HAART Is 'Optimal Treatment' for Reducing Mother-to-Child HIV Transmission

Newswise — Highly active antiretroviral therapy (HAART) should be the new standard treatment for prevention of mother-to-child transmission of HIV in poor countries, according to an editorial in response to a research study in the August 15 issue of JAIDS: Journal of Acquired Immune Deficiency Syndromes. JAIDS is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health, a leading provider of information and business intelligence for students, professionals, and institutions in medicine, nursing, allied health, pharmacy and the pharmaceutical industry.

At this point in the HIV epidemic, the ethical imperative to offer the most effective treatment for preventing HIV transmission to infants trumps economic rationales, according the editorial by Dr. Arthur J. Ammann of the University of California San Francisco Medical Center and President of Global Strategies for HIV Prevention.

HAART Reduces Drug-Resistant HIV, New Study Shows

In the new research study, HIV-positive pregnant women in Nairobi, Kenya, were randomly assigned to one of two treatments to prevent HIV transmission to their infant. One group received the standard treatment for poor countries: treatment of the mother with the antiviral drug zidovudine starting six weeks before delivery, plus a single dose of the drug nevirapine for the infant after birth (ZDV/sdNVP).

Another group received a three-drug HAART combination. This "triple therapy" combination—the standard treatment for HIV-infected pregnant women in wealthier countries—also started six weeks before delivery. HAART then continued for six months after birth, with the goal of preventing HIV transmission during breast-feeding.

The two groups were compared for measures of HIV resistance to antiretroviral drugs. Drug resistance has been a problem after short-term preventive approaches like ZDV/sdNVP. The lead author was Dara A. Lehman, M.H.S., Ph.D., and the senior author Julie Overbaugh, Ph.D., of Fred Hutchinson Cancer Research Center, Seattle.

Three months after treatment, sophisticated gene studies found that HAART reduced drug resistance, though did not eliminate it completely. Low levels of resistant virus were detected in 75 percent of women receiving ZDV/sdNVP, compared to just 18 percent of those receiving HAART. The study "provides strong evidence that short-course HAART results in lower rates of antiretroviral resistance compared with the standard ZDV/sdNVP regimen," according to the researchers.

Research Should Focus on Effectiveness, Not Economics

Dr. Ammann comments on research progress in preventing mother-to-child transmission—specifically on what should be considered "standard treatment" in poor countries. Since ZDV was introduced in 1994, major progress has been made in preventing HIV transmission from mothers to infants. However, because of economic and infrastructure constraints, many studies have sought to define the minimum duration of treatment necessary for effective prevention.

In Dr. Ammann's view, these studies have placed too many HIV-infected mothers and infants in poor countries in Africa and elsewhere at risk for disease progression. "At this point in the epidemic, there is consensus on the principles that define optimal treatment and prophylaxis of HIV infection," Dr. Ammann writes. Now that anti-HIV drugs are more widely available, he believes that treatment to prevent mother-to-child transmission "should include early initiation of HAART for all HIV-infected pregnant women, and continuation of HAART during and after breastfeeding has ceased." This should be a requirement for all current and future clinical research studies. Shorter courses or treatments using fewer drugs "should be considered suboptimal treatment and prophylaxis."

Rather than looking for a quicker or cheaper way, research should focus on further increasing safety and enhancing access, with HAART as the new standard treatment, Dr. Ammann believes. He concludes, "To do less, provides an unintentional signal to international organizations and National Ministries of Health that HIV-infected pregnant women and their infants need not receive the same level of treatment and prophylaxis as other HIV-infected or HIV-exposed individuals."

Dr. Overbaugh comments, "While the data support the use of HAART to minimize resistance that could complicate future treatment options for the mother, the issue is certainly more complex." Drs. Lehman and Overbaugh emphasize that access to HAART is still limited and that optimal adherence to HAART would be critical to achieve such low levels of resistance. "Thus programs to provide HAART for prevention of mother-to-child transmission must include ways to maximize adherence to see benefit in terms of antiviral resistance," adds Dr. Overbaugh.

About JAIDS

JAIDS: Journal of Acquired Immune Deficiency Syndromes (www.JAIDS.com) is the trusted, interdisciplinary resource for HIV- and AIDS-related information with a strong focus on basic science, clinical science, and epidemiology. Co-edited by the foremost leaders in clinical virology, molecular biology, and epidemiology, JAIDS publishes vital information on the advances in diagnosis and treatment of HIV infections, as well as the latest research in the development of therapeutics and vaccine approaches. This ground-breaking journal brings together rigorously peer-reviewed articles, reviews of current research, results of clinical trials, and epidemiologic reports from around the world.

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