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Consequences of Single-Dose Nevirapine

Peripartum single-dose nevirapine reduces virologic response to subsequent nevirapine-based antiretroviral therapy in women and infants.

Single-dose nevirapine (sd-NVP) during labor is often used in resource-poor settings to prevent maternal transmission of HIV to infants. However, sd-NVP can select for drug-resistant HIV, and many have wondered whether this treatment might compromise subsequent responses to NVP-based antiretroviral therapy (ART) in women or their infants. Now, investigators have studied the response to NVP-based ART among 218 women and 30 infants in Botswana who had previously received sd-NVP or placebo during labor (the women) or soon after delivery (the infants). The women had also received zidovudine from 34 weeks’ gestation through delivery.

By 6 months after ART initiation, 18% of the women who had received sd-NVP showed virologic failure, compared with only 5% of those who had received placebo (P=0.002). This difference was seen only in women who initiated ART <6 months after delivery (virologic failure rates, 42% among NVP recipients vs. 0% among placebo recipients). Among the 158 women who initiated ART 6 months postpartum, sd-NVP and placebo recipients had similar virologic failure rates at 6, 12, and 24 months. (Of note, HIV RNA levels were available at 24 months for only 32% of the patients in this group.) Finally, infants who received sd-NVP had much higher virologic failure rates by 6 months after initiation of NVP-based ART than did those who received placebo (77% vs. 9%; P<0.001).

Comment: Single-dose nevirapine given to prevent mother-to-child HIV transmission adversely affects virologic response to NVP-based ART in women who initiate therapy <6 months postpartum and in infants. Protease inhibitor–based therapy should be considered for these groups. Among women who initiated NVP-based ART 6 months postpartum, sd-NVP and placebo recipients had similar virologic response rates, but longer follow-up is necessary to ensure that no differences emerge. Researchers are currently comparing the response to protease inhibitor– and nonnucleoside reverse- transcriptase inhibitor–based therapies in women who received sd-NVP during pregnancy.

— Rajesh T. Gandhi, MD

Published in Journal Watch Infectious Diseases January 10, 2007

Citation(s):

Lockman S et al. Response to antiretroviral therapy after a single, peripartum dose of nevirapine. N Engl J Med 2007 Jan 11; 356:135-47.

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