Treatment of HIV and AIDS in Adults and Adolescents

Table 6.1 Recommended First-Line Regimens for Adults and Adolescents

Mother-to-child transmission (MTCT) of HIV refers to the transmission of HIV infections from HIV- infected  mothers  to  their  infants.  MTCT  can  occur  during  pregnancy,  labour  and  delivery,  and  breast-feeding. Without intervention, the overall risk of MTCT is approximately 20%–45%. However,  with interventions, this risk can be reduced to less than 5%. Transmission of HIV from mother to her  child accounts for over 90% of all HIV infections in children aged below 15 years. 

All HIV infected pregnant women and lactating mothers are eligible for ART regardless of CD4 cell  count  and  clinical  stage.  The  pregnant  or  breast-feeding  women  with  HIV  should  be  started  on  lifelong ART at the time of diagnosis. 

The  recommended  first  line  regimen  is  once  a  day  fixed  dose  regimen  of  TDF  +  3TC  +  DTG.  Although TDF + 3TC + EFV may be an option for use during the pre-conception period through the  first eight weeks of pregnancy to avoid potential risk of neural tube defects. Then TLD should be  continued postpartum.  

• A women-centered approach is adopted. Women of childbearing potential including those who are using long term effective contraception should be given adequate information to enable making informed decision and choice.
• Women should  receive  on-going  counselling  support  to  continue  with  HIV  care  and treatment in order to maintain good health and to reduce the risk of HIV transmission to others.

Available alternative first-line ART regimen includes 

A:TDF+FTC+EFV 600mg (FDC) 

OR 

A: ABC+3TC+EFV600 or DTG 

OR 

A: AZT+3TC+EFV600 or DTG 

Prophylaxis for HIV Exposed Infants 

• Administer NVP syrup immediately after birth to all HIV exposed infants and continue until six weeks of age

• In case a high risk HIV exposed infant is identified, administer duo prophylaxis containing NVP  syrup  (once  daily)  and  AZT  syrup  (twice  daily)  for  the  first  6  weeks  of  life,  then continue with daily NVP alone up to 12 weeks of life
• High-risk infants are those who are:
  • Born to women diagnosed to be living with HIV during current pregnancy or breast-feeding period.
  • women known to be HIV positive but not yet on ART or
  • already on ART but with high viral load (≥50/UL of blood)
• Infant prophylaxis is most effective when given as soon as possible after birth, preferably within 6–12 hours
• HIV exposed  infants  identified  beyond  the  age  of  4  weeks  should  not  be  given  ARV prophylaxis

Table 6.2: NVP Dosing Recommendation 

Based on the dosing required to sustain exposure in the infant of >100 ng/mL with the fewest dose changes.

Low birth weight infants <2000g should receive mg/kg dosing; suggested starting dose is 2mg/kg  once daily.   

Before treatment failure is confirmed every effort should be made to rule out causes other than drug  resistance.  

Table 6.3: Recommended Second-Line Regimens for Adults and Adolescents 

The  second  line  NRTI  choice  for  adults  and  adolescents  depends  on  the  first  line  regimen.  For  patients  on  TDF  based  regimens  in  first  line,  the  preferred  second  line  option  is  AZT  plus  3TC  combined with a ritonavir-boosted PI, preferably ATV/r because it is dosed once daily and has fewer  metabolic complications and side effects. The same NRTIs, with exception of 3TC and FTC used in  previous  regimen  should  not  be  used  in  subsequent  regimens  during  switching  due  to  treatment  failure. LPV/r can be used as an alternative to ATV/r in patients using anti-TB drugs (with ritonavir  super boosting) and children below six years. Also, ATV/r (300/100mg) cannot be used in children  below 30kg.  

For patients who were on AZT and had never used TDF regimen, the default second line option will  be TDF or ABC based regimen combined with a boosted PI (TDF+FTC+ATV/r). 

For patients who were introduced to TDF in first line due to AZT toxicity, the default second line  option is to use ABC plus 3TC combined with a ritonavir-boosted PI ATV/r or LPV/r (ABC + 3TC +  LPV/r  or  ATV/r).  However,  ABC  may  be  rendered  ineffective  due  to  cross  resistance  with  TDF  associated resistance mutations.

Patients  failing  2^nd  line  regimens  may  have  extensive  NRTI  and  NNRTIs  associated  resistance  mutations  (RAMS)  which  preclude/minimise  their  use  in  third-line  regimens.  Therefore,  3^rd  line regimens, in order to have at least two or preferably three effective drugs, need to be constructed  using  other  new  classes  of  drugs  or  second-generation  formulations  of  previous  drugs.  These  second-generation drugs usually have a higher genetic barrier to resistance and their efficacy is not  compromised by RAMs associated with the first-generation formulations. 

Therefore, this guideline recommends the use of: 

• Integrase  Strand  Transfer  Inhibitors  (INSTIs)  or  Integrase  Inhibitors  Dolutegravir  50mg (DTG) and Raltegravir 400mg (RAL)
• Second generation PIs Darunavir 800mg /Ritonavir 100mg (DRV/r),

Table 6.4: Recommended Third-Line Regimens for Adults and Adolescents

Note:

• DTG  in  third  line  regimen  should  be  given  twice  daily  for  clients  who  were  previously  exposed  to INSTIs. 
• For  TB  and  HIV  co-infected  patients  on  LPV/r  should  be  switched  to  DRV/r  after  completion  of  TB treatment. 
• For second- and third-line regimens which are non TDF based, in case of new Hepatitis B co - infection TDF with FTC should be added to the new regimen as treatment of Hepatitis B.