A 32-year-old man with newly diagnosed HIV-1 infection (CD4 count 350 cells/μL, viral load 150,000 copies/mL) presents to the antiretroviral clinic. He has no prior antiretroviral exposure and no contraindications to standard therapy. Which of the following is the preferred first-line integrase strand transfer inhibitor (INSTI)-based regimen in India?

Explanation

## First-Line INSTI-Based Regimen in HIV-1 **Key Point:** Dolutegravir (DTG) is the preferred integrase inhibitor in first-line regimens globally and in India due to superior potency, barrier to resistance, and tolerability. ### Why Dolutegravir is Preferred **High-Yield:** Dolutegravir has: - Highest genetic barrier to resistance among INSTIs - Excellent CNS penetration - Minimal drug interactions - Once-daily dosing (50 mg) - Superior virological suppression rates (>95% at 48 weeks) - Pregnancy-safe (no teratogenicity in animal studies; human data reassuring) ### Recommended Backbone with DTG **Clinical Pearl:** The standard backbone is **tenofovir disoproxil fumarate (TDF) + lamivudine (3TC)** or **tenofovir alafenamide (TAF) + 3TC**. TDF + 3TC remains the most widely used and cost-effective in India. ### Comparison of INSTIs in First-Line | INSTI | Dosing | Barrier to Resistance | Drug Interactions | Preferred? | |-------|--------|----------------------|-------------------|------------| | Dolutegravir | 50 mg OD | High | Minimal | **Yes** | | Raltegravir | 400 mg BD | Moderate | Moderate | No (BD dosing) | | Elvitegravir | 150 mg OD | Moderate | High (needs cobicistat) | No | | Bictegravir | 50 mg OD | High | Minimal | Emerging (newer) | **Mnemonic:** **DTG-TDF-3TC** = **"Dolutegravir is The Gold standard"** — the preferred first-line INSTI regimen. ### Guideline Basis **High-Yield:** WHO 2023, DHHS (US), and Indian National AIDS Control Organization (NACO) guidelines all recommend DTG-based regimens as first-line for treatment-naive patients with CD4 >50 cells/μL. [cite:Harrison 21e Ch 197]