ArticlesTriple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV-1 (Kesho Bora study): a randomised controlled trial
Introduction
In 2004, WHO issued guidelines1 for the use of antiretroviral regimens for prevention of mother-to-child transmission (MTCT) of HIV-1 in resource-poor settings, which included recommendations for long-term antiretroviral therapy (ART) for women eligible for treatment (WHO clinical stage 4 or CD4 count <200 cells per μL); peripartum prophylaxis for women not eligible for treatment; and exclusive breastfeeding up to 6 months unless replacement feeding becomes acceptable, feasible, affordable, sustainable, and safe before that time. In practice, most HIV-infected mothers breastfeed their infants, often not exclusively, which is associated with a significant risk of transmission.2
For immunocompromised mothers, ART is not only beneficial for maternal health but also reduces the risk of MTCT during pregnancy, delivery, and breastfeeding.3, 4, 5 For women infected with HIV who have a CD4 count greater than 500 cells per μL, the risk of transmission during breastfeeding is low, around 1%,5, 6 and any time-limited antiretroviral-based intervention was thought at the time of protocol development to potentially carry more risks (toxicity or emergence of resistance to antiretroviral drugs) than benefits in women who did not require ART for their own health.7 For women with CD4 counts of 200–500 cells per μL, alternatives to replacement feeding to prevent postnatal HIV transmission are particularly important because breastfeeding is essential for child health and development in low-resource settings.2 One alternative would be to provide antiretroviral prophylaxis to the mother or child during breastfeeding.8, 9, 10
We aimed to assess the efficacy and safety of triple antiretrovirals compared with those of zidovudine and single-dose nevirapine for prevention of MTCT during pregnancy and breastfeeding for pregnant women infected with HIV-1 who had CD4 cell counts of 200–500 copies per μL.
Section snippets
Patients
Full details of the rationale for the study and methods are provided elsewhere.7 Key elements are summarised here. The Kesho Bora Study (“A better future” in Swahili) was a randomised controlled trial in antiretroviral-naive pregnant women infected with HIV-1 who visited antenatal clinics associated with five study sites (Centre Muraz, Bobo-Dioulasso, Burkina Faso; International Centre for Reproductive Health, Mombasa, Kenya; Kenyatta National Hospital, Nairobi, Kenya; University of
Results
Between June, 2005, and August, 2008, 824 pregnant women were randomly assigned treatment and delivered 805 singleton or first, liveborn babies (figure 1). There were 11 multiple pregnancies (four in the triple antiretroviral group and seven in the zidovudine and single-dose nevirapine group). Maternal baseline characteristics were balanced across study groups (table 1). Overall, 73% of women reported no missed antenatal antiretroviral dose (table 2). 87% of women in the zidovudine and
Discussion
Maternal triple antiretroviral prophylaxis reduced the risk of MTCT of HIV by 43% at 12 months compared with a standard zidovudine and single-dose nevirapine regimen. Women with CD4 cell counts of less than 350 cells per μL had a higher relative risk reduction and number of infections averted than did those with higher counts. Transmission rates at birth and age 6 weeks did not differ significantly between groups. However, because of slower than anticipated recruitment, the study did not have
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