July 20, 2010
Since WHO issued revised guidelines in 2006, important new evidence has emerged on the use of antiretroviral (ARV) prophylaxis for the prevention mother to child transmission of HIV (PMTCT), and on safe feeding practices for HIV-exposed infants.
At AIDS 2010, WHO is releasing new guidelines on PMTCT and infant feeding practices. If widely implemented, these guidelines will provide the basis for more effective PMTCT interventions in resource-limited settings, and will virtually eliminate the number of new paediatric HIV infections. For the first time, the elimination of mother-tochild transmission of HIV (MTCT) is considered a realistic public health goal.
The PMTCT and infant feeding guidelines were developed in coordination with the new WHO guidelines on adult and adolescent ART and paediatric ART.
The key recommendations of the new guidance on ARV drugs for treatment of pregnant women and prevention of HIV in infants are as follows:
The 2010 revised PMTCT guidelines refer to the following two key approaches:
The 2006 guidelines recommended AZT + 3TC + NVP. In the 2010 guidelines, the recommended first-line regimens for pregnant women are:
The expanded number of recommended treatment options in the 2010 guidelines will enable countries to choose the treatment option that is most suited to their national circumstances and the needs of their populations.
The 2006 guidelines proposed starting ARV prophylaxis in the third trimester (28 weeks) of pregnancy. They recommended a regimen of twice daily zidovudine (AZT), single-dose nevirapine at onset of labour, a combination of AZT+3TC during delivery and one week postpartum, as well as infant prophylaxis for one week after birth.
The 2010 guidelines include two options, both of which should start earlier in pregnancy, at 14 weeks or as soon as possible thereafter. The two options provide significant reduction in MTCT with equal efficacy in this group of women who are not eligible for ART:
In many countries, both health services and individual mothers have not been able to adequately support and provide safe replacement feeding. HIV-positive mothers have faced the dilemma of either giving their babies all the benefits of breastfeeding but exposing them to the risk of HIV infection, or avoiding all breastfeeding and increasing the risk of death from diarrhoea and malnutrition.
At the time of the 2006 PMTCT guidelines, there were insufficient data supporting the use of ARVs to prevent HIV transmission from mother to baby during breastfeeding.
Since then, several clinical trials have shown the efficacy and acceptability of prophylaxis either to the mother or to the infant during breastfeeding. The new PMTCT recommendations outlined above reflect this exciting breakthrough.
The 2010 guidelines on HIV and infant feeding build on the new recommendations for lifelong ART and the two prophylaxis options for HIV-positive women who breastfeed and are not taking ART - see Options A and B as above.
The effectiveness of ARVs to reduce transmission through breastfeeding has resulted in two major changes from previous guidelines:
The 2010 guidelines have great potential to improve the mother's own health and to reduce mother-to-child HIV transmission risk to 5% or lower in a breastfeeding population, from a background transmission risk of 35% (in the absence of any interventions and with continued breastfeeding).The 2010 guidelines have great potential to improve the mother's own health and to reduce mother-to-child HIV transmission risk to 5% or lower in a breastfeeding population, from a background transmission risk of 35% (in the absence of any interventions and with continued breastfeeding).
The new guidelines offer the potential for all countries to virtually eliminate paediatric HIV. Combined with improved infant feeding practices, the guidelines can help to reduce both child mortality and new HIV infections.The new guidelines offer the potential for all countries to virtually eliminate paediatric HIV. Combined with improved infant feeding practices, the guidelines can help to reduce both child mortality and new HIV infections.
PMTCT can also act as a gateway to improved reproductive, maternal and child health services at primary level and, in turn, bolster progress towards achieving the health-related Millennium Development Goals of reducing under-five mortality rates by two thirds, decreasing maternal mortality rates by three quarters, and halting and reversing the spread of HIV/AIDS by 2015.
The new guidelines enable more consistent policies and support for infant feeding practices among both HIV-positive and HIV-negative mothers in the general population. Given the importance of breastfeeding as a child survival intervention, the availability of ARV interventions could make a major contribution to reducing child mortality in the entire community.
The major challenges in scaling-up national PMTCT services and implementing the new guidelines are weak health infrastructure, limited human resources, limited management capacity, and limited funding and support for PMTCT. However there are many hopeful signs that PMTCT now have greater priority both at the national and international level.
Given the confusion in the past around HIV and infant feeding, comprehensive communications strategies are now needed to give health workers confidence to recommend breastfeeding and ARVs and for HIV-positive mothers to want to breastfeed.
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