First-Line ART Regimen Selection Pathway

Evidence-based HIV Treatment Initiation · v1.7
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How to use this tool: Enter the demographics, staging and baseline investigations. The tool returns a first-line ART regimen. Start ART rapidly in everyone testing positive, preferably within 7 days, unless a specific opportunistic infection needs stabilising first.
1. Patient Demographics & Vitals
2. Clinical & Laboratory Parameters
3. Disease Staging
Illness Scripts: Acute Retroviral Syndrome

Acute HIV infection often presents as a mononucleosis-like illness 2 to 4 weeks post-exposure. The clinical triad of fever, pharyngitis, and rash with mucocutaneous ulcers should raise suspicion.

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
1. Clinical Pearls & Caveats
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; never rechallenge (risk of 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)
Algorithm 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. DRV/r becomes the preferred boosted PI; supports reuse of TDF and ABC in subsequent regimens; long-acting injectable ART and oral two-drug regimens in defined circumstances; revised vertical transmission and TB preventive treatment guidance. NACO remains the operative source for Indian practice.]
  4. Venter WDF et al. N Engl J Med. 2019;381(9):803-815.
  5. NACO. National Technical Guidelines on ART. 2018 (Updated 2021).
How to Cite This Tool

AMA: Umakanth S. First-Line ART Regimen Selection Pathway. MEDiscuss. Published 2026. Accessed .

Vancouver: Umakanth S. First-Line ART Regimen Selection Pathway [Internet]. MEDiscuss.org; 2026 [cited ]. Available from:

Disclaimer and scope
Disclaimer: This decision-support system is intended for healthcare professionals. It does not substitute clinical judgment. These algorithms are evidence-based, but medical knowledge evolves continuously. The treating physician retains absolute responsibility for all diagnostic, dosing, and therapeutic decisions. Always verify outputs against current institutional protocols and individual patient contexts.
© 2026 MEDiscuss.org. All rights reserved. This CDSS Module was designed and developed by Dr. Shashikiran Umakanth using the available evidence base. 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: 8 August 2026
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