Safety and Efficacy of Starting Antiretroviral Therapy in the First Week of Life

Kenneth Maswabi, Gbolahan Ajibola, Kara Bennett, Edmund V Capparelli, Patrick Jean-Philippe, Sikhulile Moyo, Terence Mohammed, Oganne Batlang, Maureen Sakoi, Shahin Lockman, Joseph Makhema, Mathias Lichterfeld, Daniel R Kuritzkes, Michael D Hughes, Roger L Shapiro, Kenneth Maswabi, Gbolahan Ajibola, Kara Bennett, Edmund V Capparelli, Patrick Jean-Philippe, Sikhulile Moyo, Terence Mohammed, Oganne Batlang, Maureen Sakoi, Shahin Lockman, Joseph Makhema, Mathias Lichterfeld, Daniel R Kuritzkes, Michael D Hughes, Roger L Shapiro

Abstract

Background: Early antiretroviral therapy (ART) is recommended for infants with human immunodeficiency virus (HIV) infection. However, few antiretroviral options are available for neonates.

Methods: The Early Infant Treatment Study in Botswana tested HIV-exposed infants within 96 hours of birth, and HIV-infected infants started nevirapine (NVP) 6 mg/kg twice daily, zidovudine (ZDV), and lamivudine (3TC) at age < 7 days. NVP trough concentrations were tested at 1 and 2 weeks. NVP was switched to ritonavir-boosted lopinavir (LPV/r) at week 2, 3, 4, or 5 according to delivery gestational age.

Results: Forty HIV-infected infants started ART at median age 2 days (range, 1-5 days). NVP trough concentrations were highly variable and below therapeutic target (3000 ng/mL) for 50% of 2-week measurements; concentrations did not correlate with viral decline at weeks 2, 4, or 12. Two deaths unrelated to ART occurred through 24 weeks. Only 1 unscheduled treatment modification was required. Within 4 weeks of transition to LPV/r, 9 (22.5%) had transient HIV RNA increases, likely due to poor LPV/r palatability. At 12 weeks, 22 (55%) of 40 were <40 copies/mL (93% <400 copies/mL); by 24 weeks, 27 of 38 (71%) were < 40 copies/mL (84% < 400 copies/mL). HIV-1 RNA response at 12 and 24 weeks did not differ by baseline HIV RNA or other factors.

Conclusions: NVP/ZDV/3TC started in the first week of life was safe and effective, even when trough NVP levels were below target. Transient viral increases occurred following transition to LPV/r, but by 12 and 24 weeks most children achieved and maintained viral suppression.

Clinical trials registration: NCT02369406.

Keywords: Botswana; combination antiretroviral drugs; early infant treatment; efficacy; safety.

© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America.

Figures

Figure 1.
Figure 1.
Nevirapine pharmacokinetics. Abbreviation: QL, quantification limit.
Figure 2.
Figure 2.
Median HIV RNA and proportion suppressed to

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