Prevention of Mother-to-Child Transmission of HIV: Future Directions

1
Prevention of Mother-to-Child Transmission of
HIV Future Directions

• Jennifer S. Read, MD, MS, MPH, DTMH
• Medical Officer
• Pediatric, Adolescent, and Maternal AIDS Branch
• CRMC-NICHD
• National Institutes of Health
• Bethesda, MD
• Clinical Associate Professor
• Childrens National Medical Center
• The George Washington University
• Washington, DC

2
Overview

• Background
• Rates, Timing, Risk Factors
• Efficacious interventions to prevent transmission
• PMTCT future directions
• Existing interventions, interventions under study
• Future research
• Risk factors for transmission
• Interventions to prevent transmission

3
Overview

• Background
• Rates, Timing, Risk Factors
• Efficacious interventions to prevent transmission
• PMTCT future directions
• Existing interventions, interventions under study
• Future research
• Risk factors for transmission
• Interventions to prevent transmission

4
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5
Estimated Timing of Mother-to-Child Transmission
of HIV With or Without Breastfeeding De Cock
et al JAMA 2000 283 1175-1182
23
30
35
70
42
No Breastfeeding
Breastfeeding for 18-24 Months
6
Risk Factors for Mother-to-Child Transmission of
HIV

• Amount of virus to which the fetus/infant is
  exposed
• Duration of such exposure
• Factors facilitating transfer of the virus from
  mother to infant
• Characteristics of the virus
• Infants susceptibility to infection

7
Efficacious Interventions to Prevent
Mother-to-Child Transmission of HIV 2005

• Antiretroviral prophylaxis
• Decreases maternal viral load
• Provides pre-exposure prophylaxis for infant
• Cesarean section before labor and before ruptured
  membranes
• Decreases duration of infants exposure to HIV
• Complete avoidance of breastfeeding
• Decreases duration of infants exposure to HIV

8
Overview

• Background
• Rates, Timing, Risk Factors
• Efficacious interventions to prevent transmission
• PMTCT future directions
• Existing interventions, interventions under study
• Future research
• Risk factors for transmission
• Interventions to prevent transmission

9
Existing Interventions, Interventions Under Study

• Antepartum/Intrapartum Transmission
• Antiretrovirals
• (Treatment)
• Prophylaxis
• Intrapartum Transmission
• Cesarean section before labor and before ruptured
  membranes
• Postnatal Transmission
• Interventions to prevent breastfeeding
  transmission

10
Existing Interventions, Interventions Under Study

• Antepartum/Intrapartum Transmission
• Antiretrovirals
• (Treatment)
• Prophylaxis
• Intrapartum Transmission
• Cesarean section before labor and before ruptured
  membranes
• Postnatal Transmission
• Interventions to prevent breastfeeding
  transmission

11
Antiretroviral Treatment of HIV-Infected Women
12
Increased risk of transmission with more advanced
HIV disease in the mother

• Clinical disease status (e.g., CDC or WHO
  clinical classification systems)
• Immunologic (e.g., CD4 lymphocyte count/percent)
• Virologic (e.g., viral load copies HIV RNA
  per unit volume of body fluid)

13
As more HIV-infected women who require care and
treatment for their own health receive such
treatment, MTCT rates will decrease
14
Adults and children estimated to be living with
HIV as of end 2004
15
Antiretroviral Prophylaxis for HIV-Infected Women
16
Perinatal Transmission HIV-infected Women with
Viral Loads lt 1000 copies/mLIoannidis et al JID
2001
17
Antiretroviral Prophylaxis for Prevention of
MTCT

• An ideal prophylaxis regimen would be simple,
  cheap, non-toxic, and without associated
  development of resistance.
• In 2005, such an ideal regimen does not exist.

18
Antiretroviral Prophylaxis for Prevention of
MTCT

• Simplest, cheapest, and with very limited
  toxicity to date HIVNET 012 regimen
• One 200 mg dose to the mother at the onset of
  labor
• One 2 mg/kg dose to the infant shortly after birth

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HIVNET 012 Nevirapine Prophylaxis

• Effectiveness only about 50
• Resistance
• Associated with acquisition of nevirapine
  resistance in HIV-infected mothers and in
  infected infants
• Implications for subsequent treatment of
  HIV-infected mothers (and any of their infants
  who become HIV-infected) under study

20
Maternal and Infant Response to Nevirapine-Based
Antiretroviral Treatment Following Peripartum
Single-Dose Nevirapine or Placebo
Presented at the IDSA meeting San Francisco
October 6-9, 2005

• Shahin Lockman, Laura Smeaton, Roger Shapiro,
  Carolyn Wester, Ibou Thior, Lisa Stevens, Thumbi
  Ndungu, Fatima Chand, Claire Moffat, Aida
  Asmelash, Patrick Ndase, Peter Arimi, Anchilla
  Owor, Erik van Widenfelt, Stephen Lagakos, Max
  Essex
• Brigham and Womens Hospital, Boston MA
• Harvard School of Public Health, Boston MA
• Beth Israel Deaconess Medical Center, Boston MA
• Botswana-Harvard School of Public Health AIDS
  Initiative Partnership, Gaborone, Botswana

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Methods Mashi Plus Study Design
Presented at the IDSA meeting San Francisco
October 6-9, 2005

• 1200 HIV-infected pregnant women randomized in a
  placebo (Plc)-controlled MTCT prevention trial in
  Botswana (the Mashi Study) between March 2001 and
  October 2003

Mom
Infant
Antepartum/ to infant
AZT from 34 wks
AZT, 1 vs. 6 mo
Mom Infant
Mom Infant
Peripartum
NVP
NVP
Plc
Plc
By 72 hr
Labor
By 72 hr
Labor
Postpartum/ to infant
NVP-based ART when Botswana treatment criteria
met
Modification partway through trial SD NVP to
all infants, but maternal NVP / placebo
continued. Only infants enrolled prior to
modification are included in the primary infant
analyses
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MASHI Followup Maternal Virologic Failure on
HAART ( gt400 RNA copies/ml). Lockman IDSA 2005
23
MASHI follow up Maternal Virologic Failure, By
Time From Placebo/NVP Exposure
Presented at the IDSA meeting San Francisco
October 6-9, 2005
Treatment begangt 6 Months Since Exposure
Treatment began lt6 Months Since Exposure
Log rank test p 0.678
Log rank test p lt 0.001
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Study Conclusions
Presented at the IDSA meeting San Francisco
October 6-9, 2005

• Among women starting NVP-based ART lt 6 months
  from SD NVP exposure, prior SD NVP exposure was
  associated with lower virologic suppression rates
  on ART
• Among women starting NVP-based ART gt 6 months
  from SD NVP exposure, no evidence thus far that
  prior SD NVP compromised ART efficacy
• Among this group of infants that started
  NVP-based ART at young median age, prior SD NVP
  exposure associated with virologic failure and
  smaller CD4 increase

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Other Prophylaxis Regimens Simpler, Cheaper

• Simpler end of the spectrum
• Tenofovir studies underway, under development
• Why tenofovir?
• Pro-drug can be administered orally
• Long systemic T1/2 (12 hours)
• 1-2 doses in the peripartum period could be
  efficacious
• Phase I underway
• Phase III studies being planned

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Other Prophylaxis Regimens More Complex,
Expensive

• U.S./France -- ACTG 076 regimen zidovudine
• Oral zidovudine from 14-34 weeks gestation, IV
  zidovudine, 6 weeks of oral zidovudine to the
  infant
• Efficacy 71
• But - cost, IV administration intrapartum,
  overall complexity
• Thailand -- Lallemant long-long zidovudine
  regimen, with or without addition of the 2-dose
  nevirapine (HIVNET 012 regimen)
• Oral zidovudine from 28 weeks, oral zidovudine
  intrapartum, 1 week of oral zidovudine to the
  infant (with or without one oral dose of
  nevirapine to mother and to infant)
• Efficacy 80
• WHO, June 2005 recommended regimen
• But cost, overall complexity

27
Operational Research Regarding Prevention of
Mother-to-Child Transmission in Rural South India
N. M. Samuel, Mini Jacob, Parameshwari
Srijayanth, Shoba Dharmarajan, et al3rd IAS
Conference on HIV Pathogenesis and Treatment (Rio
de Janeiro, Brazil, July 2005) (abstract
MoPe11.7C04) other abstracts

• HIV-1-infected pregnant women receiving antenatal
  care at two rural hospitals in southern India
  offered the opportunity (after informed consent)
  to enroll into a prospective cohort study
  (follow-up until 12 months after delivery/birth
  for women/infants).
• Beginning December 31, 2003
• Enrolled women were offered (after informed
  consent)
• zidovudine 300 mg po BID beginning at 28 weeks
  gestation
• one 300 mg dose at the onset of labor, and
• 300 mg po q 3 hours thereafter until delivery.
• Their infants were offered six weeks of
  zidovudine (4 mg/kg po BID).

28
Operational Research Regarding Prevention of
Mother-to-Child Transmission in Rural South India
N. M. Samuel, Mini Jacob, Parameshwari
Srijayanth, Shoba Dharmarajan, et al3rd IAS
Conference on HIV Pathogenesis and Treatment (Rio
de Janeiro, Brazil, July 2005) (abstract
MoPe11.7C04) other abstracts

• Subsequently (as of December 4, 2004), the
  protocol was amended to add two doses of
  nevirapine to the regimen
• 200 mg at the onset of labor
• 2 mg/kg to the infant
• The standard of care was nevirapine prophylaxis
  (one dose to mother and to infant).
• Women requiring antiretrovirals for their own
  health were referred to treatment programs.

29
Operational Research Regarding Prevention of
Mother-to-Child Transmission in Rural South India
N. M. Samuel, Mini Jacob, Parameshwari
Srijayanth, Shoba Dharmarajan, et al3rd IAS
Conference on HIV Pathogenesis and Treatment (Rio
de Janeiro, Brazil, July 2005) (abstract
MoPe11.7C04) other abstracts

• Preliminary results of this study indicate high
  proportions of this population of HIV-1-infected
  pregnant women in rural Tamil Nadu found it
  acceptable to
• enroll into a research study 90 of eligible
  women enrolled into the prospective cohort
  study.
• enroll into the antiretroviral prophylaxis
  portion of the study where a significantly more
  complex antiretroviral prophylaxis regimen was
  offered 94 of eligible women received such
  prophylaxis.
• have their infants receive a significantly more
  complex antiretroviral prophylaxis regimen than
  was available as part of routine care 100 of
  eligible infants received such prophylaxis.
• Further analyses are underway.

30
PRELIMINARY Percentages and Totals All CTA Sites
(cumulative as of 6/30/05)
Excluding Support to Thailand National Program
1,718,049
1,558,937
1,141,633
1,271,703
108,983
63,464
149,774
31
Prophylaxis vs. Treatment?CD4 count
(cells/mm3)lt 200 Treatment200-500
?Prophylaxis vs. Treatmentgt
500 Prophylaxis
32
Impact of HAART during Pregnancy and
Breastfeeding on MTCT of HIV and Mothers Health
The Kesho-Bora Study
Antepartum (34-36 weeks) Intrapartum
Postpartum
ZDV X 1 NVP x1
ZDV
ZDV/3TC/LPV/r
ZDV/3TC/LPV/r
ZDV/3TC/LPV/r - Mother 6 mo.
Randomization arms for women with CD4 counts
200-500. All infants receive NVP X 1 within 72
hours of birth.
33
Judicious Use of Antiretrovirals During Pregnancy

• Toxicity
• Risk to mother
• Risk to infant
• Adverse effects infant
• Risk of low birth weight, preterm birth
• Risk of congenital anomalies
• Risk of mitochondrial dysfunction

34
Existing Interventions, Interventions Under Study

• Antepartum/Intrapartum Transmission
• Antiretrovirals
• (Treatment)
• Prophylaxis
• Intrapartum Transmission
• Cesarean section before labor and before ruptured
  membranes
• Postnatal Transmission
• Interventions to prevent breastfeeding
  transmission

35
Randomized Trial of Mode of Delivery and
Mother-to-Child Transmission of HIV (n370)
Source The European Mode of Delivery
Collaboration, Lancet, 1999
36
Individual Patient Data Meta-Analysis Mode of
Delivery and Mother-to-Child Transmission of HIV
(N8533)
Source The International Perinatal HIV Group,
NEJM, 1999
37
Increasing Rates of Cesarean Delivery Among
HIV-infected Women 1994-2000, U.S. Dominguez K
et al JAIDS 2003 33(2) 232-238
N6,467
38
Mode of Delivery as an Intervention to Prevent
MTCT of HIV in Settings Where Adequate Staffing
and Infrastructure Exist

• Should all HIV-infected women deliver by cesarean
  section?
• Effectiveness among women with low viral loads or
  who are receiving potent antiretroviral therapy?

39
Recommendations Regarding Cesarean Delivery
Before Labor and Before Ruptured Membranes for
the Prevention of MTCT of HIV USA

• American College of Obstetricians and
  Gynecologists and U.S. Public Health Service
• Cesarean section as an intervention to prevent
  transmission should be discussed and recommended
  for women with peripheral blood viral loads
  greater than 1000 copies/mL irrespective of
  receipt of antiretroviral therapy

40
Mode of Delivery Remains Associated with
Transmission When Controlling For Maternal Viral
Load, ThailandShaffer N et al JID 1999

• Multivariate analysis of risk factors for
  transmission
• Preterm birth
• Vaginal delivery
• NK cell lt 11
• Higher maternal viral load

41
Predicted Probabilities (Percent) of Vertical
Transmission According to Viral
LoadMultivariate Logistic Regression Modeling (N
373)
The European Collaborative Study AIDS 1999
42
Transmission Rates Among Women Receiving
Combination Antiretroviral Therapy According to
Mode of Delivery
Fiscus S et al 13th International AIDS
Conference Durban, South Africa 2000 Abstract
WePpC1388
43
Perinatal Transmission of HIV by Pregnant Women
with Viral Loads lt 1000 Copies/mLIoannidis et
al JID 2001

• Independent predictors of transmission
• Birth weight (OR 0.89 P 0.014)
• Cesarean delivery (OR 0.09 P 0.028)
• CD4 cell count (OR 0.85 P 0.041)

44
European Collaborative Study (Clin Infect Dis
2005 40 458-65)

• Evaluated the risk of MTCT of HIV among women
  receiving HAART
• Of 560 women with undetectable HIV RNA levels,
  cesarean section before labor and before ruptured
  membranes was associated with a 90 reduction in
  MTCT risk (OR 0.10 95CI 0.03-0.33),
  compared with vaginal delivery or other cesaran
  sections

45
Risks associated with cesarean section for PMTCT

• Risks to mother, infant, obstetrician
• Read JS, Newell M-L. Efficacy and safety of
  cesarean delivery for prevention of
  mother-to-child transmission of HIV-1. Cochrane
  Database Syst Rev 2005 Issue 4 Art. No.
  CD005479.
• Read JS. Preventing mother-to-child transmission
  of HIV the role of cesarean section. Sex Trans
  Inf 2000 76 231-232.

46
Existing Interventions, Interventions Under Study

• Antepartum/Intrapartum Transmission
• Antiretrovirals
• (Treatment)
• Prophylaxis
• Intrapartum Transmission
• Cesarean section before labor and before ruptured
  membranes
• Postnatal Transmission
• Interventions to prevent breastfeeding
  transmission

47
Prevention of Breastfeeding Transmission of HIV-1

• Decrease duration of exposure to
  HIV-1-contaminated breast milk
• Complete avoidance of breastfeeding
• Early weaning
• Decrease maternal infectiousness (decrease viral
  load in breast milk)
• Antiretroviral drugs to the mother while
  breastfeeding
• Chemical/heat treatment of breast milk
• Decrease infant susceptibility
• Antiretroviral prophylaxis to the infant while
  breastfeeding
• Passive immunization
• Active immunization
• Avoidance of mixed feeding

48
Early weaning

• If complete avoidance of breastfeeding not
  possible
• If feasible
• Limit exposure to HIV-1 while allowing child to
  experience benefits of breastfeeding
• Being evaluated in several studies
• Preliminary results (e.g., from Kisumu, Kenya)
  suggest significant morbidity associated with
  early weaning

49
CDC HAART Trial Rates of GE Hospitalizations by
infant age, comparing KiBS and Vertical
Transmission (VT) Study in Kisumu Kenya
Age in months
50
KiBS Study Growth Faltering Post Weaning at 6
months Compared to VT Study without Early
Weaning Kisumu Kenya
KiBS N63
VT Study N440
51
Prevention of Breastfeeding Transmission of HIV-1

• Decrease duration of exposure to
  HIV-1-contaminated breast milk
• Decrease maternal infectiousness (decrease viral
  load in breast milk)
• Decrease infant susceptibility

52
Prevention of Breastfeeding Transmission of
HIVDecrease Viral Load in Breast Milk

• Antiretroviral drugs to the mother while
  breastfeeding
• Chemical/heat treatment of breast milk

53
Impact of HAART during Pregnancy and
Breastfeeding on MTCT of HIV and Mothers Health
The Kesho-Bora Study
Antepartum (34-36 weeks) Intrapartum
Postpartum
ZDV X 1 NVP x1
ZDV
ZDV/3TC/LPV/r
ZDV/3TC/LPV/r
ZDV/3TC/LPV/r - Mother 6 mo.
Randomization arms for women with CD4 counts
200-500. All infants receive NVP X 1 within 72
hours of birth.
54
Chemical or Heat Treatment of Breast Milk to
Prevent Transmission of HIV-1

• Sodium dodecyl sulfate (SDS)
• Virucidal agent
• Does not alter protein content of milk
• Can be efficiently removed from breast milk
  samples
• Allowing expressed breast milk to stand at room
  temperature for six hours
• Did not destroy virus
• Boiling expressed breast milk
• Decreased infectivity of the milk
• Pasteurization of breast milk (including use of
  devices that can be used in home setting)
• Can reduce infectious titer of cell-free HIV-1 (5
  log) and HIV-1-infected cells (6 log)

55
Chemical or Heat Treatment of Breast Milk to
Prevent Transmission

• Feasibility
• ?Complete elimination of HIV from milk completely
• ?Extent to which the treatment diminishes the
  protective or nutritional components of breast
  milk

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Prevention of Breastfeeding Transmission of HIV-1

• Decrease duration of exposure to
  HIV-1-contaminated breast milk
• Decrease maternal infectiousness (decrease viral
  load in breast milk)
• Decrease infant susceptibility

57
Prevention of Breastfeeding Transmission of
HIV-1Decrease Infant Susceptibility

• Antiretroviral prophylaxis to the infant
  while breastfeeding
• Passive immunization
• Active immunization
• Avoidance of mixed feeding

58
Does Infant Prophylaxis Improve SD NVP in BF
infants? Is Duration of Infant Prophylaxis
Important?
IP PP
HPTN 046
NVP x1
Infant NVP x1
Infant NVP x 6 months
NVP x1
Infant NVP x1
Infant Placebo x 6 months
Ethiopia Uganda (HIV1Glob/NVP) India
NVP x1
Infant NVP x1
Infant NVP x 6 wks
Infant NVP x1
NVP x1
Infant Placebo x 6 wks
59
Mashi Infant Feeding Component, Botswana Thior I
et al. 12th Retrovirus Conf, Boston 2005 (Abs.
75LB)
AZT Backbone
Effect of BF with Infant Prophylaxis
34 wk
oral
N591
N588
Formula feed 1 Month AZT
Breastfeed 6 Months AZT

60
HIV-1 Infection at Age 7 Months is Higher in
Breastfed than Formula-Fed Infants Despite 6
Months AZT Thior I et al. 12th Retrovirus Conf,
Boston 2005 (Abs. 75LB)
p0.04
61
Immunoprophylaxis

• Passive immunoprophylaxis
• HIV1GLOB/NVP study - Kampala, Uganda
• Mother NVP at onset of labor
• Infant NVP at birth
• Randomization to the following arms
• 1) Infant 6 wks NVP
• vs
• 2) HIV1GLOB Mother 37-38 weeks pregnancy
  Infant within 1st 24 hours of life
• vs
• 3) Neither of the above.
• Active immunoprophylaxis
• HIVNET 027 canarypox HIV vaccine in neonates

62
ZVITAMBO Study Pattern of Breastfeeding and
Postnatal Transmission in ZimbabweIliff PJ et
al AIDS 2005 19 699-708

• Randomized trial of postpartum vitamin A
  supplementation
• Pattern of infant feeding and risk of postnatal
  transmission
• N 2060 infants born to HIV-infected women, all
  with negative HIV diagnostic tests at birth (DNA
  PCR)
• Definitions
• Exclusive breastfeeding (N156) Only breast
  milk.
• Predominant breastfeeding (N490) Breast milk
  and non-milk liquids.
• Mixed breastfeeding (N1414) Breast milk and
  non-human milk and/or solid food

63
ZVITAMBO Study Pattern of Early Feeding (0-3
months) and Risk of Transmission, Zimbabwe Iliff
PJ et al AIDS 2005 19 699-708
Childs Age
64
Pattern of Infant Feeding and HIV Transmission in
Breastfeeding Children, South Africa Coutsoudis
A et al. AIDS 200115379-87
Infant Age
65
Studies of Avoidance of Mixed Breastfeeding (and
Promotion of Exclusive Breastfeeding) to Decrease
the Risk of Transmission of HIV Through Breast
Milk

• South Africa
• Zambia
• Zimbabwe
• Cote dIvoire
• Botswana

66
Rates of Exclusive Breastfeeding in HIV-Infected
Women are Low in Resource-Poor Countries (Even
in Clinical Trials)
67
Ongoing and Future Research Prevention of
Breastfeeding Transmission of HIV-1

• Decreasing duration of breast milk exposure
• ?Safety of early weaning
• Decreasing maternal infectiousness
• Ongoing research regarding efficacy, safety of
  maternal ARV prophylaxis while breastfeeding
• Ongoing research to further characterize the
  virologic and immune factors associated with
  breast milk infectivity
• Decreasing infant susceptibility
• Ongoing research regarding efficacy, safety of
  infant ARV prophylaxis while being breastfed
• Ongoing research regarding passive and active
  immunization
• ?Feasibility of avoidance of mixed breastfeeding

68
Overview

• Background
• Rates, Timing, Risk Factors
• Efficacious interventions to prevent transmission
• PMTCT future directions
• Existing interventions, interventions under study
• Future research
• Risk factors for transmission
• Interventions to prevent transmission

69
Future Research Risk Factors for Transmission

• Maternal factors
• Infant factors
• Viral factors

70
Maternal plasma selenium concentrations and MTCT
of HIVR. Kupka et al JAIDS 2005 39 (2)
203-210

• N 670 HIV-infected women in Tanzania
• Plasma selenium concentrations at 12-27 weeks of
  gestation
• Low plasma selenium levels associated with
  increased risk of fetal death, child death, and
  intrapartum transmission of HIV

71
a Defensins in the Prevention of HIV
Transmission Among Breastfed InfantsL. Kuhn et
al JAIDS 2005 39 138-142

• Nested case-control study in Zambia
• N 32 HIV-infected women who transmitted HIV to
  their infants
• N 52 randomly selected HIV-infected women who
  did not transmit HIV to their infants
• Concentrations of a defensins increased as
  breast milk HIV RNA concentration increased
• After adjusting for milk viral load, a defensin
  concentration was significantly associated with a
  decreased risk of intrapartum and postnatal HIV
  transmission OR 0.3 (95CI 0.09, 0.93)

72
Gender differences in perinatal HIV acquisition
among African infantsT. Taha et al Pediatrics
2005 115 (2) e167-e172.

• Almost 1000 boys and 1000 girls born to
  HIV-infected mothers enrolled
• At birth, significantly more girls (12.6) than
  boys (6.3) were infected with HIV
• Association remained significant after
  controlling for maternal viral load and other
  factors
• At 6-8 weeks (among those not previously
  infected), more girls acquired HIV (10.0) vs.
  boys (7.4)
• Conclusions Girls may be more susceptible to
  HIV infection in utero and postnatally.
  Alternatively, in utero mortality rates of
  HIV-infected male infants may be higher than
  those of girls (and thus more HIV-infected girls
  are born).

73
Subtype C is associated with increased vaginal
shedding of HIV-1GC John-Stewart et al J
Infect Dis 2005 192 492-6

• Kenyan cohort of HIV-1-nfected women
• Pregnant women infected with subtype C were
  significantly more likely to shed HIV-1-infected
  vaginal cells than were those infected with
  subtype A or D OR 3.6, 95CI 1.4-8.8 p
  0.006
• Similar results after adjustment for age, CD4
  cell count, and plasma viral load
• Conclusions HIV-1 subtype may influence mucosal
  shedding of HIV-1

74
Number of cases
75
Future Research Interventions to Prevent
Transmission

• Why a need for continued research?
• Because existing interventions, even if
  universally implemented, may not prevent all
  infections

76
Missed Opportunities for Prevention of MTCT of
HIVDIppolito M et al 3rd IAS Conference on
HIV Pathogenesis and Treatment (Rio de Janeiro
July 2005 abstract TuPe5.1P03)

• Data (2002-2005) from a cohort of HIV-infected
  women in Latin America and the Caribbean analyzed
  (NISDI Perinatal Study)
• No breastfeeding
• All with access to antiretroviral
  prophylaxis/treatment, cesarean section
• Very low transmission rate (1.2)
• But, among the few transmissions, almost 40
  occurred despite appropriate medical/surgical
  management

77
Summary Future Directions

• Management of HIV-infected, pregnant women
• Need to use existing treatment and prophylaxis
  regimens wisely
• Anticipate risks/side effects of each
  intervention
• Need to continue research into risk factors for
  transmission, interventions to prevent
  transmission
• Primary prevention essential in order to
  eradicate MTCT of HIV