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What is your opinion of nevirapine as a way to prevent mother-to-child transmission of HIV?
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There will always be a role for single-dose nevirapine in settings where prevention of mother-to-child transmission is suboptimal, such as cases when pregnant women frequently present late for antenatal care (after 28 weeks gestation).
Single-dose nevirapine is often given to both the mother and infant, but it seems equally effective if only given to the infant — provided it is given as soon as possible after birth. Most programs prefer to give the treatment to both mother and infant because this reduces the opportunity for a missed dose.
Postnatal antiretrovirals to the mother will drastically reduce or eliminate nevirapine resistance in the mother, thereby allowing nevirapine to be retained as an option.
The more women using ART from before 28 weeks, the less there will be a need for single-dose nevirapine.
Regarding the role of nevirapine in mother-to-child transmission in general, it is a useful medication for women of child-bearing age commencing ART if contraception is uncertain. For those with higher CD4 counts, there is a danger of hypersensitivity with nevirapine. For pregnant women in their first trimester, there is definitely a place for nevirapine if ART needs to commence for the mother’s health.
Mark Cotton, MD, PhD, head of the division of pediatric infectious diseases at Tygerberg Children’s Hospital at Stellenbosch University in South Africa.
As a start, single-dose nevirapine prophylaxis is a good strategy. As a political tool to allow for a rapid transition to ART rollout, it has been very effective. Beyond that, I am not convinced. I would not let a patient of mine take nevirapine by itself. To me, it breaks the basic principle of “first do no harm.”
We have not seen any data from any region showing that the burden of HIV has been lessened in that community by single-dose nevirapine. Furthermore, this strategy is never used in the United States. How can we propose a different standard of care in Africa than we have here? It does not make sense.
Rapid development of nevirapine resistance has been well-recognized since the early 1990s.
Therapeutically, nevirapine is useless by itself. Still, the desire to use it alone to prevent mother-to-child transmission has persisted. Giving this drug to infected women and their infants leads to resistance, and it will leave most with no second-line options. Most important, the strategy has no maternal benefits, and likely some harm. Sadly, in most of the world, orphaned HIV-exposed infants are unlikely to survive, whether they themselves are infected or not.
Karen P. Beckerman, MD, of the department of obstetrics & gynecology and women’s health at Albert Einstein College of Medicine in New York.