Tale of Two Epidemics. Part 5

It is increasingly recognized that programs to prevent MTCT must also consider the health of the mother. Antiretroviral prophylaxis regimens, although they prevent MTCT, do not stop progression of HIV infection in the mother. Studies in Africa have shown a 3–4-fold increase in the risk of death in children, regardless of their HIV infection status, whose mothers have died of HIV infection. Programs such as MTCT-Plus, which is sponsored by private philanthropic foundations and based at Columbia University’s Mailman School of Public Health (New York), will work through existing MTCT programs to provide basic care for prevention and/or treatment of HIV-related opportunistic infections and treatment with antiretroviral drugs for HIV-infected mothers and other family members who require therapy. Data from Kenya published in this issue of The Journal of Infectious Diseases show that women with advanced HIV disease (as demonstrated by high virus loads in plasma and breast milk and low CD4+ cell counts) are more likely to transmit HIV through breast milk, suggesting that, in addition to improving maternal health, treatment of such women with antiretroviral therapy may also reduce the risk of transmission through breast milk to their infants. Provision of antiretroviral therapy for HIV-infected, ill individuals may be the most effective inducement for HIV testing in countries with limited resources

It is easy to become overwhelmed by the enormity of the worldwide perinatal HIV epidemic and the extent of resource and infrastructure needs; however, this cannot be an excuse for inaction. A global collaborative effort and political commitment to extend the benefits that now exist in resource-rich countries to resource-limited countries is needed. Implementation will be challenging. However, the cost of indecision and delay in program implementation is high. Every pediatric HIV infection that is not prevented increases the ultimate economic and social cost to each family, community, and country.

To determine the efficacy and safety of 2 inexpensive and easily deliverable antiretroviral (ARV) regimens for the prevention of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) type 1 during labor and delivery, HIV-infected pregnant women were screened at 11 maternity health institutions in South Africa and were enrolled in an open-label short course ARV regimen of either nevirapine (Nvp) or multiple-dose zidovudine and lamivudine (Zdv/3TC). The overall estimated HIV-1 infection rates in 1307 infants by 8 weeks were 12.3% (95% confidence interval [CI], 9.7–15.0) for Nvp and 9.3% (95% CI, 7.0–11.6) for Zdv/3TC (P=.11). Excluding infections detected within 72 h (intrauterine), new HIV-1 infections were detected in 5.7% (95% CI, 3.7–7.8) and 3.6% (95% CI, 2.0–5.3) of infants in the Nvp and Zdv/3TC groups, respectively, in the 8 weeks after birth. There were no drug-related maternal or pediatric serious adverse events. Common complications were obstetrical for mothers (Nvp group, 24.3%; Zdv/3TC group, 26.3%) and respiratory for infants (Nvp group, 16.1%; Zdv/3TC group, 17.0%). This study further confirms the efficacy and safety of short-course ARV regimens in reducing MTCT rates in developing countries