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Epilepsy Specialists in Sub-Saharan Africa

Epilepsy Specialists in sub-Saharan Africa warn of the dangers of interaction between epilepsy and HIV/AIDS medication

Open letter to: WHO African Region, UNAIDS local coordinators (Zambia, Zimbabwe, Uganda, Malawi), IBE

We would like to draw your attention to an emerging problem in epilepsy care in resource poor settings, particularly for regions heavily impacted by the HIV/AIDS. As you know, people in southern Africa are now gaining access to antiretroviral agents. Within our own ART clinics, Triomune® which contains stavudine, lamivudine, and navirapine (NVP), is the most common fixed-dose, combination provided. In reality, many public antiretroviral (ART) clinics in our regions are only able to provide Triomune. Second line agents are not affordable or accessible, particularly in the rural areas.

Unfortunately, for people in resource-limited settings with epilepsy who also require antiretroviral therapy, access to ARTs represents a mixed blessing. Phenobarbitone is the mainstay of treatment for people with epilepsy in many such areas. As you may be aware, NVP’s half-life is substantially shortened by the use of such enzyme-inducing agents.

Co-administration of Triomune with the older, enzyme-inducing anticonvulsants results in suboptimal levels of nevirapine1, which may well lead to NVP resistance and ART treatment failure2.

We are concerned that the development of HIV resistance to NVP would have a negative impact on the health of the person undergoing treatment as well as the public. Newer AEDS without enzyme induction properties are at present virtually unavailable for routine epilepsy care in our settings.

This evolving situation places people with comorbid epilepsy and HIV in resource-poor regions in a difficult situation – essentially for each of these conditions they have one treatment available, but combining the two treatments (Triomune + phenobarbitone) has serious potential adverse outcomes for the individual and major public health implications for the community at large.

It is not clear that epilepsy and HIV care providers are aware of this hazard. ART provision is largely facilitated by the development of separate, stand-alone clinics and exchange between HIV/AIDS and epilepsy healthcare providers in Africa may be quite limited despite the reality that both conditions are exceedingly common in Africa relative to other parts of the world.

We believe this is a complex, urgent and important issue that requires the consideration and attention of international groups such as yours. Recognized interactions between NVP and TB treatment regimens has resulted in the development of recommendations for and access to alternative ART regimens for individuals with HIV/AIDS and TB comorbidity3. Similar attention and consideration is needed for persons suffering from HIV/AIDS and epilepsy.

Thank you for hearing our concerns.

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