Antiretroviral treatment and prevention of peripartum and postnatal HIV transmission in west africa: Evaluation of a two-tiered approach

Background Highly active antiretroviral treatment ( HAART) has only been recently recommended for HIV-infected pregnant women requiring treatment for their own health in resource-limited settings. However, there are few documented experiences from African countries. We evaluated the short-term ( 4 wk) and long-term ( 12 mo) effectiveness of a two-tiered strategy of prevention of mother-to-child transmission of HIV ( PMTCT) in Africa: women meeting the eligibility criteria of the World Health Organization ( WHO) received HAART, and women with less advanced HIV disease received short-course antiretroviral ( scARV) PMTCT regimens. Methods and Findings The MTCT-Plus Initiative is a multi-country, family-centred HIV care and treatment program for pregnant and postpartum women and their families. Pregnant women enrolled in Abidjan, Cote d'Ivoire received either HAART for their own health or short-course antiretroviral ( scARV) PMTCT regimens according to their clinical and immunological status. Plasma HIV-RNA viral load ( VL) was measured to diagnose peripartum infection when infants were 4 wk of age, and HIV final status was documented either by rapid antibody testing when infants were aged >= 12 mo or by plasma VL earlier. The Kaplan-Meier method was used to estimate the rate of HIV transmission and HIV-free survival. Between August 2003 and June 2005, 107 women began HAART at a median of 30 wk of gestation, 102 of them with zidovudine ( ZDV), lamivudine ( 3TC), and nevirapine ( NVP) and they continued treatment postpartum; 143 other women received scARV for PMTCT, 103 of them with sc( ZDV+3TC) with single-dose NVP during labour. Most ( 75%) of the infants were breast-fed for a median of 5 mo. Overall, the rate of peripartum HIV transmission was 2.2% ( 95% confidence interval [ CI] 0.3%-4.2%) and the cumulative rate at 12 mo was 5.7% ( 95% CI 2.5%-9.0%). The overall probability of infant death or infection with HIV was 4.3% ( 95% CI 1.7%-7.0%) at age week 4 wk and 11.7% ( 95% CI 7.5%-15.9%) at 12 mo. Conclusions This two-tiered strategy appears to be safe and highly effective for short-and long-term PMTCT in resource-constrained settings. These results indicate a further benefit of access to HAART for pregnant women who need treatment for their own health.