RECCOMENDED SECOND LINE ADULTS, ADOLESCENTS, PREGNANT WOMEN AND CHILDREN

Patients may need to be swiched to second line regimens in case of treatment failure, and to third line if they fail on second line drugs. Third line regimens require resistance testing to inform the choice of appropriate drugs, and needs
referral to specialised ART centres.

Factors involved in treatment failure are poor adherence, inadequate drug levels or prior existing drug resistance.

Before switching therapy, it is essential to assess and address adherence issues, and provide intensive adherence counselling if necessary.

Criteria for defining treatment failure are presented in the following table:

DEFINITION COMMENT
VIROLOGICAL FAILURE

Two consecutive viral loads >1000
copies/ml, done at three to six months
apart, with intensive adherence support
following the 1st VL test

Patient should
have been on
ART for at least
six months
CLINICAL FAILURE

Adults and adolescents:

New or recurrent WHO clinical stage 3
or 4 (with exception of TB) in a patient
who has been on effective ART regimen
for at least six months

Children:

New or recurrent WHO clinical stage 3 or
stage 4 event (with the exception of TB)
in a patient who has been on effective
ART regimen for at least six months.

The condition
must be
differentiated
from Immune
Reconstitution
Inflammatory
Syndrome
(IRIS)
occurring after
initiating ART

AZT+3TC+ATV/rTDF/3TC/LPV/r2A>

POPULATION FAILING FIRST-LINE
REGIMENS
SECOND-LINE
REGIMENS
Adults,
Pregnant and
Breastfeeding
Women, and
Adolescents
TDF + 3TC + EFV AZT+3TC+ATV/r
(Recommended)
or
AZT+3TC+LPV/r1
(alternative)
TDF + 3TC + DTG
TDF+3TC+NVP
ABC+ 3TC+ DTG
ABC+ 3TC+ EFV
ABC+3TC+NVP
AZT+3TC+EFV TDF+3TC+ATV/r
(Recommended)
or
TDF+3TC+LPV/r
AZT+3TC+NVP
TDF+3TC+ATV/r AZT/3TC/LPV/r2
TDF+3TC+ATV/r AZT/3TC/LPV/r2
Children 3 – 9.9
Years
>ABC + 3TC + EFV AZT+3TC+LPV/r3
ABC+ 3TC + NVP
AZT+3TC+NVP ABC+3TC+LPV/r3
AZT/3TC/EFV
AZT+3TC+LPV/r BC+3TC+RAL
ABC+3TC+LPV/r AZT+3TC+RAL
Children Under
3 Years
ABC+3TC+LPV/r
Pellets
AZT+3TC+RAL
AZT+3TC+LPV/r
pellets
ABC+3TC+RAL
ABC +3TC+NVP AZT+3TC+LPV/r
  1. LPV/r should be used as alternative to ATV/r ONLY if patient weighs < 40 kg
  2. LPV/r can be used by ATV/r experienced individuals
  3. Lopinavir in children 3-10 years is preferred because there is no optimal formulation of ATV/r yet

Paediatric ARV Dosing Tables

FORMULATION WEIGHT (KG)
3–
5.9
6–
9.9
10–
13.9
14–
19.9
20–
24.9
25–
34.9
ABC/3TC
120/60mg
Take at night
1
od
1.5
od
2
od
2.5
od
3
od
AZT/3TC
60/30mg
1 bd 1.5
bd
2
bd
2.5
bd
3 bd
AZT/3TC/NVP
60/30/50mg
1 bd 1.5
bd
2
bd
2.5
bd
3
bd
ABC 60mg
Take at night
1 od 1.5
od
2
od
EFV 200 mg
Take at night
1 od 1.5
od
1.5
od
2 od
NVP 10 mg/ml
syrup
5ml
bd
8 ml
bd
10
ml
bd
NVP 50 mg
tablet
1 bd 1.5
bd
2
bd
2.5
bd
3
bd
LPV/r 40/10 mg1
pellets
2 bd 3
bd
4
bd
LPV/r 100/25 mg
tablet2
2
om 1
on
2
bd
2
bd
3
bd
Ral 100 mg
chewable tab
1
bd
1.5
bd
DRV 75 mg +
(RTV 100 mg)3
3 bd 5 bd 5 bd
RTV 25 mg 2 bd 2 bd 3 bd
Cotrimoxazole
120 mg
1 od 2
od
2
od
4
od
Isoniazid
100 mg
0.5
od
1
od
1.5
od
2
od
2.5
od

Notes

od = once daily, bd = twice daily, om = morning, on = night

  1. For children ≥10 kg that are able to swallow tablets, give LPV/r 100/25 mg tablet
  2. Tablets of LPV/r 100/25 mg can be substituted with 1 tablet of LPV/r 200/50 mg in order to reduce the pill burden. Administer tablets fully intact/whole i.e. not cut or crushed
  3. DRV must be administered with 2 tablets of RTV 25 mg in children ≤15 to 25 kg and 3 tablets of RTV 25 mg in children above 25 kg. DRV is always taken with food
  4. DRV 600 mg must be co-administered with RTV 100 mg
  5. SQV 500 mg must be co-administered with RTV 100 mg, and should only be used in adolescents and adults above 16 years

Adult ARV Dosing Tables

FORMULATION WEIGHT (KG)
20–24.9 25–34.9 ADOLESCENTS
>35 KG AND
ADULTS
ABC/3TC
600/300 mg
1 od 1 od
AZT/3TC
300/150 mg
1 bd 1 bd
AZT/3TC/NVP
300/150/200 mg
1 bd 1 bd
TDF/3TC/EFV
300/300/600 mg
1 od,
At night
DTG 50 mg 1 od
LPV/r 200/50 mg 1 bd 2 in morn
1 at night
2 bd
ATV/r 300/100
mg
1 od
RAL 400 mg
Twice daily
1 bd 1 bd
DRV 600 mg1
(+ RTV 100 mg)
1 bd
RTV 100 mg 1 bd
ETV 200 mg 1 bd
SQV 500 mg2
(+ RTV 100 mg)
2 bd
Cotrimoxazole
960 mg
0.5 1 od 1 od
Dapsone 100 mg 1 od 1 od
Isoniazid
300 mg
1 od 1 od

Notes

  1. DRV 600 mg must be co-administered with RTV 100 mg
  2. SQV 500 mg must be co-administered with RTV 100mg, and should only be used in adolescents and adults above 16 years.