Outcomes for Efavirenz versus Nevirapine-Containing Regimens for Treatment of HIV-1 Infection: A Systematic Review and Meta-Analysis

Abstract

IntroductionThere is conflicting evidence and practice regarding the use of the non-nucleoside reverse transcriptase inhibitors (NNRTI) efavirenz (EFV) and nevirapine (NVP) in first-line antiretroviral therapy (ART).MethodsWe systematically reviewed virological outcomes in HIV-1 infected, treatment-naive patients on regimens containing EFV versus NVP from randomised trials and observational cohort studies. Data sources include PubMed, Embase, the Cochrane Central Register of Controlled Trials and conference proceedings of the International AIDS Society, Conference on Retroviruses and Opportunistic Infections, between 1996 to May 2013. Relative risks (RR) and 95% confidence intervals were synthesized using random-effects meta-analysis. Heterogeneity was assessed using the I2 statistic, and subgroup analyses performed to assess the potential influence of study design, duration of follow up, location, and tuberculosis treatment. Sensitivity analyses explored the potential influence of different dosages of NVP and different viral load thresholds.ResultsOf 5011 citations retrieved, 38 reports of studies comprising 114 391 patients were included for review. EFV was significantly less likely than NVP to lead to virologic failure in both trials (RR 0.85 [0.73–0.99] I2 = 0%) and observational studies (RR 0.65 [0.59–0.71] I2 = 54%). EFV was more likely to achieve virologic success than NVP, though marginally significant, in both randomised controlled trials (RR 1.04 [1.00–1.08] I2 = 0%) and observational studies (RR 1.06 [1.00–1.12] I2 = 68%).ConclusionEFV-based first line ART is significantly less likely to lead to virologic failure compared to NVP-based ART. This finding supports the use of EFV as the preferred NNRTI in first-line treatment regimen for HIV treatment, particularly in resource limited settings.

Paediatric European Network for Treatment of AIDS (PENTA) guidelines for treatment of paediatric HIV‐1 infection 2015: optimizing health in preparation for adult life

“…As seen in adult studies 77, two recent retrospective paediatric cohort studies, in resource‐limited and resource‐rich settings, comparing EFV and NVP showed that EFV was associated with superior virological outcomes 78 73, although in the UK/Ireland CHIPS cohort, the benefit of EFV‐based regimens over NVP‐based regimens in terms of virological failure was very modest after 2 years of therapy 73. In the ARROW trial, a nonrandomized comparison of NNRTI‐ based regimens showed favourable short‐term VL suppression with EFV; however, long‐term suppression depended on age, and was better with EFV in children aged < 10 years, and with NVP in those aged > 10 years 79.…”

Low-Frequency Drug Resistance in HIV-Infected Ugandans on Antiretroviral Treatment Is Associated with Regimen Failure

“…Initiating cART earlier in disease is obviously beneficial to patient outcome, but only if the patient remains adherent to the cART with full viral suppression (61). Full viral suppression on first-line cART is achieved in Ͼ85% of treatmentnaive HIV-infected individuals/year in HICs (62)(63)(64), but in LMICs, these rates are less than 80% per year (64)(65)(66). Antiretroviral treatment failure is largely due to poor adherence in subSaharan Africa, but purely behavior-based decisions to stop medications are rare, and with access to medication, adherence rates are similar to those in HICs (64,66).…”

“…Full viral suppression on first-line cART is achieved in Ͼ85% of treatmentnaive HIV-infected individuals/year in HICs (62)(63)(64), but in LMICs, these rates are less than 80% per year (64)(65)(66). Antiretroviral treatment failure is largely due to poor adherence in subSaharan Africa, but purely behavior-based decisions to stop medications are rare, and with access to medication, adherence rates are similar to those in HICs (64,66). Thus, poor adherence in LMICs is generally related to limited access to clinical centers, high travel costs, intermittent antiretroviral drug supply, and interruptions of funding programs that provide cART (67).…”

Challenges Associated with Management of Buruli Ulcer/Human Immunodeficiency Virus Coinfection in a Treatment Center in Ghana: A Case Series Study

“…Studies have shown that taking ART containing nevirapine alongside SR treatment leads to a decreased C max and C min of nevirapine due to interaction with rifampicin. [48][49][50] This notwithstanding, early onset of ART and co-trimoxazole prophylaxis is highly recommended by WHO preliminary guidelines for management of HIV/BU coinfection 51 to build up immunity and to fight opportunistic infections associated with HIV as these could worsen the prognosis of the condition. Here 4/7 BU/HIV coinfected patients did not start with ART treatment within the study period because of unavailability of an ART center within or close to the study center.…”