Rapid Immunological
Decline Is Common in South African Infants Infected with HIV Despite Maternal
Use of Nevirapine (Viramune)
Use
of antiretroviral therapy has
reduced both the rate of mother-to-child HIV transmission
and HIV/AIDS disease progression in children. However, it is unclear whether individuals
treated in resource-poor settings have benefited to the same degree as those in
wealthy countries.
As described in the June 2007 issue of AIDS,
researchers conducted a study to determine the natural history of HIV infection
following maternal use of peripartum single-dose nevirapine
(Viramune) prophylaxis in South Africa.
Infants of HIV positive mothers
in KwaZulu-Natal were tested on days 1 and 28 after birth to detect intrauterine
(during gestation) and intrapartum (during delivery) HIV infection. Infant follow-up
included monthly viral load and CD4 cell measurements. Infected infants started
antiretroviral therapy when their CD4 cell percentage fell to 20% or lower. Results
• Among 740 infants
born to 719 HIV positive women, the mother-to-child HIV transmission rate was
10.3%.
• Of
these infections, 69% were attributed to intrauterine and 31% to intrapartum transmission.
• Mothers of infants
with intrapartum infection had higher HIV viral loads than those of infants with
intrauterine infection (279,000 vs 86,600 copies/mL; P = 0.039).
•
Mothers of uninfected infants had the lowest viral loads (median
26,750 copies/mL; P < 0.001).
•
Peak viremia was higher in infants with intrapartum versus intrauterine
infection (5,160,000 vs 984,000 copies/mL; P < 0.001).
•
Median viral load at birth in infants with intrauterine infection
(155,000 copies/mL) fell by 1.4 logs to 6510 copies/mL by day 5, and was beneath
the limit of detection in 38%.
•
CD4 cell percentage declined rapidly, to 20% or lower in 70%
of infants, and to 25% or lower in 85%.
Conclusion
"Mother-to-child
transmission was reduced by single-dose nevirapine through an effect on intrapartum
transmission," the researchers concluded. "Where mother-to-child transmission
occurred despite nevirapine, two-thirds of transmissions arose intrauterine; intrapartum-infected
babies were born to mothers with very high viral load." "Disease
progression was particularly rapid, [with] 85% [of] infants meeting World Health
Organization (WHO) criteria for antiretroviral within 6 months," they continued.
"These findings argue for more effective mother-to-child transmission-prevention
programmes in resource-limited countries."
HIV Pathogenesis Programme,
Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South
Africa; Imperial College London, UK; University of Oxford, UK; Partners AIDS Research
Center, Massachusetts General Hospital, Boston, MA; Howard Hughes Medical Institute,
Chevy Chase, MD.
07/03/07
Reference W
Mphatswe, N Blanckenberg, G Tudor-Williams, and others. High frequency of rapid
immunological progression in African infants infected in the era of perinatal
HIV prophylaxis. AIDS 21(10): 1253-1261. June 2007.
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