Lack of Appropriate Treatment for People with Comorbid HIV/AIDS and Epilepsy in Sub‐Saharan Africa

Abstract

To the Editors: We would like to draw your readership's attention to an emerging problem in epilepsy care in resource poor settings, particularly for regions heavily impacted by the HIV/AIDS pandemic such as sub-Saharan Africa (SSA). Through the efforts of the Global Fund, the President's Emergency Plan for HIV/AIDS Relief (PEPFAR), and the World Health Organization's three by five initiative, people in southern Africa are now gaining access to antiretroviral (ART) agents. Access to ARTs for people in the SSA region has been long-awaited and is clearly a humanitarian necessity—not only to decrease the global morbidity and mortality of HIV/AIDS, but also to facilitate social, economic, and political stability and development in such regions. Triomune, which contains stavudine, lamivudine, and nevirapine (NVP), is the most common fixed-dose, combination provided. In reality, many public ART clinics in SSA have only Triomune routinely available. Second-line agents are not affordable or accessible, particularly in the rural areas. Unfortunately, for people in resource-limited setting with epilepsy who also require ART therapy, access to ARTs represents a mixed blessing. Phenobarbitone is the mainstay of treatment for people with epilepsy in SSA. NVP's half-life is substantially shortened by the use of such enzyme-inducing agents. Coadministration of Triomune with the older, enzyme-inducing anticonvulsants results in suboptimal levels of NVP (L'Homme et al., 2006), which will likely lead to NVP resistance and ART treatment failure (Nowak et al., 1997). Development of HIV resistance to NVP has a negative impact on the health of the person undergoing treatment as well as public health implications for the long-term efficacy of presently affordable ART regimens. Newer antiepileptic drugs (AEDs) without enzyme induction properties are at present virtually unavailable in the region. This evolving situation places people with comorbid epilepsy and HIV in resource-poor regions in an untenable situation—essentially for each of these conditions they have one treatment available, but combining the two treatment (Triomune + phenobarbitone) has serious potential adverse outcomes for the individual as well as major public health implications for the community at large. Whether epilepsy care providers and/or ART clinic staff are aware of this concerning situation is unclear. ART provision has been largely facilitated by the development of separate, stand-alone clinics, and exchange between HIV/AIDS and epilepsy healthcare providers in Africa may be quite limited despite the reality that both conditions are exceedingly common in SSA relative to other parts of the world. We believe this is a complex, urgent, and important issue that requires the consideration and attention of international groups such as the International League against Epilepsy, the World Health Organization, and UNAIDS. Recognized interactions between NVP and TB treatment regimens have resulted in the development of recommendations for and access to alternative ART regimens for individuals with HIV/AIDS and TB comorbidity (Moreno et al., 2006). Similar attention and consideration is needed for persons suffering from HIV/AIDS and epilepsy.