3 Introduction to anti-retrovirals (ARVs)

3.10 Treatment choice

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Over 20 HIV drugs have been approved, but not all drugs are available in every country.

Although there are many hundreds of possible combinations with these individual drugs, only a few combinations are recommended in treatment guidelines.

Most guidelines recommend that first-line treatment is a combination of:

• 2 nukes combined with EITHER a non-nuke OR a PI (preferably a PI boosted with ritonavir)

WHO guidelines recommend four non-nuke based combinations:

• 3TC + d4T + nevirapine
• 3TC + d4T + efavirenz
• 3TC + AZT + nevirapine
• 3TC + AZT + efavirenz

Fixed dose combinations (FDCs) are where the 3 drugs in these combinations are supplied in 1 pill. Generic manufacturers produce FDCs but they are only available in some countries.

There are advantages and disadvantages of each WHO combination:

• nevirapine-based combinations are preferred in women who are pregnant – but only if they have a CD4 count under 250 cells/mm³.
• efavirenz-based combinations should not be used by women who want to become pregnant.
• efavirenz-based combinations are preferred in people who need TB treatment at the same time.
• efavirenz-based combinations are used if people are intolerant to, or have side effects with nevirapine.
• d4T-based combinations are often recommended because this is a very inexpensive drug – but if you get side effects like neuropathy, the d4T needs to be changed to AZT.
• In 2007, the WHO cautioned against d4T because of the risk of side effects – peripheral neuropathy, fat loss and lactic acidosis – and recommended reducing the dose from 40mg to 30mg, or from 30mg to 20mg, depending on body weight.
• d4T-based combinations are generally recommended in people who develop AZT-related side effects.
• AZT-based combinations have a higher risk of causing anaemia and are not recommended if you have anaemia.

WHO recommended ARVs and European ARV drugs and doses