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42 Maternal and Infant Treatment Strategies for Preventing MTCT Elaine Abrams Harlem Hosp Ctr, Columbia Univ New York, NY, USA |
Enormous strides in care and treatment have led to dramatic reductions in mother-to-child- transmission (MTCT) in high resource settings. Widespread use of potent combination therapies during pregnancy coupled with intrapartum and postpartum treatment to the newborn has resulted in MTCT rates of 1-2%.Similarly, the efficacy of simple and inexpensive regimens has stimulated establishment of prevention of MTCT (pMTCT) programs in low resources settings. Single dose nevirapine (SDNVP) given to women during labor and to the newborn at birth can result in a 50% reduction of MTCT. While most HIV-infected pregnant women still do not have access to HIV testing and treatment, pMTCT programs are being implemented worldwide. Initial enthusiasm for SDNVP for pMTCT has been tempered by concerns about the detection of nevirapine resistance mutations in women and HIV-infected children who have received preventive therapy. Depending upon timing and methodology, 25% to 60% of women and HIV-infected children treated with SDNVP have one or more detectable NNRTI mutations postpartum. Mutations in mother and child fade during the first year postpartum without further therapy. The potential impact of these mutations on the efficacy of future NNRTI-based treatment regimens has been hotly debated. Will long term treatment outcomes be compromised? Does timing of treatment initiation in relation to SDNVP exposure affect response? Can pMTCT regimens be modified to diminish the rate of resistance? Furthermore, concerns about dissemination of resistant virus into treatment naïve communities have been voiced. These issues are particularly pertinent in light of recent WHO recommendations to use NNRTI-based first-line regimens for the treatment of adults and children in resource poor settings. In the context of these controversies new data from a clinical trial of NNRTI-based treatment for SDNVP exposed and unexposed women will be addressed. Questions of how to continue and expand pMTCT efforts while preserving treatment options for women and children will be explored.
Keywords: adverse effects; myocardial infarction; cardiovascular disease
