E-DRUG: Mother To Child Transmission (MTCT) and breastfeeding
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[copied as fair use from lancet website; WB]
http://www.thelancet.com/usr/issues/vol356no9226/news_sm315.html
Hope for prevention of mother-to-child transmission of HIV
Lancet 2000; 356: 315 - 322
The late breakers session on the last day of the XIIIth International
AIDS Conference in Durban, South Africa (July 9-14) offered great
hope for the beleaguered African nations in the prevention of HIV
infection. Investigators of trials in several countries reported
success with simple, cheap regimens of nevirapine given to
mothers and newborn infants.
Results from the South African Intrapartum Nevirapine Trial (SAINT)
confirmed that nevirapine is safe and effective at reducing mother-to-
child transmission of HIV. Further, preliminary findings of long-term
follow-up of the HIVNET-012 trial in Uganda (see Lancet 1999; 354:
795-802) showed that the benefits of this drug (42% reduction in
relative risk versus zidovudine) are maintained at 18 months.
Worryingly, however, the investigators of the PETRA study
(placebo-controlled trial of zidovudine and lamivudine combination
regimens) reported that infection and mortality rates (of 21-26%) at
18 months in the various groups did not differ from those for
placebo. Notably, breastfeeding rates were high--69% overall and
as much as 99% in east Africa. The trialists attributed the loss of
efficacy to "a high number of HIV-1 infections in breast-fed
children", with breastfeeding doubling the risk of infection at 18
months. Additionally, the SAINT investigators recorded a seven-fold
increase in HIV infection at 4-8 weeks in breastfed infants.
Anna Coutsoudis (University of Natal, South Africa) presented the
completed 15 month results of a vitamin A intervention trial in
South Africa (see Lancet 1999; 354: 471-76). Most mothers (72%)
chose to breastfeed, despite counselling about the associated risk
of HIV transmission. Socioeconomic status was an important
factor in this decision. Coutsoudis explained that the culture of
breastfeeding, especially in sub-Saharan countries, was to
introduce sugar water and cereals at about 6 weeks (mixed
breastfeeding). At 15 months' follow-up, infection rates were high in
babies who were mixed fed (26%), but remained lower in those
exclusively breastfed for 3-6 months (19%). She suggested that
adding other foods into the child's diet at this early stage
introduces allergens or contaminants to the gut, which in turn lead
to an inflammatory response. The resulting damage to the gut
might allow the virus to enter the baby's system.
Clearly, breastfeeding is a major factor in transmission from mother
to child in African countries. But treatment substantially reduces
transmission. Nevertheless, in South Africa, the Department of
Health is hesitating about introducing nevirapine: "We are
encouraged by the benefits that intrapartum nevirapine seems to
offer ... we note, however, that more work is needed to confirm
safety and efficacy ... particularly as regards the development of
resistance".
Stephanie Clark
Wilbert Bannenberg, SADAP Coordinator
Hallmark 938, P/Bag X 828, Pretoria 0001, South Africa
Tel work +27-12-3120374/5 Fax +27-12-3236745 Cellphone +27-82-5756249
Email bannew@health.gov.za (work)
Email WilbertBannenberg@compuserve.com (private)
[The Coutsoudis study has stimulated a lot of interest in further
investigation of the impact of exclusive breastfeeding on MTCT, BS
co-moderator.]
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