Topics / Medical / HIV and related conditions

Summary TLD is the new first line regime in South Africa. However, patients that are on different regimes need to have a recent viral load (within the last 6 months) and a viral load < 1000. Dolutegravir has several benefits such as rapid viral suppression, a high genetic barrier to resistance, no interactions with hormonal contractives and very mild side effects. The main side effects include insomnia, headache and gastrointestinal disturbances. Drug-Drug interaction with Metformin, Rifampicin and anti-epileptics is very important.

Basics

Benefits: (1) rapid viral suppression (2) high genetic barrier to resistance (3) no interactions with hormonal contraceptives (4) mild/uncommon side effects.
Side Effects: You should tell the patient about the new side effects that they might experience from Dolutegravir, such as: Insomnia, headache, gastrointestinal disturbances. Dolutegravir has a very low risk of neural tube defects if take during conception or the first 6 weeks of pregnancy.
Drug-Drug Interactions: It has very important drug-drug interactions, the most important being with TB-treatment (Rifampicin), Diabetes treatment (Metformin) and the anti-epileptics to name a few.
Patients should NOT be switched if a viral load is ≥ 1000
If the viral load has not been performed in the last 6 months, then you can wait for the next routine viral load to assess if the patient is a candidate for the switch.
In Summary, only switch to Dolutegravir (DTG) if the patient has a viral load < 1000 AND if they have a recent viral load done (within 6 months).
Remember that children have different regimes, hence once the patient reaches the correct weight and age one should aim to switch their regime to the appropriate one.
Of note, patients with a non-standard second line regime such as TDF + 3TC/FTC + LPV/r OR ABC + 3TC + LPV/r should also not be switched.

Viral load < 50	Regime	New Regime
	TDF+(FTC or 3TC)+(EFV or NVP)	TLD
	(AZT or ABC) + 3TC + (EFV or NVP)	(AZT or ABC) + 3TC + DTG
	AZT + 3TC+(LPV/r or ATV/r)	AZT + 3TC + DTG
Viral Load 50 – 999	Find out why the patient might be having an elevated viral load. Provide adherence counseling. Then repeat the viral load in 3 months time. If the new viral load is < 1000 then you may switch the patient to DLT. However, if the patient’s next viral load is ≥ 1000 then do not switch the patient. Read the article on Adherence counseling to find out what to do in response to this viral load.
Viral load ≥ 1000	Do not switch these patients. Provide them with adherence counseling.

NRTI: Dolutegravir (TLD), Emtricitabine (FTC), Lamivudine (3TC), Abacavir (ABC), Zidovudine (AZT)
NNRTI: Efavirenz(EFV), Nevirapine (NVP)
Protease Inhibitors: Lopinavir/Ritonavir (LPV/r), Atazanavir/Ritonavir (ATV/r)
Integrase Inhibitors: Dolutegravir (DTG)

Further Reading 1. 2019 ART Clinical Guidelines - March 2020 updates

Published on 19 August 2022