Use of antiretrovirals during pregnancy and breastfeeding in low-income and middle-income countries

Abstract

Purpose of review The purpose of the study was to review recent evidence on the use of antiretrovirals during pregnancy and breastfeeding in low-income and middle-income settings. Recent findings Access to antiretroviral prophylaxis strategies for HIV-infected pregnant women has increased globally, but two-thirds of women in need still do not receive even the simplest regimen for the prevention of mother-to-child transmission of HIV, and most pregnant women in need of antiretroviral treatment do not receive it. The use of combination antiretroviral treatment in pregnancy in low-resource settings is safe and effective, and increasing evidence supports starting ongoing antiretroviral treatment at a CD4 cell count below 350/μl in pregnant women. The use of appropriate short-course antiretroviral prophylactic regimens is effective for prevention of mother-to-child transmission of HIV in women with higher CD4 cell counts. New data on the use of antiretroviral prophylaxis to prevent transmission through breastfeeding demonstrate that both maternal antiretroviral treatment and extended infant prophylaxis are effective. Summary Antiretroviral use in pregnancy can benefit mothers in need of treatment and reduce the risk of mother-to-child transmission. Emerging evidence of the effectiveness of antiretroviral prophylaxis in preventing transmission through breastfeeding is encouraging and likely to influence practice in the future.

AIDS Vaccines and Preexposure Prophylaxis: Is Synergy Possible?

“…11,12 Treatment of mother and/or child before and after childbirth has reduced the risk of mother-to-child transmission. 13,14 Very recently, the first successful demonstration of protection by tenofovir-containing vaginal gel has provided proof-ofconcept for topical microbicide preexposure prophylaxis (PrEP). Tenofovir gel reduced HIV acquisition by an estimated 39% overall, and by 54% in women with high adherence to the dosing regimen of before and after sexual exposure.…”

Mother to child transmission of HIV: What works and how much is enough?

“…19 In a randomised controlled trial for PEP infants born to mothers who did not have treatment in pregnancy, Nielson-Saines et al, 2012 have shown that perinatal MTCT rates halved when 2 or 3 drug regimen was used intrapartum compared to zidovudine monotherapy (after excluding in-utero transmission). 10 In this study infant combination therapy with ZDV and NVP was equally effective as triple therapy with Nelfinavir, lamivudine and zidovudine. 16 However it is important to point out that Nelfinavir is very poorly absorbed by neonates and is no longer available.…”

“…Termination of breastfeeding before 6 months of age increases the risk of gastro-enteritis and associated morbidity and mortality as well as increasing the risk of malnutrition in the absence of safe and nutritious feeding alternatives. 10 Recent randomised controlled studies have demonstrated the low risk of breast milk transmission where the mother is on ART, or the infant is on preexposure prophylaxis. 10,11 Therefore in such settings PMTCT programmes should be designed around breastfeeding which is the most appropriate way to safely feed infants.…”

“…10,11 Therefore in such settings PMTCT programmes should be designed around breastfeeding which is the most appropriate way to safely feed infants. 10 The combined effect of maternal ART and infant post exposure prophylaxis has been adopted into programmes in Africa to reduce MTCT, and so despite breastfeeding the risk of transmission is 1e2%, this compares to the UK where the risk of transmission is as low as 0.1% with maternal ART and formula feeding.…”

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“…They cover all classes and strata of the population especially women of reproductive age. The most vulnerable among women of reproductive age are pregnant women 10,11,12 . Women infected with HIV during pregnancy are a high-risk population.…”