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More Progress on Preventing HIV Infection in Infants

Three trials this year pointed to the benefits of extending maternal antiretroviral prophylaxis throughout the breast-feeding period.

Providing antiretroviral drugs during pregnancy and delivery dramatically reduces the likelihood of a mother transmitting HIV to her infant. This year, three randomized trials demonstrated the benefits of extending antiretroviral prophylaxis throughout breast-feeding — and ultimately led to a change in the WHO treatment guidelines.

The most dramatic results came from the Mma Bana study in Botswana, which involved 730 HIV-infected pregnant women with CD4 counts ≥200 cells/mm3 who were randomized to receive one of two triple-drug regimens in the third trimester and continue through 6 months of breast-feeding. By 6 months, only 1% of the women had transmitted HIV to their infants — the lowest rate ever reported for an HIV-infected breast-feeding population (JW AIDS Clin Care Aug 31 2009).

The other two trials to provide supporting evidence were the Kesho Bora study in Kenya and the BAN study in Malawi. In the Kenyan trial, the rate of HIV transmission at 6 months was 4.9% among women who received triple-drug antiretroviral regimens from the third trimester through 6.5 months postpartum, versus 8.2% among women who received standard, short-course prophylaxis (Abstract LBPEC01, IAS 2009). Likewise, in the Malawian study, the rate of HIV transmission between 1 and 28 weeks postpartum was 3.0% with a maternal triple-drug regimen, 1.8% with daily infant nevirapine, and 6.4% with neither (Abstract WELBC103, IAS 2009).

More recently, results became available from a nonrandomized interventional cohort study, in which 562 pregnant women in Rwanda received triple-drug regimens from 28 weeks' gestation onward. At 9 months, HIV-free survival rates were comparable between infants who were breast-fed and those who were formula fed (95% and 94%, respectively) (AIDS 2009; 23:2415).

Although these various studies differed subtly in design, aims, outcomes, and treatment regimens, the take-home message is the same: It may now be feasible to offer HIV-infected women in resource-limited settings the opportunity to breast-feed their infants without undue risk of transmitting HIV infection.

— Sonia Nagy Chimienti, MD

Published in Journal Watch HIV/AIDS Clinical Care January 4, 2010

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