Drug study finds more effective AIDS regimen

The World Health Organization reported that more than 22 million people in sub-Saharan Africa - about 34 times the population of Baltimore - are currently living with AIDS.

New research from the Bloomberg School of Public Health suggests that many of them may not be getting the most effective treatment possible.

The research, published in the Oct. 18 issue of the journal AIDS, evaluates the effectiveness of treating AIDS with a combination of three drugs, including efavirenz and nevirapine, recommended by the World Health Organization for initiation treatment of AIDS in resource-limited settings.

"However, despite these drugs' widespread use, direct comparisons of their effectiveness in the real world were limited and conflicting," Jean Nachega, the lead author of the paper and associate scientist in the Department of International Health at the School of Public Health, said in an e-mail interview with the News-Letter.

The study, which included 2,817 adults from nine countries in sub-Saharan Africa, found that patients taking efavirenz-based regimens were less likely to get sick or die and more likely to consistently take their medication than patients taking nevirapine.

The researchers assessed patients' treatment responses based on viral load, which indicates the amount of active HIV cells in the blood, treatment discontinuation and all-cause mortality.

"Our findings add to existing limited evidence that efavirenz-based therapies produce more favorable virological and clinical outcomes than nevirapine in Africa," Nachega said in a press release about the publication of the paper.

Nevirapine is commonly used in poor countries because it is cheaper than efavirenz, and until recently, it was widely believed to be just as successful a drug.

"The assumption that efavirenz and nevirapine are equally effective needs to be reassessed," Nachega said. "We are calling for a large randomized controlled trial in Africa to definitively compare efavirenz and nevirapine. Our results originate from a retrospective observational study design which can still suffer from biases and is confounding as compared to a more gold standard study design."

So how does Nachega's study affect the 22 million people with AIDS in sub-Saharan Africa? One key factor is the cost of the drugs and their availability as a fixed-dose combination.

Drugs that come in generic form, like nevirapine, are cheaper and therefore more accessible in Africa, while drugs that aren't available in generic form are expensive and difficult to obtain.

Also, the form of the medication is important. Right now, efavirenz doesn't exist in a fixed-dose combination, or single pill, so patients can't simply take their efavirenz in a single dose. Generally, as the number of pills patients have to take decreases, the patient's adherence to drug regimen increases, which helps produce better health outcomes.

"We hope our results will help accelerate efforts to develop lower cost formulations of efavirenz, including generic, fixed-dose combinations for use in Africa," Nachega, who is also a director for the Center of Infectious Diseases as well as professor of Medicine and Clinical Epidemiology at Stellenbosch University in Cape Town, South Africa, said.?

Nachega's interest in AIDS research stemmed from his medical studies in Brussles, Belgium, and a clinical rotation in his native country of Zaire - now the Democratic Republic of Congo - that involved taking care of patients with AIDS.

"This disease [AIDS], which was first recognized in the early 1980s in Los Angeles, had initially been labeled a disease of "the four Hs": homosexuals, heroin addicts, hemophiliacs and Haitians. In Belgium, the latter "H" became a "Z," and referred to Zaire. It was later proved that the disease can affect anyone," Nachega said in the interview.

Nachega decided to devote his career to the study of AIDS in sub-Saharan Africa and received the Stelion M. Stelson scholarship to study at the Bloomberg School in 1998.

"The Johns Hopkins Masters in Public Health program equipped me with tools in epidemiology, biostatistics and international health that I critically needed to start my research career, which focused on AIDS and related opportunistic infections of public health importance in Africa, like tuberculosis," Nachega said.