HIV This Week

Simpore J, Pietra V, Pignatelli S, Karou D, Nadembega WM, Ilboudo D, Ceccherini-Silberstein F, Ghilat-Avoid-Belem WN, Bellocchi MC, Saleri N, Sanou MJ, Ouedraogo CM, Nikiema JB, Colizzi V, Perno CP, Castelli F, Musumeci S. Effective program against mother-to-child transmission of HIV at Saint Camille Medical Centre in Burkina Faso. J Med Virol 2007;79:873-9.

The present research was aimed to prevent mother-to-child transmission of HIV; to use RT-PCR in order to detect, 6 months after birth, infected children; and to test the antiretroviral resistance of both children and mothers in order to offer them a suitable therapy. At the Saint Camille Medical Centre, 3,127 pregnant women (aged 15-44 years) accepted to be enrolled in the mother-to-child transmission prevention protocol that envisages: (i) Voluntary Counselling and Testing for all the pregnant women; (ii) Antiretroviral therapy for HIV positive pregnant women and for their newborns; (iii) either powdered milk feeding or short breast-feeding and RT-PCR test for their children; (iv) finally, pol gene sequencing and antiretroviral resistance identification among HIV positive mothers and children. Among the patients, 227/3,127 HIV seropositive women were found: 221/227 HIV-1, 4/227 HIV-2, and 2/227 mixed HIV infections. The RT-PCR test allowed the detection of 3/213 (1.4%) HIV infected children: 0/109 (0%) from mothers under ARV therapy and 3/104 (2.8%) from mothers treated with Nevirapine. All children had recombinant HIV-1 strain (CRF06_CPX) with: minor PR mutations (M36I, K20I) and RT mutations (R211K). Among them, two twins had Non-Nucleoside Reverse Transcriptase Inhibitor mutation (Y18CY). Both mothers acquired a major PR mutation (V8IV), investigated 6 months after a single-dose of Nevirapine. Prevention by single-dose of Nevirapine reduced significantly mother-to-child transmission of HIV, but caused many mutations and resistance to antiretroviral drugs. Based on present study the antiretroviral therapy protocol, together with the artificial-feeding, might represent the ideal strategy to avoid transmission of HIV from mother-to-child.

Editors’ note: Not having to wait into the second year of life to know whether your baby is infected or not is a great advantage for parents. Using two or more antiretroviral drugs for prophylaxis clearly reduces both HIV transmission and the risk of drug resistance in the mother and baby but success in rolling out single drug programmes remains elusive. It is also clear that breast milk replacement with milk powder can save lives only if sustainable access to milk powder can be ensured, the water supply is safe, and equipment is not contaminated. A better alternative if equipment is available is heat treating breast milk.

There have been no clinical trials in resource-rich regions that have addressed the question of which highly active antiretroviral therapy (HAART) regimens are more effective for optimal viral response in antiretroviral-naive, human immunodeficiency virus (HIV)-infected pregnant women. Data on 240 HIV-1-infected women starting HAART during pregnancy who were enrolled in the prospective European Collaborative Study from 1997 through 2004 were analyzed. An interval-censored survival model was used to assess whether factors, including type of HAART regimen, race, region of birth, and baseline immunological and virological status, were associated with the duration of time necessary to suppress viral load below undetectable levels before delivery of a newborn. Result revealed that protease inhibitor-based HAART was initiated in 156 women (65%), 125 (80%) of whom received nelfinavir, and a nevirapine-based regimen was initiated in the remaining 84 women (35%). Undetectable viral loads were achieved by 73% of the women by the time of delivery. Relative hazards of time to achieving viral suppression were 1.54 (95% confidence interval, 1.05-2.26) for nevirapine-based HAART versus PI-based regimens and 1.90 (95% confidence interval, 1.16-3.12) for western African versus non-African women. The median duration of time from HAART initiation to achievement of an undetectable viral load was estimated to be 1.4 times greater in women receiving PI-based HAART, compared with women receiving nevirapine-based HAART. Baseline HIV RNA load was also a significant predictor of the rapidity of achieving viral suppression by delivery, but baseline immune status was not. The authors of this study concluded that nevirapine-based HAART (compared with PI [mainly nelfinavir]-based HAART), western African origin, and lower baseline viral load were associated with shorter time to achieving viral suppression.

Editors’ note: Knowing which regimen is most effective in achieving an undetectable viral load by delivery seems like such a basic, essential question to answer. Almost three quarters of the women in this study had undetectable viral loads by the time of delivery, with nevirapine based treatment acting more quickly than the protease inhibitor-based regimens.