Chewe Luo, a senior adviser for UNICEF, discussed efforts to eliminate vertical HIV transmission from the perspective of treatment as prevention at the International Treatment as Prevention Workshop on Wednesday in Vancouver.
She acknowledged that the maternal and child health platform could be a very effective entry point for treatment as prevention and for the provision of family-centered HIV care and treatment. Luo provided a chart illustrating the response of high burden countries to the World Health Organization (WHO) guidelines on prevention of mother-to-child transmission of HIV (PMTCT). Most countries have adopted “Option A,” which calls for providing one or two antiretrovirals during pregnancy, with provision of neviripine to the infant during the breastfeeding period. While countries have argued that this option is easier to provide, the reality is that in many settings the protocol is not provided appropriately and infants do not receive the neviripine, making them vulnerable to HIV infection during the breastfeeding period. Choosing Option A is less about ease of administration and more about cost, according to Luo.
There are a number of concerns that facilitated the recent guidance from WHO urging countries to consider moving to “Option B” or “Option B+.” Option B is triple combination antiretroviral therapy (ART) for women with CD 4 counts above 350 that continues throughout pregnancy and the breastfeeding period. Option B+ is initiating ART in all pregnant women, irrespective of CD4 count, for life. A recent study—HPTN 046—found that 26 percent of pregnant women with CD4 counts above 350 saw a loss of CD4 cells to below 350 within six months post-partum. Thirty-nine percent of these women had CD4 counts below 350 by 12 months post-partum. Luo concluded her summary of these findings by saying, “Do we really want to stop ART in these women only to re-start again?”
Luo also argued that shifting from Option B to B+ simplifies treatment and extends protection. According to modeling, if the 21 high-burden countries implemented Option B+, we would see 20,000 fewer infant infections between 2013 and 2015.