Approximately 200,000 infants worldwide become infected with human immunodeficiency virus type 1 (HIV-1) annually through breast-feeding. While formula feeding reduces the risk of postnatal HIV transmission, it is associated with other important complications. Thus significant controversy persists regarding the optimal and sustainable approach to maternal-to-child transmission (MTCT) of HIV-1 in resource-limited settings. Two new randomized trials show that antiretroviral regimens in breast-feeding infants or lactating mothers significantly decrease postnatal acquisition of HIV-1.
In the BAN study, Chasela et al. randomized 2369 mother–infant pairs in Malawi to receive maternal antiretroviral therapy, infant nevirapine, or no extended postnatal antiretroviral regimen through 6 months of life. All mothers and infants received perinatal prophylaxis with single-dose nevirapine and 1 week of zidovudine plus lamivudine. The use of either a maternal antiretroviral regimen or infant nevirapine was found to significantly decrease the rate of MTCT of HIV-1 during breast-feeding.
In a double-blind, randomized trial in Botswana, the Mma Bana study, Shapiro et al. compared two highly active antiretroviral regimens in 560 HIV-1−infected pregnant women breast-feeding through 6 months post partum. Both regimens were highly effective in suppressing the maternal HIV-1 viral load as well as MTCT, with an overall transmission rate of 1.1%.
“These data demonstrate that we have a real opportunity to prevent MTCT transmission of HIV-1 during this especially vulnerable moment,” says NEJM deputy editor, Dr. Lindsey Baden. “Both studies demonstrate the complexities of implementing these strategies. However, the significant decrease in HIV-1 transmission will stimulate important discussion on how to incorporate these findings into practice.”
In an accompanying editorial, Protecting the Next Generation — Eliminating Perinatal HIV-1 Infection, Dr. Lynne Mofenson of the National Institute of Child Health and Human Development cautions, “Debate about which intervention is optimal and most effective should not be used to justify inaction. Success will be tied less to what regimen is provided than to the integration of services for the identification, care, and treatment of women with HIV-1 infection and their infants.”
What strategies are most feasible to prevent mother-to-child HIV transmission in resource-poor countries? What are the barriers to implementing anti-retroviral treatments in your practice setting?