First-Line ART Selection

The first-line regimen for this adult, with the renal, anaemia and coinfection changes · v1.7
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  • Enter the age and weight, the renal function, the pregnancy status and any co-infection.
  • Add the CD4 band and the WHO clinical stage, and the haemoglobin where zidovudine comes into question.
  • You get a first-line regimen, the drug pearls that go with it, and the baseline investigations checklist.
  • Advanced HIV disease raises an amber notice to screen for cryptococcal disease and tuberculosis before ART begins.
  • Copy Results to EMR puts the regimen and the handover summary on the clipboard.

  • Children below 10 years and anyone below 30 kg, which the age and weight fields refuse, and paediatric dosing of any kind.
  • Second-line switching, and the regimen choice after resistance testing.
  • Treatment of the opportunistic infections it says to screen for. It names the screen and refers onward.
  • A reduced dose for renal impairment. Below a creatinine clearance of 50 mL/min it changes the backbone instead, because the components of a fixed-dose combination cannot be adjusted separately.
1. Patient Demographics & Vitals
2. Clinical & Laboratory Parameters
3. Disease Staging

1. Acute Retroviral Syndrome

Acute HIV infection often presents as a mononucleosis-like illness 2 to 4 weeks after exposure. Fever, pharyngitis and a rash with mucocutaneous ulcers together are the presentation to recognise, and the antibody test may still be negative at that point.

Acute HIVEBV MonoSecondary Syphilis
Fever, non-exudative pharyngitis, generalised tender lymphadenopathy Exudative pharyngitis, profound fatigue, atypical lymphocytes Maculopapular rash (palms/soles), condylomata lata
Maculopapular rash (trunk/face); mucocutaneous ulcers (highly specific) Hepatosplenomegaly; rash after Ampicillin Painless lymphadenopathy; history of painless chancre
High HIV RNA VL; antibody tests may be negative (window period) Positive Monospot; EBV VCA IgM positive Positive VDRL/RPR and TPHA

2. Four Cautions Around Starting ART

IRIS: Starting ART with undiagnosed OIs can trigger paradoxical worsening. Delay ART: 4 to 6 weeks for Cryptococcal Meningitis; 2 to 8 weeks for TB Meningitis. Do not delay for pulmonary TB.
Rifampicin-DTG Interaction: Rifampicin lowers DTG trough levels by ~54%. Must add DTG 50mg BD (extra dose 12 hours after TLd). Continue for 2 weeks post-Rifampicin.
ABC Hypersensitivity: Multi-organ reaction linked to HLA-B*5701. Fever, rash, GI symptoms, respiratory distress within first 6 weeks. Stop immediately, and never rechallenge: the risk is fatal anaphylaxis.
DTG and Weight Gain: Associated with excess weight gain, particularly in women and patients of African descent. Monitor fasting glucose and lipid profile.
Abbreviations ABC (Abacavir) · AHD (Advanced HIV Disease) · ALT (Alanine Aminotransferase) · ART (Antiretroviral Therapy) · ARV (Antiretroviral) · AST (Aspartate Aminotransferase) · AZT (Zidovudine) · BD (Twice Daily) · CBC (Complete Blood Count) · CD4 (Cluster of Differentiation 4) · CNS (Central Nervous System) · CPK (Creatine Phosphokinase) · CrAg (Cryptococcal Antigen) · CrCl (Creatinine Clearance) · CSF (Cerebrospinal Fluid) · DTG (Dolutegravir) · EBV (Epstein-Barr Virus) · EFV (Efavirenz) · FDC (Fixed-Dose Combination) · GI (Gastrointestinal) · Hb (Haemoglobin) · HBsAg (Hepatitis B Surface Antigen) · HBV (Hepatitis B Virus) · HIV (Human Immunodeficiency Virus) · HLA (Human Leucocyte Antigen) · HSR (Hypersensitivity Reaction) · IgM (Immunoglobulin M) · INSTI (Integrase Strand Transfer Inhibitor) · IRIS (Immune Reconstitution Inflammatory Syndrome) · LAM (Lipoarabinomannan) · LP (Lumbar Puncture) · NACO (National AIDS Control Organisation) · NSAID (Non-Steroidal Anti-Inflammatory Drug) · NTD (Neural Tube Defect) · OD (Once Daily) · OI (Opportunistic Infection) · PI (Protease Inhibitor) · PLHIV (People Living with HIV) · RNA (Ribonucleic Acid) · RPR (Rapid Plasma Reagin) · SBAR (Situation, Background, Assessment, Recommendation) · TAF (Tenofovir Alafenamide) · TB (Tuberculosis) · TDF (Tenofovir Disoproxil Fumarate) · TLd (Tenofovir + Lamivudine + Dolutegravir) · TMP-SMX (Trimethoprim-Sulfamethoxazole) · TPHA (Treponema pallidum Haemagglutination Assay) · VCA (Viral Capsid Antigen) · VDRL (Venereal Disease Research Laboratory) · VL (Viral Load) · WBC (White Blood Cell) · WHO (World Health Organization) · 3TC (Lamivudine)
References
  1. NACO. National Guidelines for HIV Care and Treatment. MoHFW, GoI; 2021.
  2. WHO. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring. 2021.
  3. World Health Organization. WHO updated recommendations on HIV clinical management: recommendations for a public health approach. Geneva: WHO; 7 January 2026. [First substantial revision since 2021.
  4. Venter WDF, Moorhouse M, Sokhela S, et al. Dolutegravir plus two different prodrugs of tenofovir to treat HIV. N Engl J Med. 2019;381(9):803-815. doi:10.1056/NEJMoa1902824.
  5. NACO. National Technical Guidelines on ART. 2018 (Updated 2021).
  6. Zash R, Holmes L, Diseko M, et al. Neural-tube defects and antiretroviral treatment regimens in Botswana. N Engl J Med. 2019;381(9):827-840. doi:10.1056/NEJMoa1905230.
  7. ViiV Healthcare. Lamivudine and Zidovudine Tablets: US prescribing information, section 8.6, Renal Impairment. [The fixed-dose combination is not recommended below a creatinine clearance of 50 mL/min, because the dose of the individual components cannot be adjusted in a fixed-dose combination. This is the source of the renal dosing alert.]
  8. Central TB Division, Ministry of Health and Family Welfare, Government of India. Co-trimoxazole prophylactic therapy in persons with HIV and TB coinfection. NTEP Knowledge Base. https://ntep.in/node/3276 [Cotrimoxazole at a CD4 below 350, or for any person with pulmonary or extra-pulmonary TB whatever the CD4, at 960 mg once daily.]
  9. Ford N, Meintjes G, Calmy A, et al. Managing advanced HIV disease in a public health approach. Clin Infect Dis. 2018;66(suppl 2):S106-S110. doi:10.1093/cid/cix1139.
How to Cite This Tool

DOIhttps://doi.org/10.5281/zenodo.22401590

AMA Style:Umakanth S. First-Line ART Selection. Version 1.7. MEDiscuss Clinical Decision Support System. Published 2026. Accessed . https://mediscuss.org/cdss/hiv-first-line-art. doi:10.5281/zenodo.22401590

Vancouver Style:Umakanth S. First-Line ART Selection [Internet]. Version 1.7. MEDiscuss.org; 2026 [cited ]. Available from: https://mediscuss.org/cdss/hiv-first-line-art. doi:10.5281/zenodo.22401590

Disclaimer and scope
Disclaimer: This decision-support system is written for healthcare professionals. It does not substitute clinical judgment, and the treating physician retains absolute responsibility for every diagnostic, dosing and therapeutic decision. The algorithms are built on the evidence as it stands, and the evidence moves. Verify the output against your current institutional protocol, and against the patient in front of you.
© 2026 MEDiscuss.org. All rights reserved. Provided free of charge for clinical use. Unauthorised reproduction or redistribution is strictly prohibited.
Category Therapeutic & Management PathwaysPathway
Specialties Internal Medicine, Infectious Diseases, HIV Medicine

Written and maintained by

Dr Shashikiran Umakanth

Last revised 24 August 2026

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