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Single-dose nevirapine, either alone or in combination with other antiretrovirals, is a key intervention for preventing mother-to-child HIV transmission (PMTCT) in most middle- to low-income countries. Unfortunately, some children acquire HIV infection perinatally despite this strategy and develop resistance to NNRTIs, which has serious clinical implications for their future antiretroviral treatment options. In this observational study, researchers evaluated treatment response among 104 HIV-infected children (age, ≤5 years) who were receiving NNRTI-based regimens through a treatment program in Uganda: 35 of the children had been exposed to single-dose nevirapine at birth, and 69 had not.
Twenty-four weeks after initiating treatment, only 34.6% of the exposed children had achieved viral loads <400 copies/mL, compared with 63.5% of the unexposed children (odds ratio, 0.30; 95% confidence interval, 0.11–0.60). Similar results were seen at 48 weeks, even after adjustment for baseline viral load. Multiple NNRTI resistance mutations — mainly K103N, Y181C, and G190A — were seen among the exposed children.
Musiime V et al. Response to nonnucleoside reverse transcriptase inhibitor-based therapy in HIV-infected children with perinatal exposure to single-dose nevirapine. AIDS Res Hum Retroviruses 2009 Oct; 25:989.
Comment
These findings support the WHO's 2008 recommendation that PI-based antiretroviral therapy be used for children with previous exposure to single-dose nevirapine. Perhaps more important, the study highlights the complexities associated with providing HIV prevention and treatment services to children in resource-poor settings. For example, a child's treatment options are driven by knowledge of whether he or she was previously exposed to antiretroviral prophylaxis, but among the 380 children under age 5 years who were screened for this study, 264 (70%) had no record of exposure status. Such patient-information challenges are common in most resource-limited countries. Given these and other difficulties in treating children, more emphasis needs to be placed on improving access to the comprehensive package of PMTCT interventions so as to prevent more perinatal infections. Although the figures in this study may not accurately reflect PMTCT coverage throughout Uganda, they are still telling: 69 (66%) of the children never received single-dose nevirapine, an intervention that might have prevented their HIV infection.