HAART during pregnancy and breastfeeding in the developing world.
Subject: Highly active antiretroviral therapy (Safety and security measures)
HIV infection (Prevention)
Perinatal infection (Prevention)
Breast feeding (Safety and security measures)
Pub Date: 05/01/2010
Publication: Name: Reproductive Health Matters Publisher: Reproductive Health Matters Audience: General Format: Magazine/Journal Subject: Family and marriage; Health; Women's issues/gender studies Copyright: COPYRIGHT 2010 Reproductive Health Matters ISSN: 0968-8080
Issue: Date: May, 2010 Source Volume: 18 Source Issue: 35
Topic: Event Code: 260 General services
Geographic: Geographic Scope: Rwanda Geographic Code: 6RWAN Rwanda
Accession Number: 236247767
Full Text: There are as yet no definitive data from randomised controlled trials with clinical end points to inform when to optimally start highly active antiretroviral therapy (HAART) in asymptomatic HIV-infected patients, particularly during pregnancy. A non-randomised cohort study in Rwanda assessed the 9-month HIV-free survival of children with two strategies to prevent HIV mother-to-child transmission. Between 2005 and 2007, all consenting HIV-infected pregnant women at four public health centres were included. Women could choose the mode of feeding for their infant: breastfeeding with maternal HAART for 6 months or formula feeding. All received HAART from 28 weeks gestation. Of the 532 first-liveborn infants, 43% were breastfed and 57% formula fed. Both approaches were safe and effective, with no significant difference in nine-month HIV-free survival, which was around 95% in both groups (p=0.66). Seven children (1.3%) were HIV-infected at nine months, of whom six were infected in utero, representing one of the lowest mother-to-child transmission rates reported in a low-income country. Breastfeeding with HAART had minimal risk of postnatal transmission (one child infected), similar to the formula feeding risk (no child infected). A key implication is that women can be offered a choice of safe and effective infant feeding options. These findings may not be generalisable as they were obtained within a specific study setting with high quality of care and follow-up, and under current Rwandan guidelines only pregnant women with low CD4 cell counts will receive HAART (compared to all women in this study). (1)

The authors of an editorial point to the urgent need to make HAART available for treatment-eligible women during pregnancy as well as post-partum as it could impact on maternal and child survival. The optimal duration of breastfeeding while on HAART still needs to be defined, as does whether maternal HAART is preferable or better than antiretroviral drug prophylaxis provided to the infant. In the meantime, use of daily infant HAART should be considered to reduce breastfeeding-related HIV transmission in infants born to women with a CD4 cell count above 350 cells/ml, and all women with CD4 cell counts below this level should receive HAART during pregnancy, breastfeeding and afterwards. (2) A separate commentary agrees and supports breastfeeding while strengthening programmes to provide antiretroviral therapy for pregnant and lactating women who need it and offering antiretroviral drug interventions to either mother or child throughout breastfeeding for women with higher CD4 counts. (3)

(1.) Peltier CA, Ndayisaba GF, Lepage P, et al. Breastfeeding with maternal antiretroviral therapy or formula feeding to prevent HIV postnatal mother-to-child transmission in Rwanda. AIDS 2009;23(18):2415-23.

(2.) Bulterys M, Wilfert CM. HAART during pregnancy and during breastfeeding among HIV-infected women in the developing world: has the time come? AIDS 2009;23(18):2473-77.

(3.) Kuhn L, Sinkala M, Thea DM, et al. HIV prevention is not enough: child survival in the context of prevention of mother to child HIV transmission. Journal of International AIDS Society 2009;12:36.
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