New WHO ART Advice for Pregnant Women -- Three ARVs at Any CD4
A third World Health Organization (WHO) option to treat HIV-positive pregnant women -- and to prevent mother-to-child transmission (MTCT) of HIV -- calls for starting triple antiretroviral (ARV) therapy (ART) for all women as soon as they test positive, regardless of CD4 count, and continuing triple therapy for life.
The new "Programmatic Update" downplays Option A, which proposes a different regimen for women with CD4 counts above or below 350 cells/µL, because it can be difficult to implement in resource-poor clinics.
"Recent developments suggest that substantial clinical and programmatic advantages can come from adopting a single, universal regimen both to treat HIV-infected pregnant women and to prevent mother-to-child transmission of HIV," the update says.
Option B "takes this unified approach" but proposes a different strategy depending on the pregnant woman’s CD4 count: triple therapy at diagnosis and continued for life for women with a CD4 count at or below 350 cells/µL, and triple therapy starting at 14 weeks gestation and continued through childbirth in nonbreastfeeding women or through breastfeeding for women with more than 350 cells/µL.
The new option B+ endorses triple therapy at diagnosis and continuing for life no matter what the woman’s CD4 count is.
Option A also recommends triple therapy at diagnosis and continued for life, but only in women with 350 or fewer CD4 cells/µL. For women with a higher CD4 count, option A calls for zidovudine starting as early as 14 weeks gestation, single-dose nevirapine at the start of labor plus the first dose of zidovudine/lamivudine, and zidovudine/lamivudine continued through 7 days postpartum.
Options B and B+ recommend daily nevirapine of zidovudine for the infant from birth through age 4 to 6 weeks, regardless of feeding method.
WHO lists several advantages for option B+: "further simplification of regimen and service delivery and harmonization with ART programmes, protection against mother-to-child transmission in future pregnancies, a continuing prevention benefit against sexual transmission to serodiscordant partners, and avoiding stopping and starting of antiretroviral drugs."
Comprehensive revision of all antiretroviral guidelines by WHO is now under way, with a planned release in early 2013.
Source: World Health Organization. Programmatic update: Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. Executive summary. April 2012.
Written by Mark Mascolini on behalf of the International AIDS Society.