Patients receiving rifampicin-based anti-tuberculosis therapy are more likely to experience virological failure when starting nevirapine-based antiretroviral therapy, an HIV treatment that is widely used in developing countries because of lower cost, than when starting efavirenz-based antiretroviral therapy, according to a study in the August 6 issue of JAMA, a theme issue on HIV/AIDS.
Andrew Boulle, MBChB, MSc, of the University of Cape Town, South Africa, presented the findings of the study at a JAMA media briefing on HIV/AIDS.
Combination antiretroviral therapy (ART) is frequently initiated in resource-limited countries when patients are being treated for tuberculosis. Co-administration of ART and anti-tubercular therapy may be complicated by shared toxicity or adverse drug interactions, according to background information in the article. Rifampicin-based anti-tubercular therapy reduces the plasma concentrations of the antiretroviral agents efavirenz and nevirapine. The virological consequences of these interactions are not well known.
Boulle and colleagues conducted a study to assess the effectiveness of efavirenz- or nevirapine-based combination ART used with rifampicin-based anti-tubercular therapy. The researchers analyzed clinical data collected from a community-based South African antiretroviral treatment program, in which adults were enrolled between May 2001 and June 2006 and were followed up until the end of 2006. The analysis included 2,035 individuals who started antiretroviral therapy with efavirenz (1,074 with tuberculosis) and 1,935 with nevirapine (209 with tuberculosis).
The researchers found that patients with tuberculosis initiating nevirapine were about twice as likely to have elevated viral loads during follow-up than those without tuberculosis (at six months, 16.3 percent vs. 8.3 percent). In the time-to-event analysis of confirmed virological failure, patients starting nevirapine with tuberculosis treatment were more than twice as likely to develop virological failure sooner. In spite of these differences, 80 percent of patients in the initial nevirapine-rifampicin group were virologically suppressed at 18 months duration of ART. There were no differences between patients starting efavirenz with and without tuberculosis treatment, or in patients developing tuberculosis while on nevirapine or efavirenz compared to those free of tuberculosis on the same antiretroviral drug.
The authors speculate that these differences, present in patients who start nevirapine-based antiretrovirals with tuberculosis, but not in those who develop tuberculosis once already established on nevirapine-based antiretroviral therapy "... could be the result of the limited power of the latter analysis to detect a difference... An alternative explanation, however, is a drug interaction mediated by rifampicin during the lead-in dosing phase of nevirapine."
"Given the continued reliance on nevirapine-containing ART regimens in Africa, together with the important role tuberculosis services play as an entry point for ART, further prospective studies exploring this outcome are warranted. One of the most striking aspects of our study was the demonstration that 40 percent of patients starting ART in recent years have concurrent tuberculosis, underscoring the public health importance of improving affordable treatment options for patients infected with HIV and tuberculosis in this setting."
Reference: JAMA. 2008;300[5]:530-539.
Source: American Medical Association
Dear Helpdesk: Working in a Toxic Health Care Environment
March 28th 2024Dear Helpdesk is your steadfast companion, offering life coaching and workplace advice from 2 seasoned IPs for some of your most challenging real-life situations. Let us help you navigate the intersection between work and life, guiding you to navigate the dynamic world of infection prevention with confidence and grace. This article is on handling a toxic health care environment.
Product Locator: Spring and Early Mother's Day Gift Guide for Infection Prevention Personnel
March 27th 2024Whether it's a spring holiday, birthdays, or no reason at all, infection prevention personnel love to give and receive gifts that help at the end of a stressful day. Infection Control Today® offers some gift ideas for infection prevention personnel and their families.
Catching Up With Vangie Dennis, AORN 2022-2023 President at AORN 2024
March 26th 2024Infection Control Today (ICT) had the privilege of catching up with Vangie Dennis, MSN, RN, CNOR, CMLSO, at the Association of periOperative Registered Nurses' (AORN’s) International Surgical Conference & Expo 2024. As the former president of AORN and an esteemed figure in perioperative services, Vangie Dennis shared insights into her recent endeavors and the exciting new chapter she's embarked upon.
How To Optimize Your Time Management Strategies for the Busy Infection Preventionist
March 25th 2024Is your calendar resembling a chaotic masterpiece of overlapping tasks? Join the club of infection preventionists striving to balance responsibilities. Dive into proven strategies from a fellow infection preventionist to reclaim control of your time, streamline tasks, and boost productivity effectively. This is an IP Lifeline article.