Mortality of infants born to HIV-infected mothers in Africa

Abstract

The article by Marie-Louise Newell and colleagues (Oct 2, p 1236)1Newell ML Coovadia H Cortina-Borja M Rollins N Gaillard P Dabis F for the Ghent International AIDS Society (IAS) working group on HIV in women and childrenMortality among infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis.Lancet. 2004; 364: 1236-1243Summary Full Text Full Text PDF PubMed Scopus (891) Google Scholar on mortality of infants born to HIV-infected mothers presents strong evidence that should inform efforts to prevent and treat paediatric AIDS in developing countries. Furthermore, the findings provide the impetus for more rapid implementation of the new WHO guidelines on prophylaxis for prevention of mother to child transmission (PMTCT) of HIV. Many clinical trials have shown that high maternal viral load increases risk of HIV transmission to the child.2Abrams EJ Wiener J Carter R et al.Maternal health factors and early pediatric antiretroviral therapy influence the rate of perinatal HIV-I disease progression in children.AIDS. 2003; 17: 867-877Crossref PubMed Scopus (74) Google Scholar, 3Cooper ER Charurat M Mofenson L Combination antiretroviral strategies for the treatment of pregnant HIV-I-infected women and prevention of perinatal HIV-I transmission.J Acquir Immune Defic Syndr. 2002; 29: 484-494Crossref PubMed Google Scholar In this study, the infants of women with high viral load or who had died also had high mortality rates, whether infected with HIV or not. These findings, therefore, strongly support treatment of immunocompromised pregnant women for their own disease (during the third trimester of pregnancy at least), so reducing both the risk of HIV infection and the risk of premature mortality in the child. These data also indicate that children infected with HIV during pregnancy account for a high proportion of premature mortality. Initiation of highly active antiretroviral therapy (HAART), or provision of zidovudine prophylaxis after 28 weeks of pregnancy, with administration of a single dose of nevirapine at delivery will have a greater effect on reducing infant mortality than would single dose nevirapine alone. The results of this study, along with the findings from clinical trials in Thailand4Jourdain G Ngo-Giang-Huong N Le Coeur S et al.Intrapartum exposure to nevirapine and subsequent maternal responses to nevirapine-based antiretroviral therapy.N Engl J Med. 2004; 351: 229-240Crossref PubMed Scopus (375) Google Scholar and South Africa5Morris L, Martinson N, Pillay C, et al. McIntyre persistence of nevirapine resistance mutations 6 months following single dose nevirapine. XV International AIDS Conference, Bangkok, Thailand, July 2004: abstract ThOrB1353.Google Scholar on development of resistance after a single dose of nevirapine, particularly in women with high viral loads and low CD4 counts, suggest that use of a single dose of nevirapine is not the best option for immunocompromised women. These women have no reduction in risk of transmission during pregnancy and are more likely to develop resistance to nevirapine that could compromise future treatment options. Efforts to scale up PMTCT Programmes in Africa have tended to use single dose nevirapine alone. Programmes have struggled to get nevirapine to pregnant women infected with HIV, but few have been able to see an effect on infant mortality. As PMTCT programmes mature across Africa, many will now have the resources and the evidence for implementing one of the more complicated regimens. This article and the new WHO PMTCT guidelines provide the basis for programmes to shift to provide better options for immunocompromised women. HAART or early antiretroviral prophylaxis (during the third trimester) should be offered. Disease staging or CD4 counts or both should be done for all HIV-infected women to provide them the best options for themselves and their child. One third of infected infants in this study died at age younger than 1 year. Efforts to diagnose children early and to provide cotrimoxazole prophylaxis to HIV-exposed newborns should be made by all PMTCT programmes to reduce infant mortality due to HIV/ AIDS. I declare that I have no conflict of interest. The opinions expressed here are those of the author and do not represent USAID policy.