What Works for Women and Girls

EVIDENCE1. ARVs, when used for treatment or prophylaxis, and can reduce mother-to-child HIV transmissionto infants. [See also 9C-2. Treatment]A randomized controlled trial from 2005–2008 in Burkina Faso, Kenya and SouthAfrica assessed both mothers’ health and mother-to-child transmission amongHIV-positive women whose CD4 count was between 200 and 500. The study foundthat triple-antiretroviral treatment initiated during pregnancy and continued until sixmonths postpartum reduced the risk of transmission to infants and improved HIV-freesurvival of infants compared to standard short-course antiretroviral therapy. At 12months, 6.7% of the 402 infants whose mothers received triple-course antiretroviraltreatment had died compared to 10.2% of the 403 infants whose mothers receivedshort-course antiretroviral treatment. This effect was especially strong in women withCD4 counts between 200 and 350. At 12 months, the rate of transmission from motherto infant for triple-antiretroviral therapy was 5.5% compared to 9.5% for those whoreceived short-course antiretroviral treatment. The infants whose mothers receivedtriple-course antiretroviral therapy experienced a 42% risk reduction in HIV infectionsand a 37% risk reduction of death at 12 months, for a combined 36% risk reduction ofeither HIV infection or death. The study also found that triple-antiretroviral therapy hadlow toxicity for mothers and infants. All infants received single-dose nevirapine pluszidovudine in the first 72 hours and all mothers received counseling on replacementfeeding or exclusive breastfeeding with weaning by six months. Formula was providedfree of cost (Kesho-Bora Study Group, 2009). (Gray I) (treatment, PMTCT, Burkina Faso,Kenya, South Africa)A study in Botswana (no date given) found a positive association between maternalviral load (in both plasma and breast milk) and mother-to-child transmission after onemonth in breastfed infants. 1,200 HIV-positive women at 4 sites were enrolled in thestudy and randomized to either exclusively breastfeed for 6 months in combinationwith infant zidovudine treatment or to exclusively formula feed. Mothers received antenatalzidovudine starting at 34 weeks of pregnancy along with intrapartum zidovudineand either single-dose nevirapine or a placebo at delivery. During the study HAARTbecame available and women with CD4 counts below 200 cells/mm 3 or AIDS definingillnesses were eligible for treatment either antenatally or postnatally. Infants receivedsingle-dose of nevirapine or a placebo at birth along with one month of zidovudineprophylaxis for formula fed infants and six months for breastfed infants. After17 months the study protocol was changed so that all infants received single-dosenevirapine at birth. Of 1,116 infants alive and HIV-negative at birth, 1.1% of formulafed and 1.3% of breastfed infants tested HIV-positive after one month. Of 547 breastfedinfants HIV-negative at one month, 4.4% tested HIV-positive before 2 years of age.Only 4 formula-fed infants tested HIV-positive after one month but before 2 years254 CHAPTER 9 SAFE MOTHERHOOD AND PREVENTION OF VERTICAL TRANSMISSION