Antiretroviral Therapy in India (2025): Drugs, Indications, Contraindications, Mechanisms, and Prophylaxis (PEP/PrEP)

BACKGROUND: India has made major gains in HIV control, with nationwide scale-up of antiretroviral therapy (ART), routine viral load monitoring, and simplified dolutegravir-based regimens. Yet gaps persist in differentiated service delivery, drug-resistance surveillance, and prevention implementation (PEP/PrEP). OBJECTIVES: To provide a comprehensive, India-focused review of currently available antiretroviral drugs and fixed-dose combinations (FDCs), indications and contraindications for ART initiation, core mechanisms of action by class, regimen selection and monitoring, and detailed, practical guidance on HIV postexposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), with attention to 2024-2025 updates. METHODS: Narrative review of national guidance (NACO), WHO recommendations, and key implementation documents and peer-reviewed Indian literature (2018-2025), emphasizing policy-relevant updates and practical algorithms. KEY FINDINGS: DCGI approved TDF/FTC for PrEP; national technical guidance exists, but programmatic rollout remains uneven. Global prevention options expanded with FDA approval (June 2025) of twice-yearly injectable lenacapavir for PrEP. Indian availability will depend on future regulatory decisions and access arrangements. CONCLUSION: India's ART platform is strong and increasingly INSTI-based. Scaling PrEP, standardizing DTG-aligned PEP, fortifying viral load and resistance monitoring, and integrating long-acting prevention as it becomes available are the next priorities.