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Eliminating perinatal HIV infection with ARVs.

The most effective antiretroviral (ARV) regimen to prevent vertical transmission of HIV during breast-feeding is unknown, but two randomised trials have shown that ARV use in breastfeeding infants or mothers significantly decreases post-natal acquisition of HIV. The one study investigated the efficacy of maternal or infant ARVs for 28 weeks during breastfeeding in Malawi. 2,369 HIV-positive, breastfeeding mothers (CD4 count >=250 cells/[micro]1) and their infants were randomly assigned to receive a maternal antiretroviral regimen, infant nevirapine, or no extended postnatal antiretroviral regimen (control group). All mothers and infants received perinatal prophylaxis with single-dose nevirapine and one week of zidovudine plus lamivudine. Among mother-infant pairs, 5% of infants were HIV-positive at two weeks of life. The estimated risk of HIV transmission between 2-28 weeks was higher in the control group (5.7%) than in either the maternal-regimen group (2.9%, p=0.009) or the infant-regimen group (1.7%, p<0.001). The estimated risk of infant HIV infection or death between 2-28 weeks was 7.0% in the control group, 4.1% in the maternal-regimen group (p=0.02), and 2.6% in the infant-regimen group (p<0.001). The use of either a maternal antiretroviral regimen or infant nevirapine for 28 weeks was effective in reducing HIV transmission during breastfeeding, but the study was not powered to address the comparative efficacy of infant vs. maternal regimens. (1)

The other study, in Botswana, randomly assigned 560 HIV-positive pregnant women (CD4 count >200 cells/[micro]l) to receive two different combinations of ARVs from 26-34 weeks gestation through to planned weaning by six months after birth. 170 women received nevirapine plus zidovudine-lamivudine (the observational group). Infants received single-dose nevirapine and four weeks of zidovudine. The rate of virologic suppression was high and did not differ significantly among the three groups at delivery (96% in the NRTI group, 93% in the protease-inhibitor group, and 94% in the observational group) or throughout the breastfeeding period (92%, 93% and 95%, respectively). The overall rate of mother-to-child transmission was 1.1% at six months of age (8/709 live-born infants), with no significant difference between the transmission rates in each group. (2)

These findings show that it would be possible to eliminate new perinatal HIV infections globally with ARV treatment with universal access. Some important lessons can be gleaned from these trials. ARV regimens must start during pregnancy. Maternal and infant regimens were no less safe than control interventions, although the use of ARV in both infants and mothers is associated with drug-resistant virus in the few infants who become HIV-positive despite prophylaxis. WHO recommends two prophylaxis options for women who do not otherwise require ARVs; it is not yet known which is more effective. Success will be tied less to which regimen is provided than to the integration of services for women with HIV and their infants. (3)

(1.) Chasela CS, Hudgens MG, Jamieson DJ, et al. Maternal or infant antiretroviral drugs to reduce HIV-1 transmission. New England Journal of Medicine 2010;362(24):2271-81.

(2.) Shapiro RL, Hughes MD, Ogwu A, et al. Antiretroviral regimens in pregnancy and breast-feeding in Botswana. New England Journal of Medicine 2010;362(24):2282-94.

(3.) Mofenson LM. Protecting the next generation--Eliminating perinatal HIV-1 infection. New England Journal of Medicine 2010;362(24):2316-18.
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Title Annotation:antiretroviral; Round Up: HIV and AIDS
Publication:Reproductive Health Matters
Article Type:Report
Geographic Code:6BOTS
Date:Nov 1, 2010
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