Research Article: Antiretroviral Treatment and Prevention of Peripartum and Postnatal HIV Transmission in West Africa: Evaluation of a Two-Tiered Approach

Date Published: August 21, 2007

Publisher: Public Library of Science

Author(s): Besigin Tonwe-Gold, Didier K Ekouevi, Ida Viho, Clarisse Amani-Bosse, Siaka Toure, Patrick A Coffie, François Rouet, Renaud Becquet, Valériane Leroy, Wafaa M El-Sadr, Elaine J Abrams, François Dabis, Lynne Mofenson

Abstract: BackgroundHighly active antiretroviral treatment (HAART) has only been recently recommended for HIV-infected pregnant women requiring treatment for their own health in resource-limited settings. However, there are few documented experiences from African countries. We evaluated the short-term (4 wk) and long-term (12 mo) effectiveness of a two-tiered strategy of prevention of mother-to-child transmission of HIV (PMTCT) in Africa: women meeting the eligibility criteria of the World Health Organization (WHO) received HAART, and women with less advanced HIV disease received short-course antiretroviral (scARV) PMTCT regimens.Methods and FindingsThe MTCT-Plus Initiative is a multi-country, family-centred HIV care and treatment program for pregnant and postpartum women and their families. Pregnant women enrolled in Abidjan, Côte d’Ivoire received either HAART for their own health or short-course antiretroviral (scARV) PMTCT regimens according to their clinical and immunological status. Plasma HIV-RNA viral load (VL) was measured to diagnose peripartum infection when infants were 4 wk of age, and HIV final status was documented either by rapid antibody testing when infants were aged ≥ 12 mo or by plasma VL earlier. The Kaplan-Meier method was used to estimate the rate of HIV transmission and HIV-free survival. Between August 2003 and June 2005, 107 women began HAART at a median of 30 wk of gestation, 102 of them with zidovudine (ZDV), lamivudine (3TC), and nevirapine (NVP) and they continued treatment postpartum; 143 other women received scARV for PMTCT, 103 of them with sc(ZDV+3TC) with single-dose NVP during labour. Most (75%) of the infants were breast-fed for a median of 5 mo. Overall, the rate of peripartum HIV transmission was 2.2% (95% confidence interval [CI] 0.3%–4.2%) and the cumulative rate at 12 mo was 5.7% (95% CI 2.5%–9.0%). The overall probability of infant death or infection with HIV was 4.3% (95% CI 1.7%–7.0%) at age week 4 wk and 11.7% (95% CI 7.5%–15.9%) at 12 mo.ConclusionsThis two-tiered strategy appears to be safe and highly effective for short- and long-term PMTCT in resource-constrained settings. These results indicate a further benefit of access to HAART for pregnant women who need treatment for their own health.

Partial Text: Mother-to-child transmission (MTCT) of HIV-1 is estimated to be the cause of at least 90% of paediatric HIV infections, with more than 700,000 children newly infected in 2006 worldwide [1]. New HIV infections in children are becoming increasingly rare in Western Europe (200 reported in 2004) and the United States (300) [1,2]. In these relatively resource-rich contexts, the availability of highly active antiretroviral therapy (HAART), usually three antiretroviral (ARV) drugs during pregnancy, in combination with the avoidance of breast-feeding and with elective caesarean section, has reduced the transmission rate to less than 2% and resulted in the near elimination of MTCT [1–3].

We evaluated a two-tiered PMTCT strategy in which treatment was selected based on maternal medical status (as indicated by CD4 T cell count and WHO staging) in a West African population. HAART was prescribed to pregnant women with advanced HIV disease who met WHO eligibility criteria based on their own health status, whereas short-course various combinations of ARV regimens for PMTCT were given to pregnant women with less advanced HIV disease, who did not qualify for HAART. Three-quarters of the infants were breast-fed, for a median of 5.4 mo. Overall, the rate of peripartum HIV transmission was 2.2%, the cumulative rate of infant HIV infection at 12 mo was 5.7%, and the 12-mo HIV-free survival was 88.3%, without measurable differences between the two groups.