Prevention of mother-to-child transmission of HIV: treatment options

Abstract

Mother-to-child transmission of HIV-1 is responsible for 1800 new infections in children daily. The use of antiretroviral therapy can significantly reduce the risk of transmission. In settings where highly active antiretroviral therapy is available, mother-to-child transmission rates have been reduced to less than 2%, in the absence of breastfeeding. Women who require ongoing highly active antiretroviral therapy for their own health should receive this in pregnancy, which is also very effective in preventing transmission. Where resources allow, combination highly active antiretroviral therapy can also be used for preventing mother-to-child transmission in those women who do not yet need to receive ongoing treatment. The potential side effects of highly active antiretroviral therapy must be considered in pregnant women and their infants. Where highly active antiretroviral therapy is not possible, a dual combination regimen of antepartum zidovudine with single-dose nevirapine to mother and baby can reduce transmission to below 5%. In many places, the only available option is single-dose nevirapine to mother and baby, which is effective in halving transmission risk, although the effectiveness in practice will be influenced by continued infection through breastfeeding, and by program factors such as the uptake of HIV testing. Exposure to nevirapine for mother-to-child transmission prevention can select for resistant virus in the majority of women. While the long-term implications of this are not completely clear, this selection can be reduced by the addition of short courses of postpartum zidovudine and lamivudine.