ARV switch fine for infants
The study confirmed that once tests confirmed that the infants’ immune system had successfully suppressed the HI Virus on the more expensive PI regimen, the child could be safely switched to the more affordable nevirapine based regimen. In fact the study showed slightly better outcomes in the children who were switched compared to those who remained on the PI regimen.
The main advantage of the study published in this week’s JAMA was that Protease Inhibitors (PI) prescribed to children are expensive while nevirapine is more affordable and could lead to more children accessing sustainable treatment, especially in sub-Saharan Africa.
“This is because in several parts of Africa where PIs are not on their guidelines, they would start nevirapine which would likely fail. This option could allow for limited use of a PI prior to switching onto the nevirapine-based regime, thereby making it safe and sustainable,” said lead researcher Professor Ashraf Coovadia at the University of Witwatersrand.
Up to now children exposed to nevirapine were given expensive protease inhibitors as researchers were unsure whether they could switch them amid concerns around resistance to nevirapine as a result of prior exposure to this drug when used as part of the prevention of mother to child HIV transmission(PMTCT) programme.
Current guidelines for nevirapine-exposed (at birth) infants advise that treatment be initiated with regimens based on ritonavir-boosted lopinavir (PI).
There are many limitations of continuing to use these PI-based regimens indefinitely in young children, including its unpleasant taste, concerns about metabolic toxicities with long-term use during critical periods of child development, the complexity of concomitant TB treatment and high cost – a major disincentive in sub-Saharan Africa.
The South African researchers in collaboration with researchers at the University of Columbia in New York, found that there was complete suppression of the HI-Virus in the group that switched to nevirapine.
Guidelines now recommend starting treatment among all HIV-infected infants as soon as possible after diagnosis following another South African trial (CHER study) demonstrating better outcomes if treatment is initiated immediately irrespective of disease stage rather than waiting.
This means large numbers of HIV-infected infants should be initiating ritonavir-boosted lopinavir-based treatment, but the high cost of this regimen poses a barrier in many low-resource settings.
“Our results suggest that a majority of nevirapine-exposed children who are successfully treated with initial regimens based on ritonavir-boosted lopinavir and achieve viral suppression could benefit from the switch strategy, which would allow reductions in costs of pediatric treatment programmes,” Coovadia said.
“However, switching should only be undertaken with adequate virologic monitoring. Although the value of virologic monitoring in HIV treatment is strongly emphasised in well-resourced settings, most programmes in low-resource settings do not include it as part of routine services because of cost. The switch could be safely undertaken in these circumstances using targeted virologic monitoring, at a few defined time points,” said Coovadia.