First-line Antiretroviral Therapy in Africa – How Evidence-based are our Recommendations?

According to the World Health Organization guidelines, a non-nucleoside reverse transcriptase inhibitor(NNRTI) along with two nucleoside reverse transcriptase inhibitors (NRTI) is the treatment ofchoice as first-line antiretroviral therapy. The results of the 2NN and different cohort studies performedin developed countries do not provide sufficient evidence by which to select between nevirapineand efavirenz as the first-line NNRTI for antiretroviral therapy in Africa. The current first-lineNNRTI-containing antiretroviral therapy regimens used in Africa are certainly not ideal. Nevirapineinteracts with rifampicin and therefore is not indicated in patients with tuberculosis. On the otherhand, efavirenz should not be given to pregnant women. NNRTI-containing regimens may be lesseffective in women who received nevirapine monotherapy at delivery. Stavudine, used in the nucleosidebackbone, may lead to lipoatrophy, lactic acidosis and polyneuritis. Zidovudine may cause seriousanemia. Mainly because of cost considerations, the generic fixed-drug combination of nevirapineplus two NRTI seems at the moment to be the best choice. It is clear, however, that antiretroviralprograms should not rely only on this combination for initial antiretroviral treatment. Most importantly,more HIV clinical trials need to be conducted in Africa, and African cohorts of patients onantiretroviral therapy need to be established in order to develop recommendations that are evidencebased.