Efavirenz or nevirapine in three-drug combination therapy with two nucleoside or nucleotide-reverse transcriptase inhibitors for initial treatment of HIV infection in antiretroviral-naïve individuals
Lawrence Mbuagbaw1,2, Sara Mursleen2, James H Irlam3, Alicen B Spaulding4, George W Rutherford5, Nandi Siegfried6,7
1. Yaoundé Central Hospital, Centre for the Development of Best Practices in Health (CDBPH), Yaoundé, Cameroon
2. McMaster University, Department of Clinical Epidemiology and Biostatistics, Hamilton, ON, Canada
3. University of Cape Town, Primary Health Care Directorate, Cape Town, Western Cape, South Africa
4. National Institute of Allergy and Infectious Diseases, Laboratory of Clinical Infectious Diseases, Bethesda, MD, USA
5. University of California, San Francisco, Global Health Sciences, San Francisco, California, USA
6. Cape Town, South Africa
7. Medical Research Council, Alcohol, Tobacco and Other Drug Research Unit, Tygerberg, South Africa
Mbuagbaw L, Mursleen S, Irlam JH, Spaulding AB, Rutherford GW, Siegfried N. Efavirenz or nevirapine in three-drug combination therapy with two nucleoside or nucleotide-reverse transcriptase inhibitors for initial treatment of HIV infection in antiretroviral-naïve individuals. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD004246. DOI: 10.1002/14651858.CD004246.pub4
To read the full-text article, please click here: 10.1002/14651858.CD004246.pub4
For people living with HIV who have never received antiretroviral therapy (ART), which drug is more effective in suppressing HIV infection in combination with two nucleoside reverse transcriptase inhibitors (NRTI): efavirenz (EFV) or nevirapine (NVP)?
The introduction of highly active ART as treatment for HIV infection has greatly reduced mortality and morbidity for adults and adolescents living with HIV around the world. The recommended initial treatments for HIV infection include two drugs from a class of drugs known as NRTI and one from a related class of drugs called non-nucleoside reverse transcriptase inhibitors (NNRTI). The two NNRTIs most commonly used are NVP and EFV. However, NVP can cause liver damage and severe rash, both of which can be fatal. EFV may also cause a rash, impair mental function, and cause foetal malformations.
Cochrane researchers examined the available literature up to 12 August 2016 and identified 12 randomized controlled trials, with a total of 3278 people, that met the inclusion criteria of this review. None of the included trials included children. Four trials included people who were also receiving treatment for tuberculosis. There was little or no difference in suppression of HIV infection (high quality evidence), probably little or no difference in mortality, progression to AIDS, stopping treatment early and changes in blood cells affected by HIV (moderate quality evidence). There may be little or no difference in treatment failure (low quality evidence). We are uncertain whether there is a difference in side-effects (very low quality evidence). No studies were found that looked at sexual transmission of HIV. Development of drug resistance is probably slightly less in the EFV group (moderate quality evidence). When the side effects were examined individually, EFV probably caused more impaired mental function (6% in the EFV group and 2% in the NVP group; moderate quality evidence), while NVP probably caused more people to have a rash (3% in the EFV group and 6% in the NVP group; moderate quality evidence), caused more people to have reduced white blood cells (2% in the EFV group and 5% in the NVP group; high quality evidence), and signs of liver damage (6% in the EFV group and 11% in the NVP group; high quality evidence). There was probably little or no difference in increases in liver enzymes and levels of cholesterol (moderate quality evidence). There may be little or no difference in digestive side-effects, fever, enzymes from the liver and pancreas, and fat in the blood (low quality evidence). People on NVP were probably more likely to die when given a once-daily regimen (2% in the EFV group and 4% in the NVP group; moderate quality evidence). In people who were taking treatment for tuberculosis compared to those who were not, there was probably little or no difference in suppression of HIV, deaths, progression to AIDS or stopping treatment early (moderate to high quality evidence).
EFV and NVP are similarly effective in viral suppression, preventing HIV progression and reducing mortality. EFV is more likely to affect mental function, while NVP is more likely to cause signs of liver damage, reduced white blood cells and rash.