First-line antiretroviral therapy in Africa--how evidence-base are our recommendations?
According to the World Health Organization guidelines, a non-nucleoside reverse transcriptase inhibitor (NNRTI) along with two nucleoside reverse transcriptase inhibitors (NRTI) is the treatment of choice as first-line antiretroviral therapy. The results of the 2NN and different cohort studies performed in developed countries do not provide sufficient evidence by which to select between nevirapine and efavirenz as the first-line NNRTI for antiretroviral therapy in Africa. The current first-line NNRTI-containing antiretroviral therapy regimens used in Africa are certainly not ideal. Nevirapine interacts with rifampicin and therefore is not indicated in patients with tuberculosis. On the other hand, efavirenz should not be given to pregnant women. NNRTI-containing regimens may be less effective in women who received nevirapine monotherapy at delivery. Stavudine, used in the nucleoside backbone, may lead to lipoatrophy, lactic acidosis and polyneuritis. Zidovudine may cause serious anemia. Mainly because of cost considerations, the generic fixed-drug combination of nevirapine plus two NRTI seems at the moment to be the best choice. It is clear, however, that antiretroviral programs should not rely only on this combination for initial antiretroviral treatment. Most importantly, more HIV clinical trials need to be conducted in Africa, and African cohorts of patients on antiretroviral therapy need to be established in order to develop recommendations that are evidence based.
Colebunders
Robert
R
The Infectious Disease Institute, Faculty of Medicine, Makerere University, Kampala, Uganda. bcoleb@itg.be
Kamya
Moses R
MR
Laurence
John
J
Kambugu
Andrew
A
Byakwaga
Helen
H
Mwebaze
Patricia Songa
PS
Muganga
Alex Muganzi
AM
Katwere
Michael
M
Katabira
Elly
E
D000349:Africa; D000480:Alkynes; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D048588:Benzoxazines; D000075202:Contraindications; D003521:Cyclopropanes; D019317:Evidence-Based Medicine; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D019829:Nevirapine / Q000627:therapeutic use; D010078:Oxazines; D018894:Reverse Transcriptase Inhibitors / Q000627:therapeutic use*; D018119:Stavudine / Q000009:adverse effects; D015215:Zidovudine / Q000009:adverse effects
D000480:Alkynes; D019380:Anti-HIV Agents; D048588:Benzoxazines; D003521:Cyclopropanes; D010078:Oxazines; D018894:Reverse Transcriptase Inhibitors; D015215:Zidovudine; D019829:Nevirapine; D018119:Stavudine; C098320:efavirenz