Extended Antiretroviral Prophylaxis Reduces Breast-Milk HIV Transmission

NEW YORK (Reuters Health) Jun 04 - In infants born to HIV-infected mothers, extended prophylaxis with nevirapine alone or combined with zidovudine for the first 14 weeks of life reduces their acquisition of HIV via breastfeeding, according to the results of a study conducted in Blantyre, Malawi.

By contrast, the results of another study, conducted in Lusaka, Zambia, indicate that early, abrupt cessation of breastfeeding does not reduce breast-milk HIV transmission and is associated with increased mortality among HIV-infected infants. Both studies are reported in the June 4th Online First issue of The New England Journal of Medicine.

Dr. Taha E. Taha, from Johns Hopkins University in Baltimore, and colleagues assessed HIV transmission in 3016 infants who were born to HIV-infected mothers and were randomized to receive single-dose nevirapine plus 1 week of zidovudine, 14 weeks of nevirapine plus 1 week of zidovudine, or 14 weeks of both nevirapine and zidovudine. Comparable rates of breastfeeding were seen in each group.

Infants treated without extended prophylaxis had consistently higher HIV infection rates from 6 weeks through 18 months, the report indicates. By 9 months, the cumulative infection rate was 10.6% in the control group, 5.2% in the nevirapine-only extended prophylaxis group (p < 0.001) and 6.4% in the nevirapine plus zidovudine extended prophylaxis group (p = 0.002).

An increased rate of treatment-emergent adverse events, mostly neutropenia, was seen in infants who received extended dual prophylaxis, the report indicates.

“This is the first study to demonstrate that extending infant prophylaxis to 14 weeks can be protective,” Dr. Taha told Reuters Health. “Earlier studies provided infant prophylaxis around time of birth; previous short-term regimens were shown to be effective and now represent the standard of care in almost all settings in Africa.”

Breastfeeding “is critical for the health and survival of infants in resource-limited settings such as sub-Saharan Africa,” she emphasized. “Making the breastfeeding period safe is important because alternatives such as formula feeding lead to diarrheal diseases and malnutrition. Extended antiretroviral infant prophylaxis is an effective and safe approach.”

In the second study, Dr. Louise Kuhn, from Columbia University in New York, and colleagues assessed HIV-free survival in 958 infants born to HIV-infected mothers who were encouraged to abruptly stop breastfeeding at 4 months or to continue feeding for as long as they wish.

Sixty-nine percent of mothers in the intervention group had stopped breastfeeding by 5 months and most of them did so in less than 2 days. The median duration of breastfeeding in the control group was 16 months.

At 24 months, the percentage of infants in the intervention group who were alive and uninfected with HIV was 68.4%, higher but not significantly different from the 64.0% seen in the control group.

Among infants infected with HIV by 4 months, mortality was significantly higher in those with early rather than later termination of breastfeeding: 73.6% vs. 54.8% (p = 0.007).

“These results suggest that early, abrupt cessation of breastfeeding for HIV-infected women in low-resource settings should be avoided,” the authors conclude.

Source:

1. Extended Antiretroviral Prophylaxis Reduces Breast-Milk HIV Transmission