Choice of initial antiretroviral drugs and treatment outcomes among HIV-infected patients in sub-Saharan Africa: systematic review and meta-analysis of observational studies

Abstract

BackgroundThe effectiveness of antiretroviral therapy (ART) depends on the choice of regimens during initiation. Most evidences from developed countries indicated that there is difference between efavirenz (EFV) and nevirapine (NVP). However, the evidences are limited in resource poor countries particularly in Africa. Thus, this systematic review and meta-analysis was carried out to summarize reported long-term treatment outcomes among people on first line therapy in sub-Saharan Africa.MethodsObservational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio to compare risk of treatment failure among HIV/AIDS patients who initiated ART with EFV versus NVP were systematically searched. Searches were conducted using the MEDLINE database within PubMed, Google Scholar, HINARI, and Research Gates between 2007 and 2016. Information was extracted using standardized form. Pooled risk ratios (RR) and 95% confidence intervals (CI) were calculated using random-effect, generic inverse variance method.ResultA total of 6394 articles were identified, of which, 29 were eligible for review and abstraction in sub-Saharan Africa. Seventeen articles were used for the meta-analysis. Of a total of 121,092 independent study participants, 76,719 (63.36%) were females. Of these, 40,480 (33.43%) initiated with NVP containing regimen. Two studies did not report the median CD4 cell counts at initiation. Patients who have low CD4 cell counts initiated with EFV containing regimen. The pooled effect size indicated that treatment failure was reduced by 15%, 0.85 (95%CI: 0.75–0.98), and non-nucleoside reverse transcriptase inhibitor (NNRTI) switch was reduced by 43%, 0.57 (95%CI: 0.37–0.89).ConclusionThe risk of treatment failure and NNRTI switch were lower in patients who initiated with EFV than NVP-containing regimen. The review suggests that initiation of patients with EFV-containing regimen will reduce treatment failure and NNRTI switch.Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-017-0567-7) contains supplementary material, which is available to authorized users.

Concomitant nevirapine impacts pharmacokinetic exposure to the antimalarial artemether-lumefantrine in African children

“…Most recent WHO guidelines recommend the use of LPV/r -based ART in children under 3 years of age and efavirenz-based ART in those above 3 years of age, with NVP-based ART as an alternate regimen[ 6 ]. However, due to delayed uptake and availability, NVP use in Africa remains high[ 30 , 31 ]. Thus it remains important to ensure the proper use of antimalarials in the context of NVP treatment.…”

The Clinical Implications of Pretreatment Drug Resistance—A Moving Target

“…Judged within the context of previous studies, including the 2 studies in which TDF/FTC/EFV was used for initial therapy [8,16], the study by Derache and colleagues suggests that the point estimate of the risk of VF with NNRTIassociated PDR in persons receiving this regimen is lower than estimates based on other regimens. Indeed, several lines of evidence suggest that the TDF/FTC/EFV combination is more efficacious than other first-line WHO-recommended NRTI/NNRTI combinations, particularly when administered as a fixed-dose combination [19][20][21][22][23]. A specific advantage of this combination is the similar half-lives of its components, making it less likely for resistance to emerge when doses are missed.…”

Antiretroviral switching and bedaquiline treatment of drug-resistant tuberculosis HIV co-infection

“…16,19 There was a reported pooled estimate of 15% increased risk of virological failure in another meta-analysis. 20 Neviripine has a more severe side-effect profile (rash and hepatotoxicity) 21,22 and has been associated with an increased risk for ART discontinuation.…”