Red Flags
- Acute opportunistic infection (PCP, cryptococcal meningitis, disseminated TB, severe Kaposi) at HIV diagnosis — treat OI first, defer or carefully time ART initiation to balance IRIS risk[1]
- Suspected HIV-associated immune reconstitution inflammatory syndrome (IRIS) — worsening of OI symptoms 2–12 weeks after ART initiation; do NOT stop ART; treat OI plus steroids in selected cases[1]
- Pregnancy with HIV requires immediate ART initiation regardless of CD4 — eliminate vertical transmission risk[1]
- Treatment failure (clinical, immunological, or virological) on first-line — do NOT just add a drug; structured switch to second-line per drug-resistance profile[1]
First-line treatment
Interventions
- Adherence counselling at every visit[1]Treatment success depends on >95% adherence; address barriers (cost, stigma, side effects, food security); peer support and SMS reminders increase adherence
- Test and treat (universal ART)[1]Initiate ART regardless of CD4 in everyone diagnosed with HIV; same-day or rapid initiation reduces loss-to-follow-up
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Tenofovir + lamivudine + dolutegravir (TLD)[1] | NRTI + NRTI + INSTI fixed-dose combination | Tenofovir 300 mg + lamivudine 300 mg + dolutegravir 50 mg PO once daily | Weight-band dosing per NACO paediatric tables | Preferred first-line for adults and adolescents. Effective in pregnancy (post first-trimester safety reassurance from Tsepamo/PROMISE) |
| Cotrimoxazole (TMP-SMX)[1] | Folate-pathway inhibitor | 960 mg PO once daily as prophylaxis | Weight-band dosing | PCP and toxoplasmosis prophylaxis when CD4 <200 or active TB; continue until CD4 >200 sustained for 3 months |
| Isoniazid preventive therapy (or 3HP / 1HP)[2] | TB preventive therapy | INH 300 mg PO daily × 6 months OR 3HP (rifapentine 900 mg + INH 900 mg weekly × 12) OR 1HP (daily INH+rifapentine × 1 month) | — | All people with HIV; 1HP regimen now NACO-endorsed for shorter completion |
| Atazanavir/ritonavir or lopinavir/ritonavir (second-line)[1] | Protease inhibitor | Atazanavir 300 mg + ritonavir 100 mg PO once daily; lopinavir/ritonavir 400/100 mg BD | — | Second-line if first-line dolutegravir failure with documented resistance |
| Darunavir/ritonavir (third-line)[1] | Protease inhibitor (high-genetic-barrier) | Darunavir 600 mg + ritonavir 100 mg PO BD | — | Third-line; combine with raltegravir or new NRTI backbone per resistance testing |
Tenofovir + lamivudine + dolutegravir (TLD)[1]
NRTI + NRTI + INSTI fixed-dose combination
- Adult
- Tenofovir 300 mg + lamivudine 300 mg + dolutegravir 50 mg PO once daily
- Paediatric
- Weight-band dosing per NACO paediatric tables
Preferred first-line for adults and adolescents. Effective in pregnancy (post first-trimester safety reassurance from Tsepamo/PROMISE)
Cotrimoxazole (TMP-SMX)[1]
Folate-pathway inhibitor
- Adult
- 960 mg PO once daily as prophylaxis
- Paediatric
- Weight-band dosing
PCP and toxoplasmosis prophylaxis when CD4 <200 or active TB; continue until CD4 >200 sustained for 3 months
Isoniazid preventive therapy (or 3HP / 1HP)[2]
TB preventive therapy
- Adult
- INH 300 mg PO daily × 6 months OR 3HP (rifapentine 900 mg + INH 900 mg weekly × 12) OR 1HP (daily INH+rifapentine × 1 month)
- Paediatric
- —
All people with HIV; 1HP regimen now NACO-endorsed for shorter completion
Atazanavir/ritonavir or lopinavir/ritonavir (second-line)[1]
Protease inhibitor
- Adult
- Atazanavir 300 mg + ritonavir 100 mg PO once daily; lopinavir/ritonavir 400/100 mg BD
- Paediatric
- —
Second-line if first-line dolutegravir failure with documented resistance
Darunavir/ritonavir (third-line)[1]
Protease inhibitor (high-genetic-barrier)
- Adult
- Darunavir 600 mg + ritonavir 100 mg PO BD
- Paediatric
- —
Third-line; combine with raltegravir or new NRTI backbone per resistance testing
Safety-net
- Take ART every day at the same time — even one missed dose can drive resistance; viral suppression protects you and your partner (U=U)[1]
- Acute illness, fever, cough, night sweats, or weight loss while on ART — same-week medical review (rule out OI, TB, IRIS)[1]
- Plan ART supply ahead during travel, festivals, or moves — interruption risks resistance and disease progression[1]
Referral criteria
- Acute opportunistic infection at HIV diagnosisInfectious diseases or HIV physician — treat OI, time ART initiation[1]
- Treatment failure on first-line ART (virological failure with VL >1000 on ≥2 occasions)ART centre with drug-resistance testing for switch to second-line[1]
- Pregnancy with HIVJoint HIV and obstetric care; PMTCT clinic[1]
- Active TB and HIV co-infectionJoint NTEP and ART centre; sequence TB then ART (after 2–8 weeks based on CD4)[2]
Clinical summary
First-line antiretroviral therapy initiation, monitoring, and switch criteria per NACO national programme, with dolutegravir-based regimens as preferred backbone.