Correspondence

Maternal –Infant Transmission of HIV-1

N Engl J Med 1995; 332:890-891March 30, 1995

Article

To the Editor:

Connor et al. (Nov. 3 issue)1 report that a multicenter clinical trial, conducted in the United States and France, demonstrated a reduction in maternal–infant transmission of the human immunodeficiency virus type 1 (HIV-1) with zidovudine treatment. Planning is now under way for studies of perinatal zidovudine in several African, Asian, and South American countries. In an ideal world, implementing zidovudine regimens to reduce maternal–infant HIV transmission in developing nations would be humane and appropriate. But in the real world, is this approach practical?

Women in rural Africa often have little or no prenatal care, and identifying HIV-infected candidates for therapy will be difficult. In addition, many deliveries are attended only by traditional birth attendants, who are not trained to test for HIV. Even in urban areas where the majority of women have prenatal visits, HIV screening will be expensive, and keeping confidential records will be a daunting task.

In AIDS Clinical Trials Group (ACTG) protocol 076, zidovudine was administered to mothers before and during delivery and to infants for six weeks after delivery. Given the shortage of trained personnel to provide and monitor long-term therapy in most areas with a high prevalence of HIV, such a treatment schedule may not be feasible. Even short-term zidovudine treatment may not be a practical option.

At Queen Elizabeth Central Hospital, a tertiary referral center in Blantyre, Malawi, 1580 women delivered infants between August 1 and September 10, 1994. Of the 1240 women for whom the time of the first vaginal examination after arriving at the hospital was recorded, 57.8 percent gave birth within three hours, and 80 percent within seven hours (Figure 1Figure 1Time between the First Clinical Examination and Delivery for 1240 Women Who Gave Birth at Queen Elizabeth Central Hospital in Blantyre, Malawi, between August 1 and September 10, 1994.). A single dose of zidovudine is unlikely to decrease HIV viremia and the risk of transmission in such a short time. At best, such a dose could serve as a means to provide the infant with zidovudine through the placenta. Clinical trials of the efficacy and safety of zidovudine in this setting are needed, although the failure of the drug to prevent HIV infection from needle-stick injuries2 is not encouraging.

Interventions to prevent HIV transmission should be targeted to the time of delivery, safe enough to administer to all women regardless of whether they are infected with HIV, and simple enough to be administered by midwives, nurses, or traditional birth attendants. We are studying the value of birth-canal cleansing in preventing perinatal HIV transmission,3 which is safe, regardless of whether a woman is infected with HIV; inexpensive; and easily taught. If effective, this procedure may also reduce the transmission of other perinatal infections.

Proposed interventions to prevent perinatal HIV transmission should be economically and logistically sustainable. Given the current circumstances in Africa,4 zidovudine prophylaxis is unlikely to meet these criteria.

Laban Mtimavalye, M.B., Ch.B.
Queen Elizabeth Central Hospital, Blantyre, Malawi

Robert J. Biggar, M.D.
National Cancer Institute, Bethesda, MD 20852

Taha E. Taha, M.B., B.S., Ph.D.
Johns Hopkins University–, Ministry of Health Research Project

John Chiphangwi, M.B., Ch.B.
University of Malawi Medical School, Blantyre, Malawi

4 References

1. 1

   Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994;331:1173-1180
   Full Text | Web of Science | Medline

2. 2

   Looke DF, Grove DI. Failed prophylactic zidovudine after needlestick injury. Lancet 1990;335:1280-1280
   CrossRef | Web of Science | Medline

3. 3

   Biggar RJ, Goedert JJ, Miotti P. Virucidal agents in the prevention of perinatal HIV transmission. In: Proceedings of the First Workshop on Antiviral Claims for Topical Antiseptics, Bethesda, Md., May 31–June 1, 1994 (in press).
   

4. 4

   Biggar RJ. When ideals meet reality -- the global challenge of HIV/AIDS. Am J Public Health 1993;83:1383-1383
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: ACTG protocol 076 demonstrated that a regimen of zidovudine given to mothers before and during delivery and to their infants for six weeks after birth reduced the risk of perinatal HIV transmission by nearly 70 percent. This finding has already had a substantial influence on the care of HIV-infected pregnant women in the United States. The study has also established the principle that it is possible to reduce the risk of perinatal transmission with antiviral strategies, thus encouraging further research in the field. As Mtimavalye and colleagues point out, the direct application of the ACTG protocol 076 regimen to clinical settings with limited health care resources will be a challenge. It is important to determine whether a simplified regimen is as effective, since zidovudine is currently the only agent that has been proved effective. In addition, it is important to study alternative approaches that may be used easily in developing countries. Birth-canal cleansing and immune-based strategies are alternatives that warrant further investigation.

Edward Connor, M.D.
MedImmune, Gaithersburg, MD 20878

Rhoda Sperling, M.D.
Mt. Sinai School of Medicine, New York, NY 10029

Richard D. Gelber, Ph.D.
Harvard School of Public Health, Boston, MA 02115

James Balsley, M.D., Ph.D.
National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892

Citing Articles (4)

Citing Articles

1. 1

   Ahmad F. Bakr, Tarek Karkour. (2005) Effect of Predelivery Vaginal Antisepsis on Maternal and Neonatal Morbidity and Mortality in Egypt. Journal of Women's Health 14:6, 496-501
   CrossRef

2. 2

   Katia Castetbon*, Valériane Leroy, François Dabis. (1998) Vitamin A supplementation and HIV-1 mother-to-child transmission in Africa. The Lancet 352:9128, 653-654
   CrossRef

3. 3

   M. Cartoux, P. Msellati, O. Rouamba, D. Coulibaly, N. Meda, D. Blibolo, L. Mandelbrot, P. Van de Perre, F. Dabis. (1996) Acceptability of Interventions to Reduce Mother-to-Child Transmission of HIV-1 in West Africa. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 12:3, 290-292
   CrossRef

4. 4

   CHERYL COX, C.N.L. MACPHERSON. (1996) MODIFIED INFORMED CONSENT IN A VIRAL SEROPREVALENCE STUDY IN THE CARIBBEAN. Bioethics 10:3, 222-232
   CrossRef