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Antiretroviral Therapy at Conception Reduces Risk of Mother-to-child HIV Transmission

SUMMARY: HIV positive women who were already receiving antiretroviral therapy (ART) at the time of conception were less likely to transmit the virus to their babies during pregnancy or delivery, according to study findings reported in the May 1, 2010 Journal of Acquired Immune Deficiency Syndromes. Women who started treatment during pregnancy were at greater risk for mother-to-child transmission, with the odds increasing by 8% for each week treatment was delayed.

By Liz Highleyman

It is well-established that antiretroviral therapy can dramatically reduce the likelihood of vertical HIV transmission. There is less extensive information, however, about the effects of different drugs or the influence of treatment timing and duration.

A team of researchers from the U.S., Belgium, and South Africa analyzed outcomes among 1142 HIV positive pregnant women with advanced immune suppression (< 250 cells/mm3 or other indications for ART) who were treated between January 2004 and August 2008 at 2 clinics in Johannesburg that provided integrated prenatal care and antiretroviral treatment.

The women had an average age of 30 years and a low median baseline CD4 cell count of 161 cells/mm3. At the time of the study, South African treatment guidelines called for ART initiation at 200 cells/mm3. (In late 2009, both South African guidelines and World Health Organization global ART guidelines were revised to recommend treatment below 350 cells/mm3). Some women had previously received single-dose nevirapine (Viramune) to prevent mother-to-child HIV transmission.


968 women (85%) started ART during pregnancy and had a mean treatment duration of 10.7 weeks at the time of delivery.
147 women (15%) became pregnant when they were already on ART and had a mean treatment duration of 93.4 weeks at delivery.
The overall rate of mother-to-child transmission was 4.9% (43 out of 874 babies with available data), as determined by a positive infant HIV DNA PCR test 4-6 weeks after birth.
No differences in the rate of vertical transmission were detected between women who took various combination ART regimens.
The transmission rate was 8-fold lower among women who became pregnant while on ART compared with those who started treatment during pregnancy (0.7% vs 5.7%, respectively; P = 0.01).
Among women who started ART during pregnancy, shorter treatment duration was associated with lower likelihood of achieving undetectable viral load.
Each additional week of treatment during pregnancy reduced the odds of vertical transmission by 8% (P = 0.02).
Women who received combination ART for 12 weeks or less had a vertical transmission rate of 7.4%, the same as women treated with single-dose nevirapine.

"Late initiation of HAART is associated with increased risk of mother-to-child transmission," the researchers concluded.

They noted that women who started ART during pregnancy had an unexpectedly high rate of vertical transmission relative to rates observed in other resource-limited countries (5.7% vs the 2.3% seen in a recent West African study, for example). Nevertheless, the transmission rate was still about 3 times lower that the 17.4% rate for women in the same area who received no antiretroviral drugs during pregnancy.

The authors recommended that "Strategies are needed to facilitate earlier identification of HIV-infected women," thereby enabling them to start treatment sooner.

David Geffen School of Medicine at UCLA, Division of Infectious Diseases and Center for Clinical AIDS Research and Education, Los Angeles, CA; Reproductive Health and HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa; Rahima Moosa Mother and Child Hospital, Enhancing Children's HIV Outcomes (ECHO), University of the Witwatersrand, Johannesburg, South Africa; Department of Obstetrics and Gynecology, University of Gent, Gent, Belgium.


RM Hoffman, V Black, K Technau, and others. Effects of Highly Active Antiretroviral Therapy Duration and Regimen on Risk for Mother-to-Child Transmission of HIV in Johannesburg, South Africa. Journal of Acquired Immune Deficiency Syndromes 54(1): 35-41 (Abstract). May 2010.















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