Rationale for Tenofovir as the First Choice in the First-Line Treatment of HIV

In its 2006 revision of the Guidelines on Antiretroviral Therapy for HIV Infection in Adults and Adolescents, the World Health Organization (WHO) recommended that countries begin planning to move away from stavudine (d4T)-containing regimens to avoid or minimize the risk of toxicity.  In the 2010 revision, WHO reinforced the need for countries to phase out stavudine-based regimens because of the drug’s long-term irreversible side effects. In its place, WHO suggests using zidovudine (AZT) or tenofovir (TDF)-based first-line regimens.

Of these two options, TDF, a nucleoside reverse transcriptase inhibitor, has a number of advantages:  it is well tolerated and requires minimal laboratory monitoring.   Further, the price of TDF has recently come down substantially. Several African countries adopted TDF as first-line therapy as early as 2007. According to WHO, almost all (97%) low- and middle-income countries are in compliance with the WHO recommendation to shift away from stavudine-containing regimens,  and around half have opted for a TDF-based first-line treatment of HIV.

This document summarises the advantages of using a TDF-based regimen when switching from stavudine (d4t), as well as when initiating adult antiretroviral therapy (ART).