Abstract
IntroductionRecent WHO guidelines for resource-limited settings recommend tenofovir in first-line antiretroviral therapy (ART) yet there are suggestions that patients receiving nevirapine with tenofovir have worse outcomes than those receiving efavirenz. We sought to compare outcomes among those taking nevirapine vs. efavirenz with tenofovir and lamivudine.MethodsWe analyzed data on ART naïve, non-pregnant patients, ≥18 years old without tuberculosis co-infection, initiating tenofovir with lamivudine and either nevirapine or efavirenz between April 1, 2010 and July 31, 2011 (when South Africa’s public-sector use of tenofovir began) at Themba Lethu Clinic in South Africa. We measured virologic suppression (viral load <400 copies/ml), virologic failure (2 consecutive viral loads >1000 copies/ml), and attrition (death/loss to follow-up) all at 12 months after ART initiation. Modified Poisson regression with robust error estimation was used to estimate risk ratios (RR) and 95% confidence intervals (CI) for predictors of each outcome.Results2,254 patients were prescribed efavirenz, 131 nevirapine. Patients were followed a median (range) of 12.0 (0.1–12.0) person-months. 62.2% were female and median (IQR) age was 37.7 years (31.5–44.1). Patients prescribed efavirenz had similar initiating CD4 counts (median 132 for both regimens) but were somewhat more likely to be WHO Stage III or IV (39.6% vs. 33.6%) than those prescribed nevirapine. No difference in attrition was found (aRR: 0.83; 95% CI: 0.49–1.41). Among patients with ≥1 viral load within 1 year on ART, those prescribed nevirapine were as likely to reach virologic suppression (aRR: 0.97; 95% CI: 0.88–1.07) but more likely to experience virologic failure (aRR: 1.84; 95% CI: 1.02–3.31) than those prescribed efavirenz.ConclusionsOur results support the notion that, among patients prescribed tenofovir and lamivudine, virologic failure is more common among those taking nevirapine than among those taking efavirenz. Longer-term follow up and larger studies will be needed to confirm this finding.
Highlights
Recent World Health Organization (WHO) guidelines for resource-limited settings recommend tenofovir in first-line antiretroviral therapy (ART) yet there are suggestions that patients receiving nevirapine with tenofovir have worse outcomes than those receiving efavirenz
In many resource-limited settings, until recently lamivudine (3TC), stavudine (d4T), and zidovudine (AZT) were the most common nucleoside reverse transcriptase inhibitor (NRTI) choices for first-line antiretroviral treatment (ART). [1,2] Due to the toxicities associated with AZT and d4T [3,4,5], the World Health Organization’s (WHO) 2010 adult treatment guidelines [6] recommend using tenofovir in first-line therapy
We used data from a large public-sector HIV treatment clinic in South Africa which initiated over 3,000 patients onto ART between April 2010 and July 2011 to assess whether rates of virologic suppression, virologic failure, and attrition over the first year on ART differed between patients taking nevirapine vs. efavirenz along with tenofovir and lamivudine
Summary
Recent WHO guidelines for resource-limited settings recommend tenofovir in first-line antiretroviral therapy (ART) yet there are suggestions that patients receiving nevirapine with tenofovir have worse outcomes than those receiving efavirenz. In many resource-limited settings, until recently lamivudine (3TC), stavudine (d4T), and zidovudine (AZT) were the most common nucleoside reverse transcriptase inhibitor (NRTI) choices for first-line antiretroviral treatment (ART). We used data from a large public-sector HIV treatment clinic in South Africa which initiated over 3,000 patients onto ART between April 2010 and July 2011 to assess whether rates of virologic suppression, virologic failure, and attrition over the first year on ART differed between patients taking nevirapine vs efavirenz along with tenofovir and lamivudine
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