Feature story

Evidence shows new drug combination dramatically reduces mother-to child transmission of HIV during breastfeeding

22 July 2009

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Credit: WHO

According to a new study led by the World Health Organization (WHO), if HIV-positive pregnant women are given a combination of antiretroviral (ARV) drugs from late in pregnancy until six months into breastfeeding, rather than a short course of drugs that ends at delivery, their babies are over 40% less likely to become infected with HIV.

The initial findings of the study, named Kesho Bora, which means ‘a better future’ in Swahili, were presented at the 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention taking place in Cape Town, South Africa, 19-22 July. WHO worked in partnership with the French National Agency for Research on AIDS and Viral Hepatitis (ANRS), the US Centers for Disease Control and Prevention (CDC) and Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) of the US National Institutes of Health.

Carried out between June 2005 and August 2008, involving 1,140 women at five sites across Africa (in Burkina Faso, Kenya and South Africa), the purpose of Kesho Bora was to assess whether the risk of passing on HIV during breastfeeding could be reduced.

It shows that a significant reduction in infant infection can be achieved when pregnant women with a CD4 immune cell count of 200-500 cells/ mm3 are given a combination of three ARVs to prevent transmission: starting in their last trimester of pregnancy, continuing through birth and six months of breastfeeding. This was shown to reduce the risk of transmitting HIV to the baby and improved survival compared with babies of mothers with HIV who are given the current WHO-recommended short-course ARV regimen in late pregnancy and around the time of delivery.

The best results in the study were recorded in the group of mothers enrolled with a CD4 count between 200 and 350 cells/mm3. There is no increased risk to the health of the mother or the infant associated with this triple-ARV regimen, consisting of zidovudine, lamivudine and lopinavir/ritonavir. The study did not randomize women with CD4 counts below 200 cells/ mm3 as these women require treatment for their own health. That treatment also substantially reduces the risk of transmitting HIV during breastfeeding.

The issue of breastfeeding is a crucial one for pregnant women living with HIV. In many developing nations they have a tough choice: either breastfeed their babies and risk transmitting the virus through their milk, or give them formula. The latter deprives infants of the natural immunity passed on through breast milk which helps protect against diarrhoea, malnutrition and other potentially deadly diseases. Sanitation can also be an issue, with a scarcity of clean water with which to mix the formula and, in any case, many may not be able to afford to buy it in the first place.

Preventing mothers from dying and babies becoming infected with HIV is one of the nine priority focus areas for UNAIDS and its Cosponsors under the Joint action for results: UNAIDS outcome framework 2009-2011.

Michel Sidibé, UNAIDS Executive Director, has championed this priority and said during a recent visit to Lesotho in Southern Africa, “Strengthened services for maternal health, for reproductive health and for paediatric health will mean we can prevent mothers from dying and babies from becoming infected with HIV in Lesotho and around the world.”

The findings from the Kesho Bora study will now be considered by WHO experts, along with other recent data, and the 2006 WHO recommendations on the use of ARVs in pregnant women and on infant feeding and the prevention of mother-to-child transmission will be reviewed in the context of this new evidence. Updated guidelines are expected to be published before the end of the year.

It is clear that this research increases the range of treatment options available to mothers living with the virus and offers them hope that, if they so wish, they have a greater chance of breastfeeding their babies without passing on HIV.

Additional funds for the Kesho Bora study were provided by the European and Developing Countries Clinical Trials Partnership, the Thrasher Foundation, the UK Department for International Development, UNICEF and the Belgian Government.