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Comparative Study
. 2008 Oct 18;22(16):2117-25.
doi: 10.1097/QAD.0b013e328310407e.

Efavirenz versus nevirapine-based initial treatment of HIV infection: clinical and virological outcomes in Southern African adults

Jean B Nachega  1 , Michael Hislop, David W Dowdy, Joel E Gallant, Richard E Chaisson, Leon Regensberg, Gary Maartens
Affiliations
Comparative Study

Efavirenz versus nevirapine-based initial treatment of HIV infection: clinical and virological outcomes in Southern African adults

Jean B Nachega et al. AIDS. .

Abstract

Objective: To determine the effectiveness of efavirenz versus nevirapine in initial antiretroviral therapy regimens for adults in sub-Saharan Africa.

Design: Observational cohort study.

Methods: Study participants were 2817 HIV-infected, highly active antiretroviral therapy-naive adults who began nevirapine-based or efavirenz-based highly active antiretroviral therapy between January 1998 and September 2004 via a private-sector HIV/AIDS program in nine countries of southern Africa. The primary outcome was time to virologic failure (two measurements of viral loads >or=400 copies/ml). Secondary outcomes included all-cause mortality, time to viral load less than 400 copies/ml, pharmacy-claim adherence, and discontinuation of nevirapine or efavirenz without virologic failure.

Results: The median follow-up period was 2.0 years (interquartile range 1.2-2.6). Patients started on nevirapine were significantly less likely than those started on efavirenz to achieve high adherence, whether defined as 100% (30.2 versus 38.1%, P < 0.002) or more than 90% (44.8 versus 49.4%, P < 0.02) pharmacy-claim adherence. In a multivariate analysis, patients on nevirapine had greater risk of virologic failure [hazard ratio (HR 1.52; 95% confidence interval (CI) 1.24-1.86)], death (2.17; 1.31-3.60), and regimen discontinuation (1.67; 1.32-2.11). Switching from nevirapine to efavirenz had no significant virologic effect, whereas switching from efavirenz to nevirapine resulted in significantly slower time to suppression (hazard ratio 0.58, 95% confidence interval 0.35-0.93) and faster time to failure (hazard ratio 3.92; 95% confidence interval 1.61-9.55) than remaining on efavirenz.

Conclusion: In initial highly active antiretroviral therapy regimens, efavirenz was associated with superior virologic and clinical outcomes than nevirapine, suggesting that efavirenz might be the preferred nonnucleoside reverse transcriptase inhibitor in resource-limited settings. However, its higher cost and potential teratogenicity are important barriers to implementation.

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Conflict of interest statement

Conflict of interest

Consultant: R.E. Chaisson (Bristol-Myers Squibb). Consultant and/or honorarium: J.B. Nachega (GlaxoSmithKline, Merck-Sharp-Dohme) and G. Maartens (Merck-Sharp-Dohme). Grants received: G. Maartens (Merck-Sharp-Dohme). Other: J.B. Nachega (Aspen Pharmaceuticals); J.E. Gallant: Grants/Research Support (Gilead Sciences, GlaxoSmithKline, Merck, Pfizer, Roche, Tibotec), consultant and/or honorarium (Bristol Myers Squibb, Gilead Sciences, Roche, Abbott Laboratories, GlaxoSmithKline, Merck, Schering Plough, Pfizer, Tibotec).

Figures

Figure 1
Figure 1
Characterization of Study Participants
Figure 2
Figure 2
Time to Virologic Failure, by initial NNRTI and adherence
Figure 3
Figure 3
Time to Virologic Suppression, by Initial and Second NNRTI Regimen for patients who switched NNRTI regimen due to virologic failure. The x-axis shows time from initiation of current (either initial or second) NNRTI regimen, among patients with HIV virus loads >400 copies/mL at initiation of current NNRTI regimen
See this image and copyright information in PMC

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