What Works for Women and Girls

of six months of age suggests that a longer course of daily infant nevirapine to preventHIV transmission via breast milk might be more effective. 5 (Six Week Extended-DoseNevirapine (SWEN) Study Team, 2008) (Gray II) (breastfeeding, treatment, PMTCT,Ethiopia, India, Uganda)A 2001–2003 study in Tanzania assessing 398 infants of HIV-positive women intendingto breastfeed who were treated with zidovudine and lamivudine at antenatal clinics,found a 3.8% transmission rate of HIV from mother-to-child at week six and a 4.9%transmission rate after six months. The cumulative rate of HIV infection or death forinfants was 8.5% at six months. Women were treated with zidovudine or lamivudinefrom 36 weeks gestation to one week post-delivery. Infants were treated with zidovudineand lamivudine for the first week of life and then lamivudine throughout six months ofbreastfeeding. Follow-up appointments included infant feeding counseling and occurredat weeks 1, 3 and 6 and months 3, 6, 9, 12, 15, 18, 21 and 24. Women were counseled tobreastfeed exclusively and wean by six months. The infants were breastfed for a medianof 18 weeks. Mothers reported 95% breastfeeding at six weeks, 86% after 12 weeks and18% after 26 weeks. A total of 19 children became HIV-positive, 15 were considered earlytransmissions and 4 were considered late transmissions. CD4+ cell count and viral loadwere significantly associated with mother-to-child transmission. No infants sufferedserious adverse outcomes due to antiretroviral treatment. The comparison group forthis study was a historical study of the same cohort where mothers received the sameantiretroviral regimen but infants were not treated throughout breastfeeding. In thisearlier study, mothers reported 85% breastfeeding at six weeks, 77% at 12 weeks and64% at 26 weeks. This study revealed a 5.4% transmission rate at six weeks and 11.9%transmission rate at six months. The cumulative risk for HIV acquisition or death was8.7% at six weeks and 15.5% at six months, about 50% higher than the current study(Kilewo et al., 2008). (Gray III) (treatment, PMTCT, breastfeeding, Tanzania)A study in Mozambique from 2005–2007 followed 313 HIV-positive mothers on HAART,who were counseled to breastfeed exclusively for six months and found that HAARTreduced the risk of mother-to-child transmission by 93%. There were a total of 8 casesof HIV transmission, 4 of which were considered late postnatal transmission. Womenwith repeat pregnancies, who had previously received antenatal care and HAARTthrough six months of breastfeeding, did not transmit HIV to their infants. HIV testingof infants was performed at 1, 6 and 12 months. Antiretroviral treatment began at 155 Note: The three co-principal investigators of this study from India published a critique of this study write upin The Lancet in the same publication issue. These investigators disagree with the statistical analyses usedin this study, express concern about the 40% of infants who experienced grade III or IV side effects duringtreatment and conclude that the recommendation to continue nevirapine beyond six weeks is “inappropriate.”The investigators suggest that a more prudent strategy is to “follow WHO/UNICEF guidelines for developedcountries and to make formula feeding safe, sustainable, acceptable, and affordable for mothers in developingcountries.”(Six Week Extended-Dose Nevirapine (SWEN) Study Team, 2008: 287).256 CHAPTER 9 SAFE MOTHERHOOD AND PREVENTION OF VERTICAL TRANSMISSION