HAART according to Nepal guidelines
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Nepal national antiretroviral therapy HAART guidelines 2023 2024
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HAART According to Nepal National HIV Testing and Treatment Guidelines 2022
(Source: Nepal National HIV Testing and Treatment Guidelines, Ministry of Health and Population, 2022)
When to Start ART
Nepal follows a "Treat All" policy - ART is offered to all HIV-positive individuals regardless of CD4 count or WHO clinical stage, including:
- All adults and adolescents
- All pregnant and breastfeeding women (regardless of CD4/staging)
- All children under 5 years
- All HIV-TB co-infected patients
- All patients with advanced HIV disease
Key principle: ART MUST BE STARTED EVEN IF LAB REPORTS ARE AWAITED
First-Line ART Regimens
Nepal transitioned to dolutegravir (DTG)-based regimens as first-line in 2020, following WHO recommendations and national pre-treatment drug resistance (PDR) data showing >10% NNRTI resistance.
Adults, Adolescents, Pregnant & Breastfeeding Women
| Category | Preferred | Alternative |
|---|---|---|
| Adults / Adolescents / Pregnant or Breastfeeding | TDF + 3TC + DTG | ABC + 3TC + DTG |
| AZT + 3TC + DTG | ||
| TDF + 3TC + EFV |
TDF + 3TC + DTG (also called TLD) is the national preferred backbone given its: high efficacy, rapid viral load suppression, high genetic barrier to resistance, and favorable side-effect profile.
Second-Line ART Regimens
For patients failing first-line DTG-based regimens, a boosted protease inhibitor (PI/r) should be used.
Adults, Adolescents, Pregnant & Breastfeeding Women
| Failing First-Line | Preferred Second-Line | Alternative Second-Line |
|---|---|---|
| TDF + 3TC + EFV | AZT + 3TC + DTG | AZT + 3TC + ATV/r (or LPV/r or DRV/r) |
| TDF + 3TC + DTG | AZT + 3TC + ATV/r or LPV/r | TDF + 3TC + ATV/r or LPV/r |
| ABC + 3TC + DTG | AZT + 3TC + DRV/r | TDF + 3TC + DRV/r |
| AZT + 3TC + DTG | TDF + 3TC + ATV/r (or LPV/r) |
Boosted PIs used: Atazanavir/ritonavir (ATV/r), Lopinavir/ritonavir (LPV/r), Darunavir/ritonavir (DRV/r)
Note: Effective contraception should be offered to women/adolescent girls of childbearing potential on DTG-containing second-line regimens.
TLD Transition Plan
Nepal has a national plan to transition all patients on:
- NVP-based regimens (6,182 patients) → DTG-based
- EFV-based regimens (10,952 patients) → DTG-based
Routine viral load monitoring is encouraged but VL testing is NOT a mandatory prerequisite for transitioning to an optimal regimen. If VL report is >12 months old in stable patients, VL testing should be done before regimen change.
Pediatric ART
- All children < 5 years: Start ART immediately regardless of CD4 or clinical stage
- Children ≥ 5 years: Treat All, same as adults
- Regimens are weight-band based (LPV/r-containing in younger children; ABC/3TC/DTG or TDF/3TC/DTG as age-appropriate)
Special Populations
Pregnant & Breastfeeding Women
- Nepal adopted Option B+ (2014): lifelong ART for all HIV-positive pregnant women regardless of CD4 count
- Preferred regimen: TDF + 3TC + DTG (with counseling on small neural tube defect risk in periconception period; effective contraception recommended)
TB-HIV Co-infection
- ART should be started within 2-8 weeks of TB treatment initiation (regardless of CD4 count)
- For those with CD4 <50 cells/mm³: start ART within 2 weeks
- Preferred ART with rifampicin-based TB treatment: TDF + 3TC + EFV (DTG dose adjustment may be required with rifampicin)
Advanced HIV Disease
- CD4 <200 cells/mm³ or WHO Stage 3/4
- Rule out TB and cryptococcal meningitis before rapid ART initiation
- Start co-trimoxazole prophylaxis for CD4 ≤350 cells/mm³ OR clinical Stage 3/4
Prophylaxis
- Co-trimoxazole preventive therapy (CPT): CD4 ≤350 cells/mm³, or WHO Stage 3/4, or any CD4 in high-prevalence malaria/severe bacterial infection settings
- INH preventive therapy (IPT): All PLHIV after excluding active TB
- Fluconazole prophylaxis: For cryptococcal antigen (CrAg)-positive patients before ART
Monitoring on ART
| Test | Timing |
|---|---|
| Viral Load (VL) | At 6 months after ART initiation, then at 12 months, then every 12 months |
| CD4 count | At baseline; less emphasis once VL monitoring available |
| Adherence assessment | Every visit |
Treatment failure is defined primarily by virological failure: VL >1000 copies/mL on two consecutive measurements 3 months apart despite adherence support.
Drug Abbreviations Reference
| Abbreviation | Drug |
|---|---|
| TDF | Tenofovir disoproxil fumarate |
| 3TC | Lamivudine |
| DTG | Dolutegravir |
| ABC | Abacavir |
| AZT | Zidovudine |
| EFV | Efavirenz |
| NVP | Nevirapine |
| ATV/r | Atazanavir/ritonavir |
| LPV/r | Lopinavir/ritonavir |
| DRV/r | Darunavir/ritonavir |
| FDC | Fixed-dose combination |
Source: Nepal National HIV Testing and Treatment Guidelines 2022, Ministry of Health and Population, Government of Nepal. The guidelines align closely with WHO 2021 consolidated HIV treatment guidelines and represent the most current national standard as of 2022.
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