What is the preferred first-line ART regimen for HIV-infected adults?

AIIMS CRE 2025

Medical Surgical Nursing

Easy

Appeared in: AIIMS CRE 2025

Explanation

The combination of Tenofovir + Lamivudine + Dolutegravir (TLD) is the current globally and nationally (NACO, India) recommended first-line ART regimen.
Dolutegravir (DTG), an integrase inhibitor, offers superior viral suppression, a higher genetic barrier to resistance, and better tolerability compared to older NNRTI-based regimens like those with Efavirenz.
This regimen is available as a convenient single, once-daily pill, which promotes better patient adherence.
The TLD regimen is effective against both HIV-1 and HIV-2 and can be used in special populations like pregnant women and patients with TB co-infection (with dose adjustment).

Option A: This is an older, alternative regimen. Zidovudine (AZT) is associated with significant side effects like anemia and bone marrow suppression. Efavirenz (EFV) can cause neuropsychiatric side effects (e.g., vivid dreams, dizziness, depression).
Option C: This regimen is obsolete and no longer recommended due to severe and irreversible toxicities. Stavudine (d4T) and Didanosine (ddI) are associated with peripheral neuropathy, pancreatitis, and lactic acidosis.
Option D: This represents an outdated treatment strategy. Current guidelines (WHO, NACO) recommend a 'Treat All' approach, meaning ART should be initiated in all individuals as soon as possible after an HIV diagnosis, regardless of their CD4 cell count.

Visual 1: Table: Comparison of First-Line ART Regimens - A table comparing TLD with older regimens (like TLE, AZT-based) on efficacy, side effects, resistance barrier, and pill burden.
Visual 2: Timeline: Evolution of HIV Treatment Guidelines - A flowchart showing the shift from 'When to start?' (based on CD4 count) to the 'Treat All' strategy.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain First-line antiretroviral therapy (ART) for HIV in adults as background academic context rather than a clinical decision trigger.
Nurses play a crucial role in educating patients about the importance of starting ART immediately upon diagnosis ('Treat All') to improve their long-term health and reduce transmission.
Patient counseling on adherence is a key nursing responsibility. Missing even a few doses can lead to viral rebound and the development of drug-resistant HIV.
Nurses must monitor for both short-term and long-term side effects, such as renal toxicity with Tenofovir and metabolic changes (weight gain) with Dolutegravir.

How to Approach the Question

This is a factual recall question that tests your knowledge of current clinical guidelines.
First, identify the core of the question: it asks for the 'preferred first-line' ART regimen for adults.
Evaluate each option based on current medical standards. Recall that HIV treatment guidelines have evolved significantly.
Eliminate options that represent outdated practices. The 'no treatment until CD4 < 200' is a classic example of an old guideline.
Eliminate options containing drugs known for high toxicity and are no longer in common use, such as Stavudine and Didanosine.
Compare the remaining modern regimens. Recognize that Dolutegravir (an integrase inhibitor) has largely replaced Efavirenz (an NNRTI) in first-line therapy due to better efficacy and tolerability. This points to the correct combination.

Concept Tested & Keywords

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