Table 1.
Summary and comparison of the South African adult ART guidelines
| 2004 | 2010 | 2012/2013 | 2015 | |
|---|---|---|---|---|
| Eligible to start | CD4 ≤ 200 cells/mm3 WHO stage IV |
CD4 count ≤ 200 cells/mm3 WHO stage IV, MDR or XDR TB if CD4 ≤ 350 cells/mm3 Pregnant women with CD4 ≤ 350 cells/mm3 or WHO stage III/IV |
CD4 count ≤ 350 cells/mm3 WHO stage III or IV TB Pregnant or breastfeeding, irrespective of CD4 |
CD4 count ≤ 500 cells/mm3 Active TB disease, HIV positive and pregnant or breastfeeding, known HBV co-infection irrespective of CD4 count or clinical stage WHO stage III or IV irrespective of CD4 count |
| First-line ART regimen | d4t + 3TC + EFV d4t + 3TC + NVP |
TDF + 3TC/FTC + EFV/NVP d4t + 3TC + EFV/NPV AZT + 3TC + EFV/NVP |
TDF + 3TC/FTC + EFV/NVP AZT + 3TC + EFV/NVP d4t + 3TC + EFV/NVP ABC + 3TC + EFV/NVP |
TDF + 3TC/FTC + EFV TDF + 3TC/FTC + NVP/LPV/r ABC + 3TC + EFV/NVP |
| Failing first-line | No resistance testing for first-line failure | |||
| Second-line ART regimen | AZT/ddI/LPV/r | TDF + 3TC/FTC + LPV/r AZT + 3TC + LPV/r |
AZT + 3TC + LPV/r TDF + 3TC/FTC + LPV/r Switch LPV/r to ATV/r with dyslipidaemia |
AZT + 3TC + LPV/r AZT + TDF + 3TC + LPV/r [if Hep B co-infected) TDF + 3TC/FTC + LPV/r Switch LPV/r to ATV/r with dyslipidaemia |
| Failing second-line/third-line ART | Specialist referral | Specialist referral for regimen with raltegravir/darunavir/etravirine | Documented PI resistance Refer to expert committee for possible darunavir-ritonavir, raltegravir, etravirine or some combination |
|
| Monitoring | CD4 and VL at baseline and 6 monthly ALT for patients on NVP at baseline, 2, 4 and 8 weeks and 6 monthly thereafter FBC at baseline, monthly for 3 month and then 6 monthly Fasting cholesterol and triglycerides at baseline, 6 month and every 12 month thereafter Fasting glucose at baseline and 12 month |
Serum creatinine at baseline if starting on TDF ALT at baseline and if symptomatic on NVP CD4 and VL at month 6, 1 year and every 12 month thereafter FBC or haemoglobin at baseline and month 1, 2, 3 and 6 if on AZT Creatinine at month 3 and 6 and every 12 month if on TDF Fasting cholesterol and triglycerides at 3 month if on LPV/r |
Serum creatinine at baseline if starting on TDF ALT at baseline and if symptomatic on NVP CD4 at 1 year on ART VL at month 6, 1 year on ART and every 12 month FBC or haemoglobin at baseline and month 3 and 6 if on AZT Creatinine at month 3, 6, 1 year on ART and every 12 months if on TDF Fasting cholesterol and triglycerides at month 3 if on LPV/r |
Serum creatinine at baseline if starting on TDF ALT at baseline and if symptomatic on NVP CD4 at 1 year on ART—once a CD4 reaches 200 cells/mm3 no further annual CD4 monitoring VL at month 6, 1 year on ART and every 12 month FBC or haemoglobin at baseline and month 3 and 6 if on AZT Creatinine at month 3, 6, 1 year on ART and every 12 months if on TDF Fasting cholesterol and triglycerides at start and month 3 if on LPV/r |