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Background:  In Africa, short regimens of zidovudine (ZDV), ZDV+lamivudine (3TC) and/or nevirapine single-dose (NVPsd) are validated ARV for the prevention of mother-to-child transmission of HIV (PMTCT). Highly active retroviral therapy (HAART) for PMTCT was added to the international guidelines in 2004 by the World Health Organization (WHO) for women who additionally need ARV for their own health. We describe use of HAART during pregnancy for women with advanced HIV disease in the Mother-to-Child Transmission Plus (MTCT+) Initiative in Abidjan., Côte d’Ivoire.

Methods:  MTCT Plus is a multi-country care and treatment program built on existing PMTCT services. It provides pregnant/postpartum women with family-centered HIV care, including ARV to the woman, her partner, and children. Pregnant women eligible for HAART (WHO stage 4, WHO stage 2 or 3 with CD4 count < 350/mm³, CD4 count < 200/mm³) received ZDV + 3TC + nevirapine (NVP) antenatally as early as 28 weeks of amenorrhea until delivery and continued postnatally. Women who were not eligible for HAART received PMTCT prophylaxis with ZDV + 3TC until 3 days postpartum, and nevirapine single dose (NVPsd) in labor. All infants received ZDV (7 days) and NVPsd on day 3. Women either used breast milk substitutes or practiced breastfeeding for 6 months. Infant plasma HIV RNA for HIV diagnosis was performed at 4 weeks and confirmed at 6 weeks.

Results:  From August 2003 to September 2004, 182 HIV+ pregnant women were enrolled; 78 began HAART with a median CD4 count of 171/mm³ at a median of 28 weeks of gestation. There were 3 stillbirths among 70 HAART-treated women who delivered. Of 51 infants tested at 4 weeks, none had HIV infection: provisional upper limit of this null transmission rate, 6.9 %, compares to historical rates in women in Abidjan with similar clinical and CD4 counts of 32.5% without prophylaxis, 23.6% with short-course ZDV, 13.6% with short-course ZDV and NVPsd, and 9.0% with short-course ZDV + 3TC and NVPsd. Among the 97 pregnant women not treated by HAART (median CD4 count of 469/mm3), 53 live births have been tested so far and none was infected. In the HAART group, 6 women had grade 3 adverse events before delivery requiring change in ARV: rash (n = 4) and hepatotoxicity (n = 1) attributed to NVP and anemia (5g/dl) attributed to ZDV (n = 1).

Conclusions:  These preliminary observations suggest that HAART during pregnancy for women with advanced HIV disease can dramatically reduce the risk of MTCT. Efforts are needed to enable wide implementation of new WHO 2004 guidelines in PMTCT programmes.

Keywords: Mother-to-child transmission; HAART; Africa