Antiretroviral therapy in resource-limited settings: is there still a role for stavudine?

Phanuphak et al. compared three strategies for first-line antiretroviral therapy in 150 Thai patients: initiating therapy with zidovudine (AZT), tenofovir disoproxil fumarate (TDF), or a 24-week lead-in phase with stavudine (d4T) followed by a switch to AZT. Those taking d4T had higher haemoglobin levels and CD4(+) T-cell counts without an increase in neuropathic symptoms, peripheral neuropathy or lipoatrophy compared with those on AZT. Because AZT is associated with more short-term side effects and toxicity than d4T, and because most d4T toxicity occurs only after long-term use, this approach may have advantages over initial use of AZT. However, TDF-based regimens, while more expensive, are more effective, better tolerated, less toxic, less likely to lead to cross-resistance, and possibly more cost-effective. The goal in resource-limited settings should be to move away from use of thymidine analogues in first-line regimens.