Persistence of nevirapine in breast milk and plasma of mothers and their children after single-dose administration

OBJECTIVES: Nevirapine is widely used in the developing world for the prevention of mother-to-child transmission (PMTCT) of HIV. A single mutation in the HIV genome is sufficient to lead to significant nevirapine resistance. Persistence of low-level drug concentrations in body compartments can foster resistance formation. In this study concentration-time courses of nevirapine after single-dose administration were analysed over an extended post-partum period. PATIENTS AND METHODS: Breast milk and plasma samples of 62 HIV-positive Ugandan mother-child pairs who had received single-dose nevirapine were collected at delivery and 1 2 and 6 weeks post-partum. Nevirapine concentrations were quantified by LC/tandem-mass-spectrometry using a quantification limit of 15 ng/mL and a population pharmacokinetic (PK) analysis was performed. RESULTS: Concentration-time profiles in breast milk maternal plasma and child plasma showed similar shapes. At week 1 median nevirapine concentrations were 164 ng/mL in maternal plasma 114 ng/mL in breast milk and 183 ng/mL in child plasma. The population PK model predicted nevirapine concentrations>10 ng/mL (IC50 for nevirapine) for 13 days in breast milk 14 days in maternal plasma and 18 days in child plasma in 80% of the samples. CONCLUSIONS: Nevirapine concentrations were present for 2-3 weeks in the three compartments. The concentrations are probably sufficiently high to protect most breastfed children from HIV transmission during the first 2 weeks. The long presence of slowly decreasing levels of nevirapine is likely to induce resistance formation. Post-natal addition of antiretrovirals for 1 week only as recommended in the current PMTCT guidelines will not suffice to avoid nevirapine resistance formation.