According to the World Health Organization guidelines, a non-
nucleoside reverse transcriptase inhibitor (NNRTI) along with two
nucleoside reverse transcriptase inhibitors (NRTI) is the treatment of choice as first-line antiretroviral
therapy. The results of the 2NN and different cohort studies performed in developed countries do not provide sufficient evidence by which to select between
nevirapine and
efavirenz as the first-line NNRTI for antiretroviral
therapy in Africa. The current first-line NNRTI-containing antiretroviral
therapy regimens used in Africa are certainly not ideal.
Nevirapine interacts with
rifampicin and therefore is not indicated in patients with
tuberculosis. On the other hand,
efavirenz should not be given to pregnant women. NNRTI-containing regimens may be less effective in women who received
nevirapine monotherapy at delivery.
Stavudine, used in the
nucleoside backbone, may lead to lipoatrophy,
lactic acidosis and
polyneuritis.
Zidovudine may cause serious
anemia. Mainly because of cost considerations, the generic fixed-
drug combination of
nevirapine plus two NRTI seems at the moment to be the best choice. It is clear, however, that antiretroviral programs should not rely only on this combination for initial antiretroviral treatment. Most importantly, more HIV clinical trials need to be conducted in Africa, and African cohorts of patients on antiretroviral
therapy need to be established in order to develop recommendations that are evidence based.