Is the time for an AIDS-free new generation different in resource-limited and industrialized countries?

Abstract

In recent years, much progress has been reported about the availability of access to three-drug combination antiretroviral therapy (cART) in resource-limited countries, but many goals still remain to be achieved. WHO’s public health recommendations for the scaling up of cART in adults and adolescents in resource-limited countries [1] define similar criteria for starting therapy as those in use in industrialized countries [2]. Unfortunately, however, the same is not true for WHO’s recommendations concerning prevention of mother-to-child transmission of HIV (PMTCT) [3,4]. In resource-rich settings, the use of three-drug cART in all HIV-infected pregnant women during the antepartum period, regardless of their immune status, has been the cornerstone of a multi-tiered PMTCT strategy that has reduced the perinatal transmission rate to less than 2% [4,5]. The same strategy has been adopted by some low-income/middleincome countries, for example, Brazil, with similar excellent results [6]. In industrialized countries, pregnancy is a major criterion for starting a three-drug cART in HIV-infected women [2]. These women, who may not require treatment for their own health, should receive three-drug cART throughout pregnancy for prevention of perinatal transmission [4]. In these settings, an antiretroviral prophylaxis with one or two drugs is considered exclusively for those HIV-infected pregnant women with near term HIV RNA less than 1000 copies or for those arriving late in pregnancy or in labour to the attention of the health services. Consequently, in the daily clinical practice of the industrialized countries, the use of three-drug cART in the antepartum period is applied to