Modern ART for South Africa

ART in South Africa

The South African Guidelines have been updated in order to ensure that all people who can take DTG are on a DTG based regimen. The terms 1st line and second line regimens are no longer in use, but instead we now have TLD1 and TLD 2.

TLD1: People on a DTG-containing regimen, having never failed a previous regimen, this is formerly known as “first-line” terminology.

TLD2: Clients on a DTG-containing regimen, who have failed a previous regimen this is formerly known as “second- line”.

Starting ART

See our booklet Starting ART for more information about dolutegravir, TLD, drug interactions, as well as viral load and CD4 tests, and adherence.

What if I am already on Efavirenz-based ART?

If your viral load has been undetectable (or virally suppressed) to less than 50 copies/mL you can easily switch from your efavirenz to dolutegravir.
The other two drugs in your regimen will stay the same. These are usually tenofovir + lamivudine or emtricitabine.

So if your current regimen is:
tenofovir + lamivudine (or emtricitabine) + efavirenz
you can switch to:
tenofovir + lamivudine (or emtricitabine) + dolutegravir or TLD.

If you current regimen is:
zidovudine (or abacavir)* + lamivudine (or emtricitabine) + efavirenz
you can switch to:
zidovudine (or abacavir) + lamivudine (or emtricitabine) + dolutegravir

This combination is called ALD

*You might also be able to switch zidovudine or abacavir to tenofovir.

What if my viral load is between 50 and 1000 copies/ml?

Your health worker will do thorough checks to find the cause of your higher viral load.

With you they will consider the possibility of:

• Adherence problems
• Other infections
• Wrong dose of ARVs
• Drug interactions
• Resistance

They will work with you to fix these and offer you increased adherence support.

With this you will be able to switch to dolutegravir.
You will have another viral load test after 3 months to make sure everything is going well.

What if my viral load is 1000 copies/ml or more?

If your viral load is 1000 copies/mL or more, you will not be able to switch to dolutegravir right away.

You will do the checks to find the cause of your high viral load with your health worker.

If you have two viral load tests with over 1000 copies/mL and you have been adherent (this is called virological failure). You will need to switch to second-line ART.

What if I haven’t had a viral load test in the last 6 months?

If you haven’t had a viral load test in the last 6 months, you should wait for your routine annual test to find out if you can switch to dolutegravir.

Is there anything else to think about before I change my ARVs?

YES!

Your hepatitis B status.

If you are taking tenofovir in your first-line regimen, it is important that you have your hepatitis B status checked before stopping it. If someone with chronic hepatitis B stops tenofovir this could lead to a severe hepatitis flare.

Your health worker will test you for hepatitis B.

How does my Hepatitis B status influence which ART regimen I take?

Hepatitis B negative:

If your current regimen is tenofovir + lamivudine or emtricitabine + efavirenz you can switch to zidovudine + lamivudine or emtricitabine + dolutegravir.

If dolutegravir is not suitable then zidovudine + lamivudine or emtricitabine + lopinavir/ritonavir.

Hepatitis B positive:

If your current regimen is tenofovir + lamivudine or emtricitabine + efavirenz you can switch to tenofovir + zidovudine + lamivudine or emtricitabine + dolutegravir.

If dolutegravir is not suitable then tenofovir + lamivudine or emtricitabine + lopinavir/ritonavir.

What if my regimen is Dolutegravir-based?

Hepatitis B negative:

If your current regimen is tenofovir + lamivudine or emtricitabine + dolutegravir you can switch to zidovudine + lamivudine or emtricitabine + lopinavir/ritonavir.

Hepatitis B positive:

If your current regimen is tenofovir + lamivudine or emtricitabine + dolutegravir you can switch to tenofovir + lamivudine or emtricitabine + lopinavir/ritonavir.

ART and pregnancy

We have a section about taking ARVs in pregnancy and for women who want to become pregnant.