Researchers from The Children's Hospital of Philadelphia and the Perelman School of Medicine at The University of Pennsylvania, along with colleagues at the Botswana-Baylor Children's Clinical Centre of Excellence, conducted the first large-scale comparison of first-line treatments for HIV-positive children, finding that initial treatment with efavirenz was more effective than nevirapine in suppressing the virus in children ages 3 to 16. However, the less effective nevirapine is currently used much more often in countries with a high prevalence of HIV. The results of the study of more than 800 children are published today in the Journal of the American Medical Association (JAMA).
There are more than 3 million HIV-positive children in the world, and more than 90 percent of them live in sub-Saharan Africa. Currently, the World Health Organization (WHO) recommends both efavirenz and nevirapine for first-line pediatric use in resource-limited settings such as sub-Saharan Africa. Lead author Elizabeth Lowenthal, MD, MSCE of The Children's Hospital of Philadelphia, says this study has the potential to change the standard of care in the parts of the world where most HIV-infected children live.
"Because nevirapine costs less than efavirenz and is more widely available in pediatric formulations, it is currently the more frequent choice for initial treatment in these children. However, our study suggests that efavirenz produces better outcomes," said Dr. Lowenthal.
Senior author Robert Gross, MD, MSCE, an associate professor of Infectious Diseases and Epidemiology at Penn Medicine, adds, "Given this evidence, it is very reasonable to adjust pediatric HIV treatment guidelines. However, as we move towards such changes, more work should be done to make efavirenz a more financially viable option for children on anti-retroviral therapy in these resource-limited settings."
Previous studies favoring efavirenz over nevirapine in adults have resulted in treatment guidelines for adults in many countries, including a few in resource-limited settings, to recommend the use of efavirenz over nevirapine. "In these low-resource settings, Non-Government Organizations typically work with countries' medical programs to forecast their HIV-related drug needs and lobby companies to lower prices for bulk purchases," explained Lowenthal. "Through such programs, drugs that were once more expensive can become cost-effective."
Doctors Lowenthal and Gross applaud the work that the government of Botswana has done to both bring high-quality HIV treatment to its citizens and to facilitate the generation of knowledge to help improve treatment options. "Botswana has been extremely supportive of clinical trials and epidemiological studies, and is very forward thinking in its willingness to inform the world. For such a small country, the amount of research that comes out of Botswana on HIV and tuberculosis is tremendous, which has not only benefitted their public health, but public health for all."
- Elizabeth D. Lowenthal et al. Association Between Efavirenz-Based Compared With Nevirapine-Based Antiretroviral Regimens and Virological Failure in HIV-Infected Children. JAMA, 2013 DOI: 10.1001/jama.2013.3710
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