Applying National Guidelines on ART - Second and Later Regimens

Authors: David Spencer, MD; Mark Nelson, MA, MBBS, FRCP
Editor In Chief: Ian M. Sanne, MBBCH, FCP(SA) (More Info)

Last Reviewed: July 8, 2016 (What's New)

Credit Information

inPractice® Africa’s Continuing Education Unit (CEU) provider, the South African Medical Association, offers physicians 3 CPD points on a 70% pass rate for completing this individual module. Nonphysicians who successfully complete the module will receive a participation certificate. To learn more on CPD credits and participation certificates, click here.


Africa bears the brunt of the HIV pandemic, with prevalence rates particularly high at the southern tip of the subcontinent. Nearly 40% of antenatal women in the South African province of KwaZulu Natal are HIV seropositive,[ZA NDOH Antenatal 2012] and rates among young women in some of the subdistricts exceed 50%.[Welz 2007; Nel 2012] Prevalence is also high in countries adjacent to South Africa, including Zimbabwe, Swaziland, Botswana, and Lesotho.[UNAIDS AIDSinfo 2015] Antiretroviral therapy (ART) has been remarkably successful in reducing HIV disease burden, even in resource-limited regions.[Bartlett 2009] More than 13.6 million people with HIV in low- and middle-income countries were receiving ART at the end of 2014,[WHO ART Coverage 2015] although many continue to succumb to HIV infection. Accessibility, availability, and affordability are barriers—particularly to the poor, the uneducated, the very young, the elderly, the rural, and informal township dwellers. Help is often sought late when CD4+ cell counts are low and infection is at an advanced stage.[Bartlett 2009] For many, stigma, denial, disbelief, and fear continue to present an obstacle to HIV testing and treatment. Even when the diagnosis is known, as many as 25% of patients are lost to follow-up.[Gardner 2011] Of those who access ART, many (5% to 24%) experience treatment failure within 1-2 years of starting medication.[Marconi 2008; Gupta 2012]

The recommended first-line ART regimen in South Africa is the fixed-dose combination (FDC) of tenofovir/emtricitabine/efavirenz (Management Guidelines).[ZA NDOH HIV Tx 2015] The principal causes of treatment failure may include lack of efficacy related to toxicity of the regimen and virologic failure related to development of resistance. Antiretroviral substitutions for toxicity in virologically suppressed patients are covered in the chapter “Starting Adult Patients on Antiretroviral Therapy in South Africa.” This chapter will primarily cover management of virologic failure of the first-line regimen, development of HIV resistance, and the management of later lines of ART.

For additional information on first-line ART in South Africa, click here.