New guidelines for antiretroviral drugs to prevent the transmission of HIV from mothers to their children

The World Health Organization has published new guidelines underlining the effectiveness of antiretroviral drugs to prevent the transmission of HIV from seropositive mothers to their children.

These guidelines take into account the most recent information on the safety and effectiveness of different drug regimens, as well as concerns over resistance to some of the drugs used, including nevirapine.

These are the key recommendations contained in the guidelines - Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants:

Women who need antiretroviral treatment for their own health should receive it in accordance with the WHO guidelines on antiretroviral treatment. The use of antiretroviral treatment, when indicated, during pregnancy substantially benefits the health of the woman and decreases the risk of HIV transmission to the infant.

HIV-infected pregnant women who do not have indications for antiretroviral treatment, or do not have access to treatment should be offered antiretroviral prophylaxis to prevent mother to child transmission of HIV using one of several antiretroviral regimens known to be safe and effective:

Zidovudine from 28 weeks of pregnancy plus single-dose nevirapine during labour and single-dose nevirapine and one-week zidovudine for the infant. This regimen is highly efficacious, as is initiating zidovudine later in pregnancy.

Alternative regimens based on zidovudine alone, short-course zidovudine + lamivudine or single-dose nevirapine alone are also recommended.

Although expanding access to programmes to prevent mother to child transmission presents many challenges and single-dose maternal and infant nevirapine is the simplest regimen to deliver, programmes should consider introducing one of the other recommended regimens where possible. The expansion of programmes to prevent mother to child transmission using single-dose nevirapine should not be hindered while necessary improvements in health systems are taking place to enable more complex antiretroviral regimens to be delivered.

The guidelines also refer to the issue of drug resistance. Drug resistance linked to short-course regimens to prevent mother to child transmission that do not fully suppress the virus has been known since early 2000. Programmes to prevent mother to child transmission and treat AIDS are rapidly expanding and antenatal clinics are able to identify more women who are HIV positive. Since these women are all expected to eventually require treatment, potential resistance has become a far greater concern.

However, concerns about resistance need to be balanced with the simplicity and practicality of delivering single-dose nevirapine compared with other regimens. Antiretroviral prophylaxis using single-dose maternal and infant nevirapine remains a practical alternative when provision of more effective regimens is not feasible. Progress in implementing programmes to prevent mother to child transmission based on single-dose maternal and infant nevirapine or other short course regimens should not be undermined.

New data being presented at the International AIDS Conference in Bangkok may offer a way of reducing resistance observed shortly after delivery and needs to be further assessed before any recommendation can be made to use this approach in programmes to prevent mother to child transmission.

Women who need ARV treatment for their own health should receive it in accordance with the WHO guidelines on ARV treatment. The use of ARV treatment, when indicated, during pregnancy substantially benefi ts the health of the woman and decreases the risk of HIV transmission to the infant.

Key recommendations in the guidelines are as follows.

1. HIV-infected pregnant women who do not have indications for ARV treatment, or do not have access to treatment should be offered ARV prophylaxis to prevent MTCT using one of several ARV regimens known to be safe and effective:
   • ZDV from 28 weeks of pregnancy plus single-dose NVP during labour and single-dose NVP and one-week ZDV for the infant. This regimen is highly effi cacious, as is initiating ZDV later in pregnancy.
   • Alternative regimens based on ZDV alone, short-course ZDV + 3TC or single-dose NVP alone are also recommended.
2. Although expanding access to programmes to prevent MTCT presents many challenges and single-dose maternal and infant NVP is the simplest regimen to deliver, programmes should consider introducing more complex ARV regimens where possible. The expansion of programmes to prevent MTCT using single-dose NVP should not be hindered while necessary improvements in health systems are taking place to enable more complex ARV regimens to be delivered.