurements < 350/mm3, one month apart;
  • CD4 count < 200/mm3, only one measurement necessary; or
  • CDC category C OI

AZT
+
3TC
+
EFV*;

ABC
+
3TC
+
EFV*;

or

TDF
+
3TC
+
EFV*

*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:

  • Evidence of severe immunosuppression (WHO pediatric clinical stage 3); or
  • Evidence of certain clinical manifestations of disease (CDC category B) and CD4% below age threshold or viral load above age threshold as follows:
    • 0 to ≤ 3 months: CD4% < 30%; viral load > 1,000,000 copies/mL
    • 3 to ≤ 6 months: CD4% < 25%; viral load > 1,000,000 copies/mL
    • 6 to ≤ 12 months: CD4% < 20%; viral load > 1,000,000 copies/mL
    • 1 to 3 years: CD4% < 20%; viral load > 300,000 copies/mL
    • 3 to 5 years: CD4% < 15%; viral load > 250,000 copies/mL
    • ≥ 5 years: CD4% < 15% or CD4 count < 200/mm3; viral load > 250,000 copies/mL

Preferred NRTI combinations:

AZT
+
3TC (or FTC);

ddI
+
3TC (FTC);

or

ABC
+
3TC (or FTC)

Alternative NRTI combinations:

AZT
+
ddI;

or

ABC
+
AZT

NNRTIs

NVP (for children < 3 and as an alternative for those ≥ 3 who cannot swallow tablets);
EFV (for children ≥ 3)

PIs

Preferred:

LPV/r

Alternatives:

FPV/r (for children ≥ 6);
ATV/r (for children ≥ 6)

Postpubertal adolescents:

NRTIs:

TDF
+
3TC

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:

  • CDC category B or C; or
  • CD4 count < 200/mm3

Consider treating patients with:

  • CD4 count between 200 and 250/mm3; or
  • CD4 count between 250 and 350/mm3 and a viral load > 100,000 copies/mL

Preferred:

AZT
+
3TC
+
EFV

* 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
+
ddI
+
FPV±r or LPV/r

If failed on AZT* or d4T + 3TC + PI switch to:

ABC
+
ddI
+
EFV or NVP

*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:

  • WHO clinical stage 4;
  • CD4 count < 200/mm3; or
  • CD4 count between 200 and 350/mm3 according to clinical and laboratory criteria

TDF
+
FTC
+
EFV or NVP

ddI
+
ABC
+
EFV or LPV/r

______

Comoros Infants and children
2007

All patients with:

  • WHO pediatric clinical stage 3 or 4; or
  • WHO pediatric clinical stage 1 or 2 and CD4% < 25%

Children ≤ 3 years or ≤ 10 kg:

AZT
+
3TC
+
LPV/r

Children > 3 years and > 10 kg:

AZT
+
3TC
+
EFV

ddI
+
ABC
+
LPV/r

______

Côte d Ivoire Adults and adolescents
2005

All patients with:

  • CD4 count < 200/mm3;
  • CD4 count < 350/mm3
    and CDC Category B; or
  • WHO clinical stage 2, 3 or 4
    or CDC Category C

d4T or AZT
+
3TC
+
NVP or EFV

ABC or TDF
+
ddI
+
LPV/r or SQV/r or IDV/r

Refer to specialized
hospital

Côte d Ivoire Infants and children
2005

Children < 18 months with:

  • WHO pediatric clinical stage 3 or CDC category C irrespective of CD4%; or
  • WHO pediatric clinical stage 1 or 2 with CD4% < 20%

Children > 18 months with:

  • CD4% < 15%; or
  • WHO pediatric clinical stage 3 or CDC category C

d4T or AZT
+
3TC
+
NVP or EFV

 

ABC
+
ddI
+
LPV/r

Refer to specialized
hospital

Cuba Adults and adolescents
2009

All patients with CD4 count < 350/mm3

Patients with special conditions, including:

  • Viral load > 55,000 copies/mL
  • Co-morbidities such as Hepatitis B or C,
    cirrhosis of the liver, or cancer
  • Age > 55 years

AZT or d4T
+
3TC or ddI
+
NVP or IDV

Refer to the guidelines for further guidance (pg. 18).

______

Democratic Republic of Congo Adults and adolescents
2005

All patients with:

  • CD4 count < 200/mm3;
  • WHO clinical stage 4; or
  • CD4 count < 350/mm3
    at WHO clinical stage 3

d4T or AZT
+
3TC
+
NVP or EFV

ABC
+
ddI
+
LPV/r

______

Democratic Republic of Congo Infants and children
2005

Children < 18 months of age with:

  • WHO pediatric clinical
    stage 3 irrespective
    of CD4%; or
  • WHO pediatric clinical
    stage 1 or 2 with CD4%
    < 20%

Children > 18 months of age with:

  • WHO pediatric clinical
    stage 3 irrespective
    of CD4%; or
  • WHO pediatric clinical
    stage 1 or 2 with CD4%
    < 15%

Children < 3 years of age:

AZT
+
3TC
+
NVP

Children > 3 years of age:

d4T
+
3TC
+
NVP

ABC
+
ddI
+
NFV

______

Djibouti Adults and adolescents
2008

All patients with:

  • CD4 count < 350/mm3;
  • WHO clinical stage 4; or
  • WHO clinical stage 3 when CD4 testing is not available

AZT
+
3TC
+
EFV or NVP;

or

d4T
+
3TC
+
EFV

Alternative:

AZT
+
3TC
+
ABC;

or

AZT or d4T
+
3TC
+
LPV/r or NFV or SQV/r

ddI or TDF
+
ABC
+
LPV/r or NFV or SQV/r;

TDF
+
3TC (± AZT)
+
LPV/r or NFV or SQV/r;

or

EFV or NVP ± ddI
+
LPV/r or NFV or SQV/r

______

Dominican Republic Adults and adolescents
2004

All patients with:

  • CD4 count < 200/mm3 and WHO clinical stage
    1, 2 or 3;
  • WHO clinical stage 4;
  • Rapid CD4 decline (>20/mm3/month)
    and viral load > 100,000 copies/mL; or
  • WHO clinical stage 2 or 3 and TLC < 1200/mm3

AZT
+
3TC
+
EFV or NVP

AZT
+
3TC
+
IDV/r

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:

  • WHO pediatric clinical stage 3; or
  • WHO pediatric clinical stage 1
    or 2 and CD4% < 20%

Children > 18 months and < 13 years of age with:

  • WHO pediatric clinical stage 3; or
  • WHO pediatric clinical stage 1
    or 2 and CD4 % < 15%

Children weighing < 10 kg:

AZT
+
3TC
+
NVP

Children weighing > 10 kg:

AZT
+
3TC
+
EFV

AZT
+
3TC
+
LPV/r

______

Ecuador Adults and adolescents
2007

All patients with:

  • CD4 count < 200/mm3;
  • AIDS-defining illness or CDC Category
    B or C symptoms; or
  • CD4 count > 200/mm3 but < 350/mm3
    with a viral load > 100,000 copies/mL

AZT or ddI or ABC or d4T
+
3TC
+
EFV;

AZT or d4T
+
3TC
+
NVP;

AZT
+
3TC
+
SQV/r or LPV/r or ATV/r;

or

TDF
+
FTC
+
NNRTI or PI

Refer to the guidelines for further guidance (pg. 42-43)

______

El Salvador Adults and adolescents
2005

Evaluate the following:

  • Presence of symptoms associated with HIV
  • Diagnostic confirmation with 2 ELISA tests and other confirmatory tests as required by diagnostic algorithm in use
  • A low CD4 count according to international standards
  • A high viral load according to international standards; and
  • A psychosocial assessment approved by the institutional committee

AZT
+
3TC
+
IDV/r or EFV or NVP

d4T (for those with anemia)
+
3TC
+
IDV/r or EFV or NVP;

or

AZT
+
ddI
+
IDV/r or EFV or NVP

______

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:

  • Clinical evidence of HIV infection (CDC Category B or C)
  • Clinical evidence of immunosuppression (WHO pediatric clinical stage 2 or 3); or
  • Viral load > 300,000 copies/mL

Children 1 to 3 years of age with:

  • Clinical evidence of HIV infection (CDC Category B or C);
  • Clinical evidence of immunosuppression (WHO pediatric clinical stage 2 or 3);
  • Viral load > 100,000 copies/mL; or
  • Drop in a Category based on a decrease in CD4 count or percent within a 3-6 month period

Children 3 to 13 years of age with:

  • Clinical evidence of HIV infection (CDC Category B or C);
  • Clinical evidence of immunosuppression (WHO pediatric clinical stage 2 or 3);
  • Viral load > 20,000 copies/mL; or
  • Drop in a Category based on a decrease in CD4 count or percent within a 3-6 month period

AZT
+
3TC
+
NVP (< 3 years) or EFV (> 3 years) or NFV or RTV or LPV/r;

AZT
+
ddI
+
NVP (< 3 years) or EFV (> 3 years) or NFV or RTV or LPV/r;

or

d4T
+
ddI
+
NVP (< 3 years) or EFV (> 3 years) or NFV or RTV or LPV/r

 

AZT or d4T
+
ddI or 3TC
+
LPV/r or NFV or RTV or NVP or IDV/r or SQV/r

Patients must visit
a specialized health center.

Ethiopia Adults and adolescents
2008

All patients with:

  • CD4 count < 200/mm3;
  • WHO clinical stage 4; or
  • CD4 count < 350/mm3 at WHO clinical stage 3

 

d4T or AZT

+
3TC
+
NVP or EFV;

or

ABC
+
3TC
+
AZT

 

ABC
+
3TC
+
LPV/r or ATV/r;

AZT
+
ABC
+
LPV/r or ATV/r;

TDF
+
3TC
+
LPV/r or ATV/r;

ABC
+
ddI
+
LPV/r;

or

EFV or NVP
+
LPV/r or ATV/r

 

______

Ethiopia Infants and children
2008

All infants (< 12 months)

Children from 1–5 years with:

  • WHO pediatric clinical stage 3 or 4; or
  • WHO pediatric clinical stage 1 or 2 at CD4% < 20%

Children > 5 years with:

  • CD4% < 15%

d4T or AZT
+
3TC
+
NVP or EFV or LPV/r

ABC
+
ddI
+
LPV/r or NFV

______

Ghana Adults and adolescents
2005

All patients with:

  • CD4 count < 350/mm3; or
  • WHO clinical stage 3 or 4

For pregnant women where CD4 count > 350/mm3, initiate ARV prophylaxis at 28 weeks for the purpose of PMTCT.

Preferred drugs, first option:

AZT
+
3TC
+
NVP

Preferred drugs, second option:

AZT
+
3TC
+
EFV

Alternative drugs, first option:

d4T
+
3TC
+
NVP

Alternative drugs, second option:

d4T
+
3TC
+
EFV

ABC
+
ddI
+
LPV/r or SQV/r or NFV

______

Ghana Infants and children
2005

Children < 18 months with:

  • WHO pediatric clinical stage 3 or 4 irrespective of CD4%; or
  • WHO pediatric clinical stage 2 with CD4% < 20%

Children > 18 months with:

  • WHO pediatric clinical stage 3 or 4 irrespective of CD4%; or
  • CD4% < 15%

d4T or AZT
+
3TC
+
NVP or EFV

ABC
+
ddI
+
SQV/r or NFV

______

Guatemala Adults and adolescents
2012

All patients with:

  • AIDS-defining illness;
  • CD4 count ≤ 350/mm3;
  • Coinfection with hepatitis B and other clinical conditions associated with HIV that compromise the life of the patient;
  • ≥ 14 months gestation;
  • TLC < 1200/mm3; or
  • declining CD4 count > 30% compared to the previous count

First option:

TDF
+
FTC
+
EFV or NVP

Second option:

AZT
+
3TC
+
EFV or NVP

Third option:

ABC
+
3TC
+
EFV or NVP

 

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
+
3TC
+
LPV/r or SQV/r;

ABC
+
ddI
+
LPV/r or SQV/r;

or

AZT
+
ddI
+
LPV/r or SQV/r

If failed on second option switch to:

ABC
+
3TC
+
LPV/r or SQV/r;

or

ABC
+
ddI
+
LPV/r or SQV/r

If failed on third option switch to:

ddI
+
3TC
+
LPV/r or SQV/r;

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:

  • Clínica de Enfermedades Infecciosas,
    Hospital Roosevelt
  • Clínica Familiar Luís Ángel García—ASI
  • Hospital General San Juan de Dios
Guatemala Infants and children
2012

All infants (< 12 months)

Children 1–5 years with:

  • CDC category B or C ;
  • CD4% < 25%; or
  • Viral load > 100,000 copies/mL

Children 6–12 years with:

  • CDC category B or C;
  • CD4 count < 350/mm3; or
  • Viral load > 100,000 copies/mL

Children < 3 years or < 10 kg:

First option:

AZT
+
3TC
+
NVP or LPV/r

Second option:

ABC
+
3TC
+
NVP or LPV/r

Third option:

d4T
+
3TC
+
NVP or LPV/r

Children > 3 years or > 10 kg:

First option:

AZT
+
3TC
+
NVP or EFV

Second option:

ABC
+
3TC
+
NVP or EFV

Third option:

d4T
+
3TC
+
NVP or EFV

 

If failed on first or third option (with EFV or NVP) switch to:

ABC
+
ddI
+
LPV/r

If failed on first or third option (with LPV/r) switch to:

ABC
+
ddI
+
EFV

If failed on second option (with EFV or NVP) switch to:

AZT
+
ddI
+
LPV/r;

or

TDF (if > 16 years)
+
ABC
+
LPV/r

If failed on second option (with LPV/r) switch to:

AZT
+
ddI
+
EFV;

or

TDF (if > 16 years)
+
ABC
+
EFV

 

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:

  • CD4 count < 350/mm3; or
  • WHO stage 3 or 4 irrespective of CD4 count

Treatment of patients with CD4 counts between 350 and 500/mm3 should be discussed with regard to:

  • clinical course;
  • viral load when available; and
  • patient motivation

AZT
+
3TC
+
NVP or EFV;

TDF
+
3TC or FTC
+
EFV;

or

AZT
+
3TC
+
LPV/r or ABC

If failed on AZT + 3TC + NVP or EFV switch to:

ABC
+
ddI
+
LPV/r (or IDV/r);

or

TDF
+
FTC
+
LPV/r (or IDV/r)

If failed on TDF + FTC + EFV switch to:

ABC
+
ddI
+
LPV/r (or IDV/r)

If failed on AZT + 3TC + LPV/r switch to:

ABC
+
ddI
+
LPV/r (or IDV/r)

 

Discuss with multidisciplinary team and refer to specialist center. Review treatment history and send for genotypic testing.

2 NRTI
+
DRV/r
+
RAL or ETV

 

Guinea Infants and children
2011

Infants ≤ 11 months with:

  • CD4% < 25% or CD4 count < 1500/mm3; or
  • WHO pediatric clinical stage 3 or 4 irrespective of CD4

Children 12–35 months with:

  • CD4% < 20% or CD4 count < 750/mm3;
  • WHO pediatric clinical stage 4 irrespective of CD4; or
  • WHO pediatric clinical stage 3 irrespective of CD4 count or TLC, but use CD4 as a guide for children with TB, LIP, OHL, or thrombocytopenia

Children 36–59 months with:

  • CD4% < 15% or CD4 count < 350/mm3;
  • WHO pediatric clinical stage 4 irrespective of CD4; or
  • WHO pediatric clinical stage 3 irrespective of CD4 count or TLC, but use CD4 as a guide for children with TB, LIP, OHL, or thrombocytopenia

Children > 5 years with:

  • CD4% < 15% or CD4 count < 200/mm3;
  • WHO pediatric clinical stage 4 irrespective of CD4; or
  • WHO pediatric clinical stage 3 irrespective of CD4 count or TLC, but use CD4 as a guide for children with TB, LIP, OHL, or thrombocytopenia

Children < 3 years or < 10 kg:

Preferred:

AZT
+
3TC
+
NVP

Alternative:

d4T
+
3TC
+
NVP

Children > 3 years and > 10 kg:

Preferred:

AZT
+
3TC
+
EFV

Alternatives:

d4T
+
3TC
+
NVP or EFV;

or

ABC
+
3TC
+
NVP or EFV

If failed on AZT or d4T + 3TC + NVP or EFV switch to:

ddI
+
ABC
+
LPV/r or SQV/r;

or

ddI
+
AZT
+
LPV/r or SQV/r

If failed on AZT or d4T + 3TC + ABC switch to:

ddI
+
NVP or EFV
+
LPV/r or SQV/r

In children < 18 months who failed on AZT or d4T + 3TC + PI/r switch to:

ddI
+
ABC
+
NVP;

or

ddI
+
AZT
+
NVP

 

______

Guyana Adults and adolescents
2011

All patients with:

  • CD4 count < 350/mm3 irrespective of WHO or CDC staging; or
  • WHO clinical stage 3 or 4 irrespective of CD4 count

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
+
FTC
+
EFV or NVP

Alternatives:

AZT
+
3TC
+
NVP or EFV;

or

ABC
+
3TC
+
NVP or EFV

 

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
+
FTC
+
AZT
+
LPV/r

If failed on ABC + 3TC + NVP or EFV switch to:

AZT
+
3TC
+
LPV/r

If failed on any NRTI-only regimen switch to:

TDF
+
FTC
+
AZT
+
EFV or NVP;

or

TDF
+
FTC
+
LPV/r

If failed on any PI regimen switch to:

TDF
+
FTC
+
AZT
+
LPV/r

 

 

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:

  • WHO pediatric clinical stage 3 or 4; or
  • CD4% < 25% or CD4 count < 750/mm3

Children > 5 years with:

  • WHO pediatric clinical stage 3 or 4; or
  • CD4% < 20% or CD4 count < 350/mm3

Can offer antiretroviral therapy to all children above initiation thresholds after conducting a thorough adherence assessment.

Preferred:

ABC
+
3TC
+
NVP or EFV

Alternatives:

d4T
+
3TC
+
NVP or EFV;

or

AZT
+
3TC
+
NVP or EFV

 

If failed on ABC + 3TC + NVP or EFV switch to:

AZT
+
3TC
+
LPV/r

If failed on AZT or d4T + 3TC + NVP or EFV switch to:

Preferred:

TDF
+
3TC
+
LPV/r

Alternative:

TDF
+
FTC
+
LPV/R (for children at least Tanner 3 or 35 kg)

If failed on AZT + 3TC + ABC switch to:

TDF
+
FTC
+
EFV or NVP;

or

TDF
+
FTC
+
LPV/r

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:

  • CD4 count < 200/mm3; or
  • WHO clinical stage 3 or 4

Those with a CD4 count > 200/mm3 but < 350/mm3 may be considered for treatment.

TDF
+
FTC
+
EFV or NVP;

or

AZT or d4T
+
3TC
+
EFV or NVP

AZT
+
3TC
+
LPV/r;

or

TDF
+
FTC
+
LPV/r

______

Haiti Infants and children
2006

Infants ≤ 11 months with WHO pediatric clinical stage 3 or 4 irrespective of CD4%

Children 12–35 months with:

  • CD4% < 20% (CD4 count < 750/mm3);
  • TLC ≤ 3000/mm3;
  • WHO pediatric clinical stage 4; or
  • TB, LIP, OHL, or thrombocytopenia

Children 36–59 months with:

  • CD4% < 15% (CD4 count < 350/mm3);
  • TLC ≤ 2500/mm3;
  • WHO pediatric clinical stage 4; or
  • TB, LIP, OHL, or thrombocytopenia

Children ≥ 5 years with:

  • CD4% < 15% (CD4 count < 200/mm3);
  • TLC ≤ 2000/mm3;
  • WHO pediatric clinical stage 4; or
  • TB, LIP, OHL, or thrombocytopenia

AZT
+
3TC
+
NVP or EFV;

d4T
+
3TC
+
NVP or EFV;

or

ABC
+
3TC
+
NVP or EFV

If failed on a regimen containing AZT or d4T switch to:

ddI
+
ABC
+
LPV/r or SQV/r or NFV

If failed on a regimen containing ABC switch to:

ddI
+
AZT
+
LPV/r or SQV/r or NFV

If failed on regimen containing 3 NRTIs switch to:

ddI
+
EFV or NVP
+
LPV/r or SQV/r or NFV

 

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:

  • WHO pediatric clinical stage 3 or 4

Children > 12 months with:

  • WHO pediatric clinical stage 4; or
  • WHO pediatric clinical stage 3, but use CD4 as a guide for children with TB, LIP, OHL, or thrombocytopenia

Immunological Markers

Infants < 11 months with:

  • CD4 count < 1500/mm3 (25%)

Children 12–35 months with:

  • CD4 count < 7500/mm3 (20%)

Children 36–59 months with:

  • CD4 count < 350/mm3 (15%)

Children > 5 years with:

  • CD4 count < 200/mm3; or
  • CD4 count < 350/mm3 at WHO pediatric clinical stage 3

 

d4T
+
3TC
+
NVP or EFV;

or

AZT
+
3TC
+
NVP or EFV

 

 

If failed on AZT or d4T + 3TC + NVP or EFV switch to:

ddI
+
ABC
+
LPV/r or SQV/r or NFV

If failed on ABC or 3TC + NVP or EFV switch to:

ddI
+
AZT
+
LPV/r or SQV/r or NFV

If failed on AZT or d4T + 3TC + ABC switch to:

ddI
+
EFV or NVP
+
LPV/r or SQV/r or NFV

 

______

India Adults and adolescents
2007

All patients with:

  • CD4 count < 200/mm3; or
  • WHO clinical stage 4

Those with a CD4 count > 200/mm3 but < 350/mm3 at WHO clinical stage 3 may be considered for treatment.

d4T
+
3TC
+
NVP or EFV;

or

AZT
+
3TC
+
NVP or EFV

 

ABC
+
ddI
+
LPV/r or SQV/r or NFV

______

Kenya Adults and adolescents
2011

All patients with:

  • CD4 count ≤ 350/mm3;
  • WHO clinical stage 3 or 4;
  • TB disease;
  • HIV/hepatitis B coinfection with evidence of active/chronic liver disease; or
  • HIV-associated nephropathy

TDF
+
3TC
+
EFV or NVP

or

AZT
+
3TC
+
EFV or NVP

AZT
+
3TC
+
LPV/r or ATV/r*;

or

TDF
+
3TC
+
LPV/r

* 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:

  • WHO pediatric clinical stage 3 or 4; or
  • CD4% < 25% or CD4 count < 1000/mm3

Children 5–12 years with:

  • WHO pediatric clinical stage 3 or 4; or
  • CD4% < 20% or CD4 count < 500/mm3

Children not previously exposed to NVP (< 3 years or < 10 kg):

Preferred:

ABC
+
3TC
+
NVP

Alternative:

AZT
+
3TC
+
NVP

Children not previously exposed to NVP (> 3 years or > 10 kg):

Preferred:

ABC
+
3TC
+
EFV or NVP

Alternative:

AZT
+
3TC
+
EFV or NVP

Children previously exposed to NVP:

ABC or AZT
+
3TC
+
LPV/r

Children not previously exposed to NVP (if failed on a regimen containing ABC) switch to:

AZT
+
3TC
+
LVP/r

Children not previously exposed to NVP (if failed on a regimen containing AZT) switch to:

ABC
+
3TC
+
LVP/r

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:

  • WHO clinical stage 3 or 4; or
  • CD4 count < 350/mm3

 

AZT
+
3TC
+
NVP or EFV;

TDF
+
3TC
+
NVP or EFV;

or

d4T
+
3TC
+
NVP or EFV

 

If failed on AZT or d4T + 3TC + NVP or EFV switch to:

TDF
+
3TC
±
AZT
+
LPV/r or ATV/r

If failed on TDF + 3TC + NVP or EFV switch to:

ddI
+
3TC
±
AZT
+
LPV/r or ATV/r;

ddI
+
ABC
+
LPV/r or ATV/r;

or

AZT
+
3TC
+
LPV/r or ATV/r

 

______

Lesotho Infants and children
2007

All infants < 12 months with:

  • WHO pediatric clinical stage 3 or 4; or
  • WHO pediatric clinical stage 1 or 2, but consult a specialist for assistance

Children 12–35 months with:

  • WHO pediatric clinical stage 3 or 4; or
  • CD4% < 20% or CD4 count < 750/mm3

Children 36–59 months with:

  • WHO pediatric clinical stage 3 or 4; or
  • CD4% < 20% or CD4 count < 350/mm3

Children ≥ 5 years with:

  • WHO pediatric clinical stage 3 or 4; or
  • CD4% < 15% or CD4 count < 350/mm3

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
+
3TC
+
NVP

Children > 3 and > 10 kg:

AZT or d4T
+
3TC
+
EFV

 

ddI
+
ABC
+
LPV/r or ATV/r

______

Liberia Adults and adolescents
2007

All patients with:

  • CD4 count < 200/mm3;
  • WHO clinical stage 4;
  • WHO clinical stage 2 and CD4 count < 200/mm3 or TLC < 1200/mm3; or
  • WHO clinical stage 3 and CD4 count < 350/mm3

AZT
+
3TC
+
NVP or EFV;

TDF
+
3TC
+
NVP or EFV;

or

d4T
+
3TC
+
NVP or EFV

TDF or AZT
+
3TC
+
LPV/r or ATV/r or NFV;

or

ABC
+
ddI
+
LPV/r or ATV/r or NFV

 

_______

Liberia Infants and children
2007

All infants and children with:

  • WHO pediatric clinical stage 3 or 4

Infants < 11 months with:

  • CD4% < 25% (CD4 count < 1500/mm3); or
  • WHO pediatric clinical stage 2 and TLC < 4000/mm3

Children 12–35 months with:

  • CD4% < 20% (CD4 count < 750/mm3); or
  • WHO pediatric clinical stage 2 and TLC < 3000/mm3

Children 36–59 months with:

  • CD4% < 15% (CD4 count < 350/mm3); or
  • WHO pediatric clinical stage 2 and TLC < 2500/mm3

Children ≥ 5 years with:

  • CD4% < 15% (CD4 count < 200/mm3); or
  • WHO pediatric clinical stage 2 and TLC < 2000/mm3

Children < 3 kg:

AZT
+
3TC
+
NVP

Children > 3 kg:

d4T
+
3TC
+
NVP

 

ABC
+
ddI
+
LPV/r or NFV

______

Malawi Adults and adolescents
2011

All patients with:

  • CD4 count ≤ 350/mm3;
  • WHO clinical stage 3 or 4; or
  • Women who are pregnant or breastfeeding

d4T
+
3TC
+
NVP;

AZT
+
3TC
+
NVP;

or

TDF
+
3TC
+
EFV (for women who are pregnant or breastfeeding and those already on TB treatment)

TDF
+
3TC
+
LPV/r;

or

AZT
+
3TC
+
LPV/r

______

Malawi Infants and children
2011

All infants and children < 24 months.

Children ≥ 24 months to < 5 years with:

  • WHO pediatric clinical stage 1 or 2 and CD4 ≤ 750/ mm3 or CD4% ≤ 25%; or
  • WHO pediatric clinical stage 3 or 4

Children ≥ 5 years with:

  • CD4 count ≤ 350/ mm3; or
  • WHO pediatric clinical stage 3 or 4

AZT
+
3TC
+
NVP

ABC
+
3TC
+
LPV/r

______

Mauritania Adults and adolescents
2005

All patients with:

  • WHO clinical stage 4 irrespective of CD4 count;
  • WHO clinical stage 3 with a CD4 count < 350/mm3;
  • WHO clinical stage 1 or 2 with a CD4 count < 200/mm3; or
  • WHO clinical stage 2 or 3 with a TLC < 1200/mm3

d4T
+
3TC
+
EFV or NVP;

or

AZT
+
3TC
+
EFV or NVP

ABC
+
ddI
+
LPV/r or IDV/r

______

Mauritania Infants and children
2005

Children < 18 months with:

  • WHO pediatric clinical stage 3 irrespective of CD4%; or
  • WHO pediatric clinical stage 1 or 2 with a CD4% < 20%

Children ≥ 18 months with:

  • WHO pediatric clinical stage 3 irrespective of CD4%; or
  • WHO pediatric clinical stage 1 or 2 with a CD4% < 15%

Children ≤ 3 years:

AZT
+
3TC
+
NVP

Children ≥ 3 years:

d4T
+
3TC
+
NVP

If failed on d4T or AZT + 3TC + NVP or EFV switch to:

Preferred:

TDF or ABC
+
ddI
+
LPV/r or SQV/r

Alternative:

ABC
+
ddI
+
NFV

______

Mexico Adults and adolescents
2012

All patients with:

  • CD4 count < 350/mm3;
  • AIDS-defining illness;
  • Pregnancy;
  • Chronic hepatitis B coinfection when HBV treatment is indicated;
  • HIV-associated nephropathy; or
  • Acute retroviral syndrome (primary infection)

 

Preferred NRTI backbone:

TDF
+
FTC

Alternative NRTI backbones:

ABC
+
3TC;

or

AZT
+
3TC

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
+
AZT

NRTI backbone (if failed on ABC + 3TC or FTC) switch to:

TDF
+
AZT

NRTI backbone (if failed on AZT + 3TC) switch to:

TDF
+
AZT

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:

  • CDC category C or B (other than single episode of severe bacterial infection or LIP;
  • CD4% < 25%; or
  • Viral load > 100,000 copies/mL

Children > 5 years with:

  • CDC category C or B (other than single episode of severe bacterial infection or LIP);
  • CD4 count < 500/mm3; or
  • Viral load > 100,000 copies/mL

 

NRTI backbones:

ABC
+
3TC or FTC;

AZT
+
3TC or FTC;

or

ddI
+
FTC

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:

  • WHO clinical stage 4;
  • CD4 count ≤ 350/mm3 at WHO clinical stage 3 (treat if CD4 is unavailable); or
  • CD4 count ≤ 250/mm3 at WHO clinical stage 1 or 2 (do not treat if CD4 is unavailable)

AZT
+
3TC
+
NVP

If failed on AZT or d4T + 3TC + NVP or EFV switch to:

TDF
+
(AZT + 3TC)
+
LPV/r;

TDF
+
3TC
+
LPV/r;

ABC
+
ddI
+
LPV/r;

or

TDF
+
(AZT + 3TC)
+
SQV/r

 

______

Myanmar Adults and adolescents
2011

All patients with:

  • CD4 count ≤ 350/mm3 irrespective of WHO clinical stage; or
  • WHO clinical stage 3 or 4 irrespective of CD4 count

AZT
+
3TC
+
EFV or NVP;

TDF
+
3TC or FTC
+
EFV or NVP

 

If failed on d4T or AZT switch to:

TDF
+
3TC or FTC
+
ATV/r or LPV/r

If failed on TDF switch to:

AZT
+
3TC
+
ATV/r or LPV/r

 

Refer to page 29 of guidelines.

Namibia Adults and adolescents
2010

All patients with:

  • WHO clinical stage 3 or 4 irrespective of CD4 count; or
  • CD4 count ≤ 350/mm3

Preferred:

TDF
+
3TC
+
NVP*

Alternative:

AZT
+
3TC
+
NVP*

* EFV should be used instead of NVP in women with CD4 > 350/mm3 or in men with CD4 > 400/mm3.

 

AZT
+
TDF
+
3TC
+
LPV/r

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:

  • WHO pediatric clinical stage 3 or 4 irrespective of CD4%; or
  • WHO pediatric clinical stage 1 or 2 with a CD4% ≤ 25%

Children ≥ 5 years with:

  • WHO pediatric clinical stage 3 or 4 irrespective of CD4 count; or
  • WHO pediatric clinical stage 1 or 2 with a CD4 count ≤ 350/mm3

Children < 24 months with known prior exposure to NVP:

d4T
+
3TC
+
LPV/r

Children < 24 months without (or with unknown) prior exposure to NVP and children ≥ 24 months, but < 14 kg:

d4T
+
3TC/NVP

Children ≥ 24 months and ≥ 14 kg and Tanner stage 1–3:

AZT
+
3TC
+
NVP

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
+
AZT
+
3TC
+
LPV/r

Children in Tanner stages 1–3 on PI-based first-line regimen switch to:

ABC
+
AZT
+
3TC
+
NVP or EFV

Children in Tanner stages 4 or 5 on NNRTI-based first-line regimen switch to:

TDF*
+
AZT
+
3TC
+
LPV/r

Children in Tanner stages 4 or 5 on PI-based first-line regimen switch to:

TDF*
+
AZT
+
3TC
+
NVP or EFV

* 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:

  • WHO clinical stage 1 or 2 with CD4 count < 350/mm3; or
  • WHO clinical stage 3 or 4 irrespective of CD4 count

AZT
+
3TC
+
NVP or EFV;

or

TDF
+
3TC
+
NVP or EFV

 

If failed on AZT or d4T + 3TC + NVP or EFV switch to:

TDF
+
3TC
+
LPV/r

If failed on TDF + 3TC + NVP or EFV switch to:

ddI
+
ABC
+
LPV/r

 

______

Nepal Infants and children
2009

All infants < 12 months

Children 12–35 months with:

  • CD4% < 20% or CD4 count < 750/mm3;
  • TLC < 3000/mm3;
  • WHO pediatric clinical stage 4; or
  • WHO pediatric clinical stage 3 guided by CD4 in those with OHL, LIP, TB, or thrombocytopenia

Children 36–59 months with:

  • CD4% < 20% or CD4 count < 350/mm3;
  • TLC < 2500/mm3;
  • WHO pediatric clinical stage 4; or
  • WHO pediatric clinical stage 3 guided by CD4 in those with OHL, LIP, TB, or thrombocytopenia

Children > 5 years with:

  • CD4% < 15% or CD4 count < 200/mm3;
  • TLC < 2000/mm3;
  • WHO pediatric clinical stage 4; or
  • WHO pediatric clinical stage 3 guided by CD4 in those with OHL, LIP, TB, or thrombocytopenia

Children < 3 years or < 10 kg:

AZT
+
3TC
+
NVP

Children > 3 years and > 10 kg:

AZT
+
3TC
+
EFV

Anemic children:

d4T
+
3TC
+
NVP or EFV

 

______

______

Nicaragua Adults and adolescents
2009

All patients with:

  • CD4 count < 350/mm3;
  • AIDS-defining illness or symptoms of advanced disease (CDC category B or C), hepatitis B, or HIV-associated nephropathy; or
  • CD4 count > 350/mm3 and viral load > 100,000 copies/mL

CD4 count > 200/mm3:

AZT
+
3TC
+
EFV or NVP;

or

TDF
+
FTC or 3TC
+
EFV or NVP

CD4 count < 200/mm3:

AZT
+
3TC
+
LPV/r;

or

TDF
+
FTC
+
LPV/r

CD4 count > 200/mm3 switch to:

ABC or ddI
+
3TC or FTC
+
LPV/r or ATV/r or SQV/r or DRV/r

CD4 count < 200/mm3 switch to:

ABC or ddI
+
3TC
+
EFV or NVP;

or

ABC or ddI
+
3TC
+
ATV/r or SQV/r or DRV/r

______

Niger Adults and adolescents
2009

All patients with:

  • WHO clinical stage 4 irrespective of CD4 count;
  • WHO clinical stage 1, 2, or 3 and CD4 count < 350/mm3; or
  • WHO clinical stage 3 if CD4 count is not available

AZT
+
3TC
+
NVP

For patients infected with HIV-2 or HIV-1 and HIV-2:

AZT
+
3TC
+
LPV/r

ABC
+
ddI
+
LVP/r

Available alternative ARVs:

ATV or SQV or DRV or RAL or ETV

Nigeria Adults and adolescents
2010

All patients with:

  • CD4 count < 350/mm3 irrespective of clinical symptoms; or
  • WHO clinical stage 3 or 4

Consider treatment in patients with CD4 count > 350/mm3 if:

  • Patient has HIV-associated nephropathy; or
  • Patient is in a discordant relationship

AZT
+
3TC
+
EFV or NVP;

or

TDF
+
3TC or FTC
+
EFV or NVP

If failed on d4T or AZT switch to:

TDF
+
3TC or FTC
+
ATV/r or LPV/r

If failed on TDF switch to:

AZT
+
3TC
+
ATV/r or LPV/r

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:

  • CD4% ≤ 25% or CD4 count ≤ 750 cells/mm3; or
  • WHO pediatric clinical stage 3 or 4

Children ≥ 5 years with:

  • CD4 < 350 cells/mm3; or
  • WHO pediatric clinical stage 3 or 4

Children < 2 years with no prior NNRTI exposure:

Preferred:

AZT
+
3TC
+
NVP

Alternatives:

ABC
+
3TC
+
NVP;

AZT
+
3TC
+
ABC;

or

d4T
+
3TC
+
NVP

Children < 12 months with prior NNRTI exposure:

Preferred:

AZT
+
3TC
+
LPV/r

Alternatives:

ABC
+
3TC
+
LPV/r;

or

AZT
+
3TC
+
ABC

Children 12 months to 2 years with NNRTI exposure:

Preferred:

AZT
+
3TC
+
LPV/r

Alternatives:

AZT
+
3TC
+
ABC;

ABC
+
3TC
+
LPV/r;

or

d4T
+
3TC
+
LPV/r

Children 2–3 years, regardless of NNRTI exposure:

Preferred:

AZT
+
3TC
+
NVP

Alternatives:

ABC
+
3TC
+
NVP;

AZT
+
3TC
+
ABC;

or

d4T
+
3TC
+
NVP

Children > 3 years:

Preferred:

AZT
+
3TC
+
EFV

Alternatives:

AZT
+
3TC
+
NVP;

AZT
+
3TC
+
ABC;

d4T
+
3TC
+
NVP;

or

ABC
+
3TC
+
EFV

If failed on AZT + 3TC + NVP switch to:

ABC
+
3TC
+
LVP/r;

or

d4T
+
3TC
+
LPV/r

If failed on ABC + 3TC + NVP switch to:

AZT
+
3TC
+
LVP/r;

d4T
+
3TC
+
LPV/r;

or

ddI
+
3TC
+
LPV/r

If failed on AZT + 3TC + ABC switch to:

ddI
+
3TC
+
NVP;

TDF
+
3TC
+
EFV;

or

ddI
+
3TC
+
LPV/r

If failed on d4T + 3TC + NVP switch to:

ABC
+
3TC
+
LVP/r;

ddI
+
3TC
+
LPV/r;

or

AZT
+
3TC
+
ABC

If failed on AZT + 3TC + LPV/r switch to:

ABC
+
3TC
+
ddI;

or

ddI
+
ABC
+
NVP or EFV

If failed on ABC + 3TC + LPV/r switch to:

AZT
+
3TC
+
ddI;

or

AZT
+
3TC
+
NVP or EFV

If failed on AZT or d4T + 3TC + EFV switch to:

ABC
+
3TC
+
LPV/r

If failed on TDF + 3TC or FTC + EFV or NVP switch to:

AZT
+
3TC
+
LVP/r;

d4T
+
3TC
+
LPV/r;

ABC
+
3TC
+
AZT;

or

ABC
+
3TC
+
d4T

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:

  • CD4 count < 200/mm3;
  • WHO clinical stage 4; or
  • Consider treatment when CD4 count < 350/mm3 and WHO clinical stage 3

If CD4 testing is not available:

  • TLC < 1200/mm3 at WHO clinical stage 2; or
  • WHO clinical stage 3 or 4

AZT
+
3TC
+
NVP

TDF or ABC
+
ddi
+
NFV

______

Panama Adults and adolescents
2011

All patients with:

  • AIDS-defining illness or symptoms of advanced disease;
  • CD4 count ≤ 350/mm3; or
  • CD4 count between 350 and 500/mm3 and viral load ≥ 100,000 copies/mL

Preferred:

TDF
+
3TC or FTC
+
EFV

Alternative:

AZT
+
3TC
+
EFV

For pregnant women:

AZT
+
3TC
+
LPV/r;

or

SQV/r

Alternative:

AZT
+
3TC
+
NVP

 

If failed on TDF + 3TC or FTC + EFV switch to:

AZT
+
ABC or ddI
+
LPV/r or SQV/r or ATV/r

If failed on AZT + 3TC + EFV switch to:

TDF
+
ABC
+
LPV/r or SQV/r or ATV/r

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:

  • AIDS-defining illness or symptoms of advanced disease; or
  • CD4% ≤ 25% or CD4 count ≤ 750/mm3 irrespective of symptoms

Consider treatment in children 2 to < 5 years with:

  • Mild symptoms or asymptomatic;
  • CD4% ≥ 25%; and
  • Viral load ≥ 100,000 copies/mL

Children ≥ 5 years with:

  • AIDS-defining illness or symptoms of advanced disease; or
  • CD4 count < 350/mm3

Consider treatment in children ≥ 5 years with:

  • Mild symptoms or asymptomatic;
  • CD4 count ≥ 350/mm3; and
  • Viral load ≥ 100,000 copies/mL

Children < 3 years:

AZT
+
3TC or FTC
+
LPV/r

Children ≥ 3 years:

AZT
+
3TC
+
EFV

 

Children < 3 years switch to:

AZT
+
3TC or FTC
+
NVP

Children ≥ 3 years switch to:

AZT
+
3TC
+
LPV/r

 

______

Papua New Guinea Adults and adolescents
2009

All patients with:

  • CD4 count < 350/mm3;
  • WHO clinical stage 3 or 4 irrespective of CD4; or
  • WHO clinical stage 2 with TLC < 1200/mm3

AZT
+
3TC
+
NVP or EFV;

or

d4T
+
3TC
+
NVP or EFV

 

If failed on AZT + 3TC + NVP or EFV switch to:

TDF or ddI
+
ABC
+
LPV/r or SQV/r

If failed on d4T + 3TC + NVP switch to:

TDF
+
ABC
+
LPV/r

If failed on d4T + 3TC + EFV switch to:

ddI
+
ABC
+
SQV/r

If failed on d4T + 3TC + EFV switch to:

TDF
+
ABC
+
SQV/r

 

______

Papua New Guinea Infants and children
2009

All infants < 12 months

Children 12–35 months with:

  • CD4% < 20% or CD4 count < 750/mm3;
  • TLC < 3000/mm3;
  • WHO pediatric clinical stage 4; or
  • WHO pediatric clinical stage 3 guided by CD4 in those with OHL, LIP, TB, or thrombocytopenia

Children 36–59 months with:

  • CD4% < 20% or CD4 count < 350/mm3;
  • TLC < 2500/mm3;
  • WHO pediatric clinical stage 4; or
  • WHO pediatric clinical stage 3 guided by CD4 in those with OHL, LIP, TB, or thrombocytopenia

Children ≥ 5 years with:

  • CD4% < 15% or CD4 count < 350/mm3;
  • TLC < 2000/mm3;
  • WHO pediatric clinical stage 4; or
  • WHO pediatric clinical stage 3 guided by CD4 in those with OHL, LIP, TB, or thrombocytopenia

Children < 3 years or < 10 kg:

AZT
+
3TC
+
NVP

Children > 3 years and > 10 kg:

AZT
+
3TC
+
EFV

Alternative:

Replace AZT with d4T in the above regimens.

 

If failed on AZT or d4T + 3TC + NVP or EFV switch to:

ddI
+
ABC
+
LPV/r or SQV/r

If failed on AZT or d4T + 3TC + ABC switch to:

ddI
+
EFV or NVP
+
LPV/r

 

______

Paraguay Adults and adolescents
2011

All patients with:

  • AIDS-defining illness;
  • CD4 count ≤ 350/mm3; or
  • TLC < 1200/mm3

Consider treatment in patients with CD4 count > 350/mm3 and:

  • > 55 years;
  • Drop in CD4 count of > 120/mm3 per year;
  • Certain comorbidities exist; or
  • Viral load >100,000 copies/mL

ART should be initiated independent of CD4 count in cases of:

  • Pregnancy;
  • HIV-associated nephropathy;
  • Hepatitis B coinfection where Hepatitis B is active and/or treatment is indicated;
  • Active Hepatitis C coinfection; or
  • High cardiovascular risk

AZT
+
3TC
+
EFV;

AZT
+
3TC
+
NVP;

d4T
+
3TC
+
NVP;

FTC
+
TDF
+
EFV ;

TDF
+
3TC
+
EFV;

or

ABC
+
3TC
+
NVP

AZT
+
3TC
+
IDV/r;

d4T
+
3TC
+
IDV/r;

AZT
+
3TC
+
LPV/r;

FTC
+
LPV/r;

d4T
+
3TC
+
LPV/r;

or

ABC
+
3TC
+
LPV/r

 

If not used in first- or second-line regimen switch to:

AZT
+
3TC
+
ABC;

AZT
+
3TC
+
TDF;

or

AZT
+
3TC
+
ddI

 

Peru Adults and adolescents
2004

All patients with:

  • CDC category C;
  • Recurrent oral candidiasis;
  • HIV-related symptoms (fever of unknown origin, involuntary weight loss, diarrhea > 1 month);
  • CD4 count < 200/mm3; or
  • Viral load > 55,000 copies/mL

AZT
+
3TC
+
EFV or NVP;

or

d4T
+
3TC
+
EFV or NVP

2 new NRTIs
+
LPV/r or ATV/r or SQV/r

______

Peru Infants and children
2009

Children < 12 months with:

  • CDC category C irrespective of immunological category and viral load; or
  • CDC category N, A, or B with moderate or severe immunosuppression (according to WHO) (CD4% < 35%)

Consider treatment in children < 12 months with:

  • CDC category A or B without immunosuppression, irrespective of viral load

Children > 12 months with:

  • CDC category C with severe immunosuppression irrespective of viral load and clinical category; or
  • Moderate immunosuppression (according to WHO) and a viral load > 100,000 copies/mL, irrespective of clinical category

Consider treatment in children > 12 months with:

  • CDC category N, A, or B with moderate immunosuppression and/or viral load < 100,000 copies/mL

For adolescents > Tanner stage 3 and/or > 40 kg, treat as adults.

Preferred:

2 NRTIs
+
1 NNRTI

Alternative:

2 NRTIs
+
1 PI or 1 NNRTI

Preferred NRTI backbone:

AZT
+
3TC

Alternative NRTI backbones:

d4T
+
3TC;

ABC
+
3TC;

ABC
+
AZT;

TDF*
+
3TC;

or

TDF*
+
FTC

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
+
PI/r;

or

1 new NRTI
+
3TC
+
PI/r

If failed on regimen of 2 NRTIs + PI/r switch to:

2 new NRTIs
+
1 new PI/r;

1 new NRTI
+
NNRTI
+
PI/r;

or

2 new NRTIs
+
NNRTI (if not previously on an NNRTI)

If failed on AZT + 3TC + NVP or EFV switch to:

Children < 6 years:

ABC
+
3TC
+
LPV/r

Children > 6 years:

TDF
+
3TC
+
LPV/r

 

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:

  • CD4 count < 200/mm3; or
  • WHO clinical stage 3 and 4

Those with a CD4 count > 200/mm3 but < 350/mm3 at WHO clinical stage 3 may be considered for treatment.

AZT
+
3TC
+
NVP or EFV;

or

d4T
+
3TC
+
NVP or EFV

AZT or TDF
+
3TC
+
LPV/r

______

Russia Adults and adolescents
2007

All patients with:

  • CD4 count < 200/mm3

The Ministry of Health of the Russian Federation also recommends treatment if:

  • CD4 count is between 200 and 350/mm3; and
  • Viral load > 100,000 copies/mL

2 NRTIs
+
NNRTI or PI

NRTI backbones:

AZT
+
3TC;

ABC
+
3TC;

PZT
+
3TC;

d4T
+
3TC;

TDF
+
FTC;

or

ABC
+
ddI

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:

  • CD4 count < 350/mm3; or
  • WHO clinical stage 4

d4T or TDF or AZT
+
3TC
+
NVP or EFV

ABC or AZT or d4T
+
3TC
+
LPV/r or EFV

______

Rwanda Infants and children
2007

Infants < 11 months with:

  • CD4 count < 1500/mm3 (25%)

Children 12–35 months with:

  • CD4 count < 7500/mm3 (20%)

Children 36–59 months with:

  • CD4 count < 350/mm3 (15%)

Children > 5 years with:

  • CD4 count < 350/mm3 at WHO pediatric clinical stage 1, 2 or 3; or
  • WHO pediatric clinical stage 4

d4T or AZT
+
3TC
+
NVP

ddI
+
ABC
+
LPV/r

______

Senegal Adults and adolescents
No Date

All patients with:

  • CD4 count ≤ 200/mm3;
  • CDC category B and CD4 count ≤ 350/mm3; or
  • CDC category C

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:

  • A history of AIDS-defining illness;
  • CD4 count < 350/mm3;
  • WHO clinical stage 3 or 4; or
  • TLC < 1000–2000/mm3 (if CD4 count is unavailable) and WHO clinical stage 2

Preferred:

AZT
+
3TC
+
NVP or EFV;

or

d4T
+
3TC
+
NVP or EFV

Alternative:

AZT
+
ABC
+
3TC

 

2 new NRTIs

+
PI/r

Preferred:

AZT
+
3TC
+
IDV/r

Alternative:

AZT
+
3TC
+
LPV/r

 

______

Sierra Leone Infants and children
2007

All children with:

  • Recurrent hospitalizations (> 2 admissions/year) or prolonged hospitalization (> 4 weeks) for HIV-related disease;
  • WHO pediatric clinical stage 4;
  • WHO pediatric clinical stage 3 irrespective of CD4 count, but use CD4 as a guide for children > 12 months with TB, LIP, OHL, or thrombocytopenia; or
  • WHO pediatric clinical stage 1 or 2 and CD4 or TLC value at or below the threshold

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
+
3TC
+
NVP;

or

d4T
+
3TC
+
NVP

Children > 3 years and > 10 kg:

AZT
+
3TC
+
EFV or NVP;

or

d4T
+
3TC
+
EFV or NVP

 

If failed on AZT + 3TC backbone switch to:

d4t
+
ddI

If failed on d4T + 3TC backbone switch to:

AZT
+
ddI

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:

  • CD4 count ≤ 200/mm3;
  • WHO clinical stage 4;
  • CD4 count ≤ 350/mm3 and coinfected with TB; or
  • MDR or XDR TB

TDF
+
3TC or FTC
+
EFV or NVP

AZT
+
3TC
+
LPV/r

______

South Africa Infants and children
2010

All infants (< 12 months)

Children 12 months to 5 years with:

  • CD4% ≤ 25% (750/mm3); or
  • WHO pediatric clinical stage 3 or 4

Children > 5 years with:

  • CD4 count < 350/mm3; or
  • WHO pediatric clinical stage 3 or 4

Children < 3 years of age or weighing < 10kg:

ABC
+
3TC
+
LPV/r

Children > 3 years and weighing > 10kg:

ABC
+
3TC
+
EFV

______

______

Swaziland Infants and children
2006

All children with:

  • WHO pediatric clinical stage 3 or 4 irrespective of CD4 count or percentage; or
  • WHO pediatric clinical stage 1 or 2, if the CD4 immunological stage is “severe”

d4T or AZT
+
3TC
+
NVP

ABC
+
ddI
+
LPV/r

______

Swaziland Adults and adolescents
2010

All patients with:

  • CD4 count < 350/mm3;
  • WHO clinical stage 3 or 4;
  • Any form of TB, especially drug-resistant TB;
  • Hepatitis B coinfection; or
  • HIV-associated nephropathy

Preferred NRTI backbone:

TDF
+
3TC

Alternative:

AZT or d4
+
3TC

Preferred NNRTI:

EFV

Alternative:

NVP

ABC
+
ddI
+
LPV/r*

* Use SQV/r or ATV/r or IDV/r in patients who cannot tolerate LPV/r.

______

Tanzania Adults and adolescents
2009

All patients with:

  • WHO clinical stage 4 irrespective of CD4 count;
  • CD4 count ≤ 200/mm3 irrespective of WHO clinical stage; or
  • CD4 count between 200 and 350/mm3 at WHO clinical stage 3

AZT
+
3TC
+
EFV

Alternatives to AZT:

d4T or TDF

Alternative to 3TC:

FTC

If failed on AZT or d4t switch to:

TDF
+
3TC or FTC
+
LPV/r or ATV/r

If initiated on TDF due to intolerance to AZT or d4T switch to:

ABC
+
ddI
+
LPV/r or ATV/r

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:

  • WHO pediatric clinical stage 3 or 4 irrespective of CD4%; or
  • WHO pediatric clinical stage 1 or 2 with CD4% < 20% or CD4 count < 750/mm3

Children > 18 months with:

  • WHO pediatric clinical stage 3 or 4 irrespective of CD4%; or
  • WHO pediatric clinical stage 1 or 2 with:
    • CD4% < 20% or CD4 count < 750/mm3 for children 19–35 months;
    • CD4% < 20% or CD4 count < 350/mm3 for children 36–59 months; or
    • CD4% < 15% or CD4 count < 200/mm3 for children ≥ 5 years

Children < 3 years:

AZT
+
3TC
+
NVP;

ABC
+
3TC
+
NVP;

or

d4T
+
3TC
+
NVP

Children > 3 years:

AZT
+
3TC
+
EFV or NVP;

ABC
+
3TC
+
EFV or NVP;

or

d4T
+
3TC
+
NVP

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
+
ABC
+
LPV/r or NFV

______

Thailand Adults and adolescents
2010

All patients with:

  • CD4 count ≤ 350/mm3;
  • AIDS-defining illness;
  • HIV-related symptoms; or
  • Pregnant women*

* But discontinue after delivery for those women with a pretreatment CD4 count of ≥ 350/mm3

Preferred:

AZT
+
3TC
+
EFV or NVP;

or

TDF
+
3TC or FTC
+
EFV or NVP

Alternatives:

ABC
+
3TC
+
EFV;

d4T*
+
3TC
+
EFV or NVP;

or

ddI
+
3TC
+
EFV or NVP

* 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
+
2 active NRTIs indicated by genotypic testing

If first regimen was PI/r-based switch to:

Active PI/r
+
2 active NRTIs indicated by genotypic testing;

Active PI/r
+
1 NNRTI ± 1 NRTI indicated by genotypic testing; or

NNRTI
+
2 active NRTIs indicated by genotypic testing

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:

  • CD4% < 25%;
  • WHO pediatric clinical stage 3 or 4; or
  • CDC category B or C

Children > 5 years with:

  • CD4 count < 350/mm3;
  • WHO pediatric clinical stage 3 or 4; or
  • CDC category B or C

Children < 3 years:

Preferred:

AZT
+
3TC
+
NVP

Alternative:

d4T
+
3TC
+
NVP

Children > 3 years:

Preferred:

AZT
+
3TC
+
EFV

Alternative:

AZT
+
3TC
+
NVP;

or

d4T
+
3TC
+
EFV or NVP

Adolescents (weight > 40kg or Tanner stage 4):

TDF
+
3TC
+
EFV

2 NRTIs
+
PI/r

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:

  • CD4 count ≤ 350/mm3; or
  • WHO clinical stage 3 or 4 irrespective of CD4 count

AZT
+
3TC
+
NVP

If failed on AZT or ABC or d4T switch to:

TDF
+
3TC
+
LPV/r or ATV/r

If failed on TDF switch to:

AZT
+
3TC
+
LPV/r or ATV/r;

or

ABC
+
3TC
+
LPV/r or ATV/r

______

Uganda Adults and adolescents
2009

All patients with:

  • CD4 count ≤ 250/mm3;
  • WHO clinical stage 4; or
  • CD4 count > 250 but ≤ 350/mm3 in those:
    • Coinfected with TB;
    • WHO clinical stage 3; or
    • Pregnant women

Preferred:

AZT
+
3TC
+
NVP or EFV

Alternative, first option:

TDF
+
3TC or FTC
+
NVP or EFV

Alternative, second option:

d4T
+
3TC
+
NVP or EFV

 

If failed on AZT + 3TC + NVP or EFV switch to:

ABC
+
ddI
+
LPV/r;

or

TDF
+
3TC or FTC
+
LPV/r

If failed on TDF + 3TC or FTC + NVP or EFV switch to:

AZT
+
ddI
+
LPV/r;

ABC
+
ddI
+
LPV/r;

or

AZT
+
3TC
+
LPV/r

If failed on d4T + 3TC + NVP or EFV switch to:

ABC
+
ddI
+
LPV/r;

or

TDF
+
3TC or FTC
+
LPV/r

 

______

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
+
3TC
+
LPV/r

Children < 5 years:

d4T
+
3TC
+
NVP or EFV

Children ≥ 5 years initiating or being switched from d4T-containing regimens:

AZT
+
3TC
+
NVP or EFV

 

 

If failed on d4T + 3TC + NVP or EFV switch to:

ABC
+
ddI
+
LPV/r or ATV/r;

TDF
+
3TC or FTC
+
LPV/r;

or

AZT
+
3TC
+
ATV/r

If failed on AZT + 3TC + NVP or EFV switch to:

ABC
+
ddI
+
LPV/r or ATV/r;

or

TDF
+
3TC or FTC
+
LPV/r

If failed on d4T + 3TC + LPV/r switch to:

ABC
+
ddI
+
NVP or EFV

 

______

Ukraine Adults and adolescents
2006

All patients with:

  • CD4 count < 200/mm3;
  • WHO clinical stage 4; or
  • CD4 count < 350/mm3 and WHO clinical stage 3

Consider treatment if CD4 count > 200/mm3 and < 350/mm3 and WHO clinical stage 1 or 2.

Preferred:

AZT
+
3TC
+
EFV;

or

TDF*
+
FTC or 3TC
+
EFV

Alternative:

AZT
+
3TC
+
NVP

Preferred PI-based regimens:

AZT
+
3TC
+
LPV/r;

or

TDF*
+
FTC or 3TC
+
LPV/r

Alternative PI-based regimen:

AZT
+
3TC
+
NFV

* TDF and FTC require registration in Ukraine.

 

If failed on AZT + 3TC + EFV or NVP switch to:

ddI
+
ABC or TDF or AZT or 3TC
+
LPV/r;

or

TDF
+
ABC or (3TC ± AZT) or ddI
+
LPV/r

If failed on TDF + FTC or 3TC + EFV or NVP switch to:

ddI
+
ABC or AZT or (3TC ± AZT)
+
LPV/r

If failed on AZT + 3TC + LPV/r switch to:

ddI
+
AZT or ABC
+
LPV/r;

or

TDF
+
ABC or AZT or (3TC ± AZT)
+
LPV/r

If failed on TDF + FTC + LPV/r switch to:

ddI
+
ABC or AZT
+
LPV/r

If failed on AZT + 3TC + NFV switch to:

AZT
+
ddI
+
LPV/r

 

Considerations for salvage regimens:

  • Addition of 2 active drugs such as T20 and TPV or another new PI
  • A combination of 2 PIs (except for TPV, which is not recommended in combination with other PIs)

 

 

 

Ukraine Infants and children
2007

Infants ≤ 11 months:

  • CD4% ≤ 25% (CD4 count ≤ 1500/mm3); or
  • WHO pediatric clinical stage 3 or 4

Children 12–35 months:

  • CD4% ≤ 20% (750/mm3);
  • WHO pediatric clinical stage 4; or
  • WHO pediatric clinical stage 3 with specific OIs*

Children 36–59 months:

  • CD4% ≤ 15% (350/mm3);
  • WHO pediatric clinical stage 4; or
  • WHO pediatric clinical stage 3 with specific OIs*

Children ≥ 5 years:

  • CD4% ≤ 15% (200/mm3);
  • WHO pediatric clinical stage 4; or
  • WHO pediatric clinical stage 3 with specific OIs*

* TB, LIP, OHL, or thrombocytopenia

Preferred NRTI backbones:

AZT
+
3TC;

d4T
+
3TC;

AZT
+
ddI;

or

ddI
+
3TC

Alternative NRTI backbones:

ABC
+
AZT;

ABC
+
3TC;

or

d4T
+
ddI

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
+
ABC
+
LPV/r or SQV/r or NFV

If failed on ABC + 3TC + NVP or EFV switch to:

ddI
+
AZT
+
LPV/r or SQV/r or NFV

If failed on AZT or d4T + 3TC + LPV/r or NFV switch to:

ddI
+
ABC
+
LPV/r or EFV or NVP

If failed on ABC + 3TC + LPV/r or NFV switch to:

ddI
+
AZT
+
LPV/r or EFV or NVP

If failed on AZT or d4T + 3TC + ABC switch to:

ddI
+
EFV or NVP
+
LPV/r or SQV/r or NFV

 

This requires consultation with an experienced professional.

Strategic approaches include:

  • T20
  • Reuse of ARVs
  • Structured treatment interruption
  • The continuation of current therapy until appropriate drugs are available

 

 

United States Adults and adolescents
2012

All patients with:

  • CD4 count ≤ 500/mm3;
  • Pregnancy
  • History of an AIDS-defining illness;
  • HIV-associated nephropathy; or
  • Hepatitis B co-infection

Preferred:

EFV
+
TDF
+
FTC;

or

ATV/r or DRV/r or RAL
+
TDF
+
FTC

 

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:

  • AIDS or significant symptoms (CDC category C or most category B conditions); or
  • Age-related CD4 threshold (CD4% ≤ 25% for ages 1 to < 5 years and CD4 count < 350/mm3 for ≥ 5 years) and viral load ≥ 100,000 copies/mL

Children < 3 years:

Preferred:

ABC or ddI or AZT
+
3TC or FTC
+
NVP or LPV/r

Alternative:

AZT
+
ABC or ddI
+
NVP or LPV/r

Children > 3 years:

Preferred:

ABC or ddI or AZT or TDF*
+
3TC or FTC
+
EFV or LPV/r

Alternative:

AZT
+
ABC or ddI
+
EFV or LPV/r or NVP

Children ≥ 6 years:

Preferred:

ABC or ddI or AZT or TDF*
+
3TC or FTC
+
EFV or LPV/r

Alternative:

AZT
+
ABC or ddI
+
ATV/r or DRV/r or FPV/r
+
NVP

* TDF for Tanner stage 4 or postpubertal adolescents only

 

If failed on 2 NRTIs + NNRTI switch to:

2 NRTIs
+
PI

If failed on 2 NRTIs + PI switch to:

2 NRTIs
+
NNRTI;

2 NRTIs
+
PI/r;

or

NRTI(s)
+
NNRTI
+
PI/r

If failed on 3 NRTIs switch to:

2 NRTIs
+
NNRTI or PI;

or

NRTI(s)
+
NNRTI
+
PI

 

Refer to guidelines for further information (pg. 130–136).

Uruguay Adults and adolescents
2006

All patients with:

  • Acute symptomatic infection;
  • HIV-related symptoms; or
  • CD4 < 250/mm3 irrespective of symptoms and viral load

AZT
+
3TC
+
NVP or IDV/r or SQV/r;

or

d4T
+
3TC
+
EFV or NFV

2 NRTIs
+
EFV or NFV or IDV/r or SQV/r;

2 NRTIs
+
1 NNRTI
+
SQV/r or LPV/r;

or

1 NRTI
+
1 NNRTI
+
SQV/r

______

Venezuela Adults and adolescents
2012

All patients with:

  • AIDS-defining illness;
  • CD4 count < 350/mm3 or CD4% < 15%;
  • HIV-related nephropathy; or
  • Coinfection with HBV or HCV

Treat patients with special considerations such as:

  • Pregnancy;
  • Any neoplastic disease;
  • Serodiscordant stable partnerships; or
  • > 55 years of age

TDF or ABC or AZT or ddI
+
3TC
+
EFV or NVP;

or

TDF or ABC or AZT or ddI
+
3TC
+
ATV/r or FPV/r or LPV/r or SQV/r

 

If failed on TDF + 3TC backbone switch to:

AZT
+
ABC;

ddI
+
AZT;

or

ddI
+
ABC

If failed on ABC + 3TC backbone switch to:

TDF
+
AZT;

or

AZT
+
ddI

If failed on AZT + 3TC backbone switch to:

ABC
+
ddI;

or

TDF
+
ABC

If failed on ddI + 3TC backbone switch to:

TDF
+
AZT;

or

TDF
+
ABC

If failed on AZT + ddI backbone switch to:

TDF
+
3TC;

or

ABC
+
3TC

If failed on d4T + ddI backbone switch to:

TDF
+
3TC;

ABC
+
3TC;

or

TDF
+
AZT

If failed on AZT + ABC + 3TC switch to:

PI/r
+
EFV
+
TDF or ddI

If failed on d4T + 3TC backbone switch to:

TDF
+
ABC;

or

ABC
+
ddI

If failed on d4T or AZT + ABC backbone switch to:

TDF
+
3TC

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:

  • Any CDC category B or C symptoms—except one episode of a severe bacterial infection—irrespective of CD4 levels; or
  • CD4% < 25%

Consider treatment in asymptomatic children 1 to < 5 years with CD4% ≥ 25% and viral load ≥ 100,000 copies/mL.

Children > 5 years with:

  • Any CDC category B or C symptoms —except one episode of a severe bacterial infection— irrespective of CD4 levels; or
  • CD4 count < 350/mm3

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
+
3TC
+
NVP or LPV/r

Children ≥ 3 years and > 10 kg:

ABC or AZT or ddI
+
3TC
+
EFV*;

or

TDF
+
3TC†
+
EFV*

* 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
+
PI/r

If failed on 2 NRTIs + PI/r switch to:

2 NRTIs
+
PI/r with a higher genetic barrier;

or

NRTI
+
NNRTI
+
PI/r with a higher genetic barrier

 

Refer to CONARESAR for further guidance. For more information, see pg. 37 of the guidelines.

Vietnam Adults and adolescents
2009

All patients with:

  • WHO clinical stage 4 irrespective of CD4 count;
  • WHO clinical stage 3 and CD4 count < 350/mm3;
  • WHO clinical stage 1 or 2 and CD4 count < 250/mm3; or
  • If CD4 count is not available, start ART in patients at WHO clinical stages 3 or 4

Preferred:

AZT
+
3TC
+
NVP;

or

d4T
+
3TC
+
NVP

Alternatives:

AZT
+
3TC
+
EFV;

or

d4T
+
3TC
+
EFV

For patients who cannot use AZT or d4T:

TDF
+
3TC
+
NVP or EFV

For patients who cannot use NVP or EFV:

AZT
+
3TC
+
TDF

 

If failed on d4T or AZT + 3TC + NVP or EFV switch to:

TDF
+
3TC (± AZT)
+
LPV/r*;

or

ddI
+
ABC
+
LPV/r*

If failed on TDF + 3TC + NVP or EFV switch to:

ddI
+
ABC
+
LPV/r*;

or

AZT
+
3TC
+
LPV/r*

If failed on AZT or d4T + 3TC + TDF or ABC switch to:

EFV or NVP
+
ddI
+
LPV/r*

* ATV/r can be used as an alternative for LPV/r.

 

______

Vietnam Infants and children
2009

All infants < 12 months

Children > 12 months with:

  • WHO pediatric clinical stage 3 or 4 irrespective of CD4 count;
  • TB, LIP, OHL, or thrombocytopenia (begin ART if CD4 represents “severe immunodeficiency”* by age once the OI is treated);
  • WHO pediatric clinical stage 2 and CD4 count (or TLC) below the level of “severe immunodeficiency”* by age; or
  • WHO pediatric clinical stage 1 and CD4 count below the level of “severe immunodeficiency”* by age

* See pg. 97 of guidelines for pediatric immunological staging.

Preferred regimen for non-NVP-exposed children:

AZT
+
3TC
+
NVP

For NVP-exposed infants < 12 months:

Preferred:

AZT
+
3TC
+
LPV/r

Alternatives:

d4T
+
3TC
+
LPV/r*;

or

ABC
+
3TC
+
LPV/r*

* If LPV/r is not available, use NVP.

 

If failed on AZT or d4T + 3TC + NVP or EFV switch to:

ddI
+
ABC
+
LPV/r*

If failed on AZT or d4T + 3TC + ABC switch to:

ddI
+
EFV
+
LPV/r*;

or

ddI
+
NVP
+
LPV/r*

If failed on ABC + 3TC + NVP or EFV switch to:

AZT
+
3TC (± ddI)
+
LPV/r*;

or

d4T
+
3TC
+
LPV/r*

* ATV/r can be used as an alternative for LPV/r.

 

______

Zambia Adults and adolescents
2007

All patients with:

  • CD4 count < 200/mm3;
  • WHO clinical stage 4; or
  • CD4 count < 350/mm3 at WHO clinical stage 3

TDF
+
FTC
+
NVP or EFV

AZT or d4T
+
3TC or TDF/FTC
+
LPV/r

______

Zambia Infants and children
2010

All children < 2 years

Children ≥ 2 and < 5 years with:

  • CD4% ≤ 25% or CD4 ≤ 750 cells/mm3; or
  • WHO pediatric clinical stage 3 or 4

Children ≥ 5 years with:

  • CD4 ≤ 350 cells/mm3; or
  • WHO pediatric clinical stage 3 or 4

Infants and children < 24 months with no previous NNRTI exposure:

2 NRTIs
+
NVP

Infants and children < 24 months with previous NNRTI exposure (e.g., from PMTCT):

2 NRTIs
+
LPV/r

Children ≥ 24 months and < 3 years:

2 NRTIs
+
NVP

Children > 3 years:

2 NRTIs
+
NVP or EFV

Preferential order of NRTI backbone:

AZT + 3TC

ABC + 3TC

d4T + 3TC

 

If failed on AZT or d4T + 3TC + NVP or EFV switch to:

ABC
+
3TC
+
LPV/r

In children > 12 years switch to:

TDF
+
FTC or 3TC
+
LPV/r

If failed on ABC + 3TC + NVP or EFV switch to:

AZT
+
3TC
+
LPV/r

If failed on AZT or d4T + 3TC + LPV/r switch to:

ABC
+
3TC
+
NVP or EFV

If failed on ABC + 3TC + LPV/r switch to:

AZT
+
3TC
+
NVP or EFV

 

Considerations:

  • For older children with more therapeutic options available, it may be possible to construct third-line regimens with novel drugs used for adults (i.e., DRV and RAL)
  • Children on failing second-line regimens with no new ARV options should continue with a tolerated regimen
  • When stopping ART, management of OIs, symptoms and pain must continue

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:

  • WHO clinical stage 3 or 4;
  • CD4 count < 350/mm3; or
  • Active TB

Preferred:

TDF
+
3TC
+
NVP

Alternative:

AZT
+
3TC
+
NVP

 

Preferred:

AZT
+
3TC*
+
LPV/r

If failed on regimen containing AZT or d4T switch to:

TDF
+
3TC*
+
LPV/r

Alternative:

ABC
+
ddI
+
LPV/r†

* 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:

  • WHO pediatric clinical stage 3 or 4; or
  • CD4% ≤ 25% or CD4 count < 750/mm3

Children ≥ 5 years with:

  • WHO pediatric clinical stage 3 or 4; or
  • CD4 count < 350/mm3

For NVP-exposed infants:

Preferred:

AZT
+
3TC
+
PI (LPV/r in use now)

Alternative:

d4T
+
3TC
+
PI (LPV/r in use presently)

For non-NVP-exposed infants and children:

Preferred:

AZT
+
3TC
+
NVP

Alternative:

d4T
+
3TC
+
NVP

 

If failed on regimen with PI switch to:

Preferred:

ABC
+
3TC
+
NVP

Alternative:

ABC
+
ddI
+
NVP

If failed on regimen with NVP switch to:

Preferred:

ABC
+
3TC
+
PI (LPV/r in use presently)

Alternative:

ABC
+
ddI
+
PI (LPV/r in use presently)

 

______