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FOCUS ON HIV CARE Betty J. Dong,
Section Advisor
Maternal, infant antiretroviral therapy decreases mother-to-child
transmission of HIV
Key point: According to two recently published
studies in the New England Journal of Medicine, the
administration of antiretroviral therapy to HIV-infected women who are
pregnant or nursing and to infants significantly decreased
mother-to-child transmission of HIV.
Finer points: A total of 2,369 HIV-positive,
breast-feeding mothers (and their infants) from Malawi participated in
the largest study to date examining methods of preventing
mother-to-child transmission of HIV. In the study, mothers and infants
were randomized to one of three groups. In the maternal treatment group,
only the mother received various antiretroviral regimens. In the infant
treatment group, infants received daily nevirapine. In the maternal,
infant, and control groups, both mothers and infants received
single-dose nevirapine and 1 week of therapy with zidovudine and
lamivudine from onset of labor to 7 days after birth. Mothers were asked
to stop breast-feeding by 28 weeks postpartum. The study results were
calculated after the maternal and infant groups completed 28 weeks of
antiretroviral therapy. At 2 weeks postpartum, 5% of infants were HIV
positive. From 2 to 28 weeks postpartum, the estimated risk of
mother-to-child transmission of HIV was highest in the control group
(5.7%) versus either the maternal treatment group (2.9%; P =
0.009) or the infant treatment group (1.7%; P < 0.001); the
estimated risk of infant HIV infection or death was 7% in the control
group, 4.1% in the maternal treatment group (P = 0.02), and
2.6% in the infant treatment group (P < 0.001).
In the second study, 560 pregnant women from Botswana who had CD4+
counts of at least 200 cells/mm3 were randomized to
treatment with either abacavir, zidovudine, and lamivudine (reverse
transcriptase inhibitor [NRTI] group) or lopinavir–ritonavir plus
zidovudine–lamivudine (protease inhibitor group) from 26 to 34
weeks gestation through 6 months postpartum. An observational group of
pregnant women with CD4+ counts less than 200
cells/mm3 received nevirapine plus
zidovudine–lamivudine. Rates of virological suppression less
than 400 copies/mL did not significantly differ among the three
treatment groups at delivery (96% for NRTI group, 93% for protease
inhibitor group, and 94% for observational group) or during the
breast-feeding period (92% for NRTI group, 93% for protease inhibitor
group, and 95% for observational group). By 6 months postpartum, 1.1% of
infants (n = 8) were infected with HIV (95% CI 0.5–2.2). Six
infants were infected in utero—four from the NRTI group, one
from the protease inhibitor group, and one from the observational
group—and two infants from the NRTI group were infected during the
breast-feeding period.
What you need to know: An editorialist commenting on
the two studies noted that “the choice of prophylaxis involves
several considerations, including relative costs, feasibility, and risks
and benefits.” According to the editorialist, while infant
prophylaxis combined with prenatal antiretroviral therapy may be more
cost-effective than maternal triple-drug regimen, it may be more
difficult to implement. Conversely, maternal triple-drug prophylaxis is
associated with more adverse outcomes (e.g., toxicity to mothers and/or
infants, adverse pregnancy outcomes). The editorialist went on to
explain that an ongoing trial (NCT01061151 at www.clinicaltrials.gov) is
investigating the comparative efficacy and safety of these two
prophylaxis options, but results will not be available for several
years.
What your patients need to know: Antiretroviral
therapy given to pregnant and nursing women suffering from HIV and to
their infants during the postpartum period decreases mother-to-child
transmission of HIV. In resource-sufficient areas, HIV-positive mothers
should still be counseled to avoid breastfeeding as the most effective
means to prevent HIV transmission to their child.
Sources:
Related resource on www.pharmacist.com:
Posted by Alex Egervary (aegervary@aphanet.org)
July 28, 2010, 9:15 am
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