title: Stavudine toxicity in adult longer-term ART patients in Blantyre, Malawi.
abstract: BACKGROUND
  Stavudine is an effective and inexpensive antiretroviral drug, but no longer recommended by WHO for first-line antiretroviral regimens in resource-limited settings due to toxicity concerns. Because of the high cost of alternative drugs, it has not been feasible to replace stavudine in most adults in the Malawi ART programme. We aimed to provide policy makers with a detailed picture of stavudine toxicities in Malawians on longer-term ART, in order to facilitate prioritization of stavudine replacement among other measures to improve the quality of ART programmes.
  
  
  METHODS
  Prospective cohort of Malawian adults who had just completed one year of stavudine containing ART in an urban clinic, studying peripheral neuropathy, lipodystrophy, diabetes mellitus, high lactate syndromes, pancreatitis and dyslipidemia during 12 months follow up. Stavudine dosage was 30 mg irrespective of weight. Cox regression was used to determine associations with incident toxicities.
  
  
  RESULTS
  253 patients were enrolled, median age 36 years, 62.5% females. Prevalence rates (95%-confidence interval) of toxicities after one year on stavudine were: peripheral neuropathy 21.3% (16.5-26.9), lipodystrophy 14.7% (2.4-8.1), high lactate syndromes 0.0% (0-1.4), diabetes mellitus 0.8% (0-2.8), pancreatitis 0.0% (0-1.5). Incidence rates per 100 person-years (95%-confidence interval) during the second year on stavudine were: peripheral neuropathy 19.8 (14.3-26.6), lipodystrophy 11.4 (7.5-16.3), high lactate syndromes 2.1 (0.7-4.9), diabetes mellitus 0.4 (0.0-1.4), pancreatitis 0.0 (0.0-0.2). Prevalence of hypercholesterolemia and hypertriglyceridemia increased from 12.1% to 21.1% and from 29.5% to 37.6% respectively between 12 and 24 months. 5.5% stopped stavudine, 1.3% died and 4.0% defaulted during follow up. Higher age was an independent risk factor for incident peripheral neuropathy and lipodystrophy.
  
  
  CONCLUSIONS
  Stavudine associated toxicities continued to accumulate during the second year of ART, especially peripheral neuropathy and lipodystrophy and more so at increasing age. Our findings support investments for replacing stavudine in first-line regimens in sub-Saharan Africa.
authors: Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi. joepvanoosterhout@gmail.com
authors: Joep J
authors: JJ
authors: van Oosterhout
authors: Jane
authors: J
authors: Mallewa
authors: Symon
authors: S
authors: Kaunda
authors: Newton
authors: N
authors: Chagoma
authors: Yassin
authors: Y
authors: Njalale
authors: Elizabeth
authors: E
authors: Kampira
authors: Mavuto
authors: M
authors: Mukaka
authors: Robert S
authors: RS
authors: Heyderman
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008295:Malawi; D008297:Male; D008875:Middle Aged; D011640:Public Policy; D012307:Risk Factors; D018119:Stavudine / Q000009:adverse effects*; D013997:Time Factors
chemical_list: D019380:Anti-HIV Agents; D018119:Stavudine