Cheaper HIV Treatment Could Be Effective

Some children infected with HIV despite exposure to nevirapine during antiretroviral prophylaxis can achieve better viral suppression under a nevirapine-based therapy than a protease inhibitor-based therapy, a new study in South Africa has shown. As a bonus, nevirapine costs about one fifth as much as PI-based regimens. Besides costing less, nevirapine also does not require the refrigeration needed by the liquid pediatric formula of ritonavir-boosted lopinavir, stavudine, and lamivudine, which is described as foul-tasting.

In the trial, all 195 nevirapine-exposed children had already achieved viral suppression of less than 400 for three or more months on a PI-based regimen initiated before 24 months of age. The children were randomized either to switch to a nevirapine-based therapy (switch group) or continue the ritonavir-boosted regimen. All were followed up for 52 weeks.

About two thirds of the switch group achieved viral loads of less than 50, and many did better than those on the more expensive PI-based therapy. Fewer of the children who were switched to nevirapine had viral loads of more than 50 than was the case in the control group. Confirmed viremia greater than 1,000 occurred more frequently in the switch group than in the control group. However, median CD4-cell percentage was better in the switch group at 52 weeks.

The study did not determine whether nevirapine was more effective or merely more palatable, thus boosting adherence. Nonetheless, "this allows treatment options for children to be expanded," says study coauthor Louise Kuhn, an epidemiology professor at Columbia University's Mailman School of Public Health. The team recommends monitoring viral loads and returning to the PI-based therapy if necessary.

The full report, "Reuse of Nevirapine in Exposed HIV-Infected Children After Protease Inhibitor-Based Viral Suppression," was published in the Journal of the American Medical Association (2010;304(10):1082-1090).