Comparative safety and effectiveness of perinatal antiretroviral therapies for HIV-infected women and their children: Systematic review and network meta-analysis including different study designs

BACKGROUND

Nearly all newly infected children acquire Human Immunodeficiency virus (HIV) via mother-to-child transmission (MTCT) during pregnancy, labour or breastfeeding from untreated HIV-positive mothers. Antiretroviral therapy (ART) is the standard care for pregnant women with HIV. However, evidence of ART effectiveness and harms in infants and children of HIV-positive pregnant women exposed to ART has been largely inconclusive. The aim of our systematic review and network meta-analysis (NMA) was to evaluate the comparative safety and effectiveness of ART drugs in children exposed to maternal HIV and ART (or no ART/placebo) across different study designs.

METHODS

We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (inception until December 7, 2015). Primary outcomes were any congenital malformations (CMs; safety), including overall major and minor CMs, and mother-to-child transmission (MTCT; effectiveness). Random-effects Bayesian pairwise meta-analyses and NMAs were conducted. After screening 6,468 citations and 1,373 full-text articles, 90 studies of various study designs and 90,563 patients were included.

RESULTS

The NMA on CMs (20 studies, 7,503 children, 16 drugs) found that none of the ART drugs examined here were associated with a significant increase in CMs. However, zidovudine administered with lamivudine and indinavir was associated with increased risk of preterm births, zidovudine administered with nevirapine was associated with increased risk of stillbirths, and lamivudine administered with stavudine and efavirenz was associated with increased risk of low birth weight. A NMA on MTCT (11 studies, 10,786 patients, 6 drugs) found that zidovudine administered once (odds ratio [OR] = 0.39, 95% credible interval [CrI]: 0.19-0.83) or twice (OR = 0.43, 95% CrI: 0.21-0.68) was associated with significantly reduced risk of MTCT.

CONCLUSIONS

Our findings suggest that ART drugs are not associated with an increased risk of CMs, yet some may increase adverse birth events. Some ART drugs (e.g., zidovudine) effectively reduce MTCT.

[CLINICAL AND PHARMACOECONOMIC RESULTS OF THE USAGE OF VARIOUS HIV REVERSE TRANSCRIPTASE INHIBITORS IN THE SCHEMES OF ANTIRETROVIRAL THERAPY OF PATIENT RECEIVING THERAPY FOR THE CHRONIC HEPATITIS C VIRUS]

Efficacy, safety, and economical aspects of treatment with abacavir, zidovudine, stavudine, and phosphazide in the schemes of antiretroviral therapy of the HIV-infected patients receiving therapy for hepatitis C virus were tested. Clinical, immunological, and virologic efficacy of treatment and dynamics of hemoglobin, thrombocytes, and alanine aminotransferase as markers of common adverse events recorded at the start of the antiviral therapy of chronic hepatitis C and after 4, 8, 12, 24, 48 weeks of the treatment were evaluated. The usage of these drugs in the schemes of antiretroviral therapy exhibited efficacy, high tolerability and safety for all HIV reverse transcriptase inhibitors.

Cost estimation of first-line antiretroviral therapy with zidovudine/stavudine as the nucleoside backbone in India: a pilot study

BACKGROUND

In India, a zidovudine-based regimen is preferred as the first-line drug treatment for HIV, despite high rates of drug toxicity. This study estimates the treatment costs for HIV.

METHODS

Eligible patients were enrolled from Antiretroviral Therapy Center, Christian Medical College, India. Baseline demographic and clinical characteristics, medical and nonmedical expenditure, and lost income were collected.

RESULTS

Of 41 patients enrolled and followed for 6 months, HIV treatment toxicity and opportunistic infections were reported by 12 (29%) and 13 (31.7%) patients, respectively. The median total costs, direct costs, and out-of-pocket expenditure were Indian rupees (INR) 9418 (US$181), 8727 (US$168), and 7157 (US$138), respectively. Diagnostic tests accounted for 58% of the expenses. HIV treatment accounted for 34% of the median income earned INR 21 000 (US$404). Expenditure for treatment with toxicity was 44% higher than without toxicity.

CONCLUSION

Current treatment is associated with toxicity, increasing treatment costs and imposing a significant economic burden.

[A fixed dose anti-HIV combination for the poor? Triomune]

Despite a relative global stabilization of its incidence, HIV infection remains a major threat for public health, principally in Africa where it concerns more than 22 million people and constitutes the first cause of death on the continent. To face the emergency of the HIV/AIDS epidemics on the African continent, the primary goal is to make available to all patients free and efficient antiretroviral medications. Such a goal cannot be dissociated from large scale prevention campaigns. In 2000, Triomune, one of the first fixed dose combinations of three antiretrovirals (stavudine, lamivudine & nevirapine) was launched by the Indian drug company Cipla, specialized in the production of low cost medications. Its convenient pill burden (one pill twice a day) and its very low cost (around 30 US $ per month) make Triomune an appealing solution for the treatment of HIV/AIDS in Africa. Unfortunately, Triomune presents several drawbacks (low genetic barrier, frequent side effects) and one of its constituents is not used in Europe anymore. Other first line treatments are urgently needed.

Stampidine as a novel nucleoside reverse transcriptase inhibit with potent anti-HIV activity

Stavudine (STV, d4T, 2',3'-didehydro-3'-deoxythymidine, CAS 3056-17-5) is a standard anti-HIV drug. Stampidine (STAMP, DDE-113, HI-113, N-[p-(4-bromophenyl)-2',3'-didehydro-3'-deoxy-5'-thymidylyl]-L-alanine methyl ester, CAS 217178-62-6) is a novel aryl phosphate derivative of stavudine with more potent anti-HIV activity and more favorable pharmacodynamic features. The remarkable potency of stampidine against clinical HIV-1 isolates with NRTI- or NNRTI-resistance (NRTI, nucleoside reverse transcriptase inhibitor; NNRTI, non-nucleoside reverse transcriptase inhibitor) warrants the further development of this new anti-HIV agent.

Evaluation of antiretroviral therapy results in a resource-poor setting in Blantyre, Malawi

OBJECTIVE

To evaluate treatment results of the paying antiretroviral therapy (ART) clinic of Queen Elizabeth Central Hospital, a large public and teaching hospital in Blantyre, Malawi. The only ART was a fixed drug combination of stavudine, lamivudine and nevirapine.

METHODS

Cross sectional study with interviews, laboratory tests (CD4 count, viral load, nevirapine plasma levels, transaminases) and data extraction from files.

RESULTS

A total of 422 (59%) of the patients who started ART since 2000 were lost to follow-up. The 176 patients enrolled in the study had good virological and excellent clinical treatment results. The most common side effect was peripheral neuropathy. Nevirapine plasma levels were remarkably high and associated with successful virological treatment results. Two simple adherence questions pertaining to the use of medication in the previous 8 days corresponded well with nevirapine levels. The most important reasons for non-adherence were shortage of drugs in the hospital pharmacy and personal financial constraints.

CONCLUSIONS

(1) Many patients were lost to follow-up. (2) High nevirapine levels contributed to good therapy results in those studied. (3) Simple adherence questions predicted subtherapeutic nevirapine levels. (4) Antiretroviral drug supply needs to be uninterrupted and free of charge, to prevent avoidable non-adherence.

[Cost effectiveness analysis of highly active antiretroviral therapy in HIV asymptomatic patients]

BACKGROUND

Assessment of cost and effectiveness in highly active antiretroviral therapy (HAART) in HIV asymptomatic patients.

PATIENTS AND METHODS

A cohort of several asymptomatic HIV-infected patients were observed under real practice and treated with two nucleosid analogues (AN) of which therapy was modified. A protease inhibitor (PI) was added and at least one AN was changed (or not), following the current clinical recommendations (1997). Data on direct cost (drug cost, visits and clinical procedures) were then recorded both three and six months after the beginning of the study. Data on effectiveness (percentage of patients with undetectable levels of viral load) and quality of life were next measured according to the EuroQol, and recorded at the same time. All patients used a monthly diary to keep record of resource consumption and quality of life progress.

RESULTS

All treatment regimens were effective in lowering the viral load and improve quality of life. The less expensive HAART was AZT + 3TC + IND (1,037,757 pesetas) and AZT + ddl + IND (1,045,339 pesetas), but both were the least effective to reduce patient's viral load to undetectable levels (52.7 and 57.7% respectively); meanwhile d4T + 3TC + IND (1,188,177 pesetas) and d4T + ddl + IND (1,212,285 pesetas) were more expensive but more effective (67.9 and 66% respectively). Cost-effectiveness ratios ranged between 9,896 and 13,122 pesetas. There was no statistically significant differences in quality of life among the different HAART regimens.

CONCLUSIONS

HAART implementation is effective in reducing patients' viral load to undetectable levels and to slightly improve their quality of life after six months. Costs and effectiveness vary according to the type of HAART treatment used.