International experts have agreed that a triple combination of d4T (stavudine), 3TC (lamivudine) and nevirapine is likely to be the best option for swift implementation of antiretroviral treatment in resource-limited settings. The recommendation was agreed at a WHO and UNAIDS-sponsored consultation in Zambia in mid-November, and follows a similar recommendation from a consensus meeting sponsored by Medecins sans Frontieres in September.
D4T/3TC/nevirapine is considered preferable because there is no need for haemoglobin monitoring before starting treatment, as there would be if AZT were used. Patients with low haemoglobin levels and borderline or frank anaemia are likely to suffer severe anaemia if treated with AZT.
However, the expert consultation does not recommend that routine testing of liver enzymes should take place. Liver toxicity is a side-effect of nevirapine treatment, with women at greater risk, but the consultation report states: "Laboratory evaluation for toxicity must be symptom dependent and not routinely performed at any level."
Patients experiencing symptomatic toxicity will be referred to district hospitals, where changes in treatment will be decided upon by doctors. Local health clinics will be able to prescribe and dispense ARVs as soon as personnel have been trained, an uninterrupted drug supply is in place and confidential patient record keeping is up and running.
WHO today announced that it has pre-qualified three fixed dose formulations of d4T, 3TC and nevirapine manufactured by Indian generic drug companies.