Current issues in prevention of mother-to-child transmission of HIV-1.
ABSTRACT To review new evidence in prevention of mother-to-child-transmission of HIV-1, which establishes, in principle, the feasibility of greatly improved effectiveness in developing countries.
This review presents evidence that demonstrates that a large gap in prevention of mother-to-child-transmission [MTCT] is being increasingly bridged. Recent studies have addressed issues on postnatal transmission of HIV-1 through breastfeeding. Breastfeeding transmission affects the majority of HIV-infected pregnant women and children in the world and who live in Africa and are often poor. Prevention of unwanted pregnancies in all women living in high HIV prevalence regions will probably reduce the risk of HIV-positive pregnancies. These studies demonstrate the success of the following three types of interventions:primary prevention of HIV-1 in women;prophylaxis with antiretroviral drugs in breastfeeding infants;prophylaxis with antiretroviral drugs for lactating mothers.It is also clear that key barriers to implementing these findings in developing countries are weak and ineffectual health systems. Therefore, identifying needs for improving health service delivery are critical; an example of the synergy between prevention and treatment through integrated services is given.
Recent data on primary prevention of HIV-1 in women of child-bearing age, and use of antiretrovirals in breastfeeding infants and lactating mothers, report successful interventions for the prevention of breastfeeding transmission of HIV-1. Health infrastructure improvement in developing countries is central to the application of research findings to implementation of MTCT programmes.
SourceAvailable from: Jolene Skordis-Worrall[Show abstract] [Hide abstract]
ABSTRACT: BACKGROUND: Women's groups and health education by peer counsellors can improve the health of mothers and children. We assessed their effects on mortality and breastfeeding rates in rural Malawi. METHODS: We did a 2×2 factorial, cluster-randomised trial in 185 888 people in Mchinji district. 48 equal-sized clusters were randomly allocated to four groups with a computer-generated number sequence. 24 facilitators guided groups through a community action cycle to tackle maternal and child health problems. 72 trained volunteer peer counsellors made home visits at five timepoints during pregnancy and after birth to support breastfeeding and infant care. Primary outcomes for the women's group intervention were maternal, perinatal, neonatal, and infant mortality rates (MMR, PMR, NMR, and IMR, respectively); and for the peer counselling were IMR and exclusive breastfeeding (EBF) rates. Analysis was by intention to treat. The trial is registered as ISRCTN06477126. FINDINGS: We monitored outcomes of 26 262 births between 2005 and 2009. In a factorial model adjusted only for clustering and the volunteer peer counselling intervention, in women's group areas, for years 2 and 3, we noted non-significant decreases in NMR (odds ratio 0·93, 0·64-1·35) and MMR (0·54, 0·28-1·04). After adjustment for parity, socioeconomic quintile, and baseline measures, effects were larger for NMR (0·85, 0·59-1·22) and MMR (0·48, 0·26-0·91). Because of the interaction between the two interventions, a stratified analysis was done. For women's groups, in adjusted analyses, MMR fell by 74% (0·26, 0·10-0·70), and NMR by 41% (0·59, 0·40-0·86) in areas with no peer counsellors, but there was no effect in areas with counsellors (1·09, 0·40-2·98, and 1·38, 0·75-2·54). Factorial analysis for the peer counselling intervention for years 1-3 showed a fall in IMR of 18% (0·82, 0·67-1·00) and an improvement in EBF rates (2·42, 1·48-3·96). The results of the stratified, adjusted analysis showed a 36% reduction in IMR (0·64, 0·48-0·85) but no effect on EBF (1·18, 0·63-2·25) in areas without women's groups, and in areas with women's groups there was no effect on IMR (1·05, 0·82-1·36) and an increase in EBF (5·02, 2·67-9·44). The cost of women's groups was US$114 per year of life lost (YLL) averted and that of peer counsellors was $33 per YLL averted, using stratified data from single intervention comparisons. INTERPRETATION: Community mobilisation through women's groups and volunteer peer counsellor health education are methods to improve maternal and child health outcomes in poor rural populations in Africa. FUNDING: Saving Newborn Lives, UK Department for International Development, and Wellcome Trust.The Lancet 05/2013; 381(9879):1721-1735. DOI:10.1016/S0140-6736(12)61959-X · 39.21 Impact Factor
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ABSTRACT: Background: Human deficiency virus (HIV) protease inhibitors (PIs) are widely used drugs whose effects are pharmacologically enhanced by ritonavir, a potent cytochrome P450 inhibitor. We reported previously that prophylactic postnatal ritonavir-PI therapy in HIV-exposed neonates was associated with increases in plasma 17-hydroxyprogesterone (17-OHP) and dehydroepiandrosterone sulfate (DHEA-S). Aims: To further investigate adrenal function in neonates and adolescents given ritonavir-PI. Methods: Adrenal function was assessed prospectively in 3 HIV-exposed neonates given short-term prophylactic treatment and 3 HIV-infected adolescents given long-term treatment. Plasma cortisol, 17-OHP, 17-OH-pregnenolone, DHEA-S, and androstenedione were measured before and after ACTH administration. Results: None of the patients had clinical signs of adrenal dysfunction. The only neonate exposed to ritonavir-PI in utero had up to 3-fold increases in plasma 17-OHP. Increases in 17-OH-pregnenolone of up to 3.1-fold were noted in 4 of the 6 patients, and all 6 patients had elevations in DHEA-S (up to 20.4-fold increase) and/or DHEA (up to 4.7-fold) and/or androstenedione (up to 5.2-fold). All these parameters improved after treatment completion. Conclusion: Neonates and adolescents given ritonavir-PI exhibit a similar adrenal dysfunction profile consistent with an impact on multiple adrenal enzymes. These abnormalities require evaluation, given the potentially long exposure times. © 2014 S. Karger AG, Basel.Hormone Research in Paediatrics 02/2014; 81(4). DOI:10.1159/000356916 · 1.71 Impact Factor
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ABSTRACT: Administration of antiretroviral drugs to mothers and infants significantly decreases mother-to-child human immunodeficiency virus (HIV) transmission; cesarean sections and discouraging breastfeeding further decreases this risk. The present study confirmed the HIV status of babies born to mothers infected with HIV and describes the characteristics of babies and mothers who received preventive treatment. This study retrospectively analyzed medical records of nine infants and their mothers positive for HIV who gave birth at Korea University Ansan Hospital, between June 1, 2003, and May 31, 2013. Maternal parameters, including HIV diagnosis date, CD4+ count, and HIV ribonucleic acid (RNA) copy number, were analyzed. Infant growth and development, HIV RNA copy number, and HIV antigen/antibody test results were analyzed. Eight HIV-positive mothers delivered nine babies; all the infants received antiretroviral therapy. Three (37.5%) and five mothers (62.5%) were administered single- and multidrug therapy, respectively. Intravenous zidovudine was administered to four infants (50%) at birth. Breastfeeding was discouraged for all the infants. All the infants were negative for HIV, although two were lost to follow-up. Third trimester maternal viral copy numbers were less than 1,000 copies/mL with a median CD4+ count of 325/µL (92-729/µL). Among the nine infants, two were preterm (22.2%) and three had low birth weights (33.3%). This study concludes that prophylactic antiretroviral therapy, scheduled cesarean section, and prohibition of breastfeeding considerably decrease mother-to-child HIV transmission. Because the number of infants infected via mother-to-child transmission may be increasing, studies in additional regions using more variables are necessary.Korean Journal of Pediatrics 03/2014; 57(3):117-24. DOI:10.3345/kjp.2014.57.3.117