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Antiretroviral drugs for preventing mother-to-child transmission of HIV in sub-Saharan Africa: balancing efficacy and infant toxicity

Ciaranello, Andrea L; Seage, George R III; Freedberg, Kenneth A; Weinstein, Milton C; Lockman, Shahin; Walensky, Rochelle P

doi: 10.1097/QAD.0b013e3283189bd7
Epidemiology and Social

Objective: Antiretroviral drugs can prevent mother-to-child transmission of HIV infection, but in-utero antiretroviral exposure may be associated with neurologic symptoms due to mitochondrial toxicity. We sought to identify the currently recommended regimen to prevent mother-to-child transmission that optimally balances risks of pediatric HIV infection and neurologic mitochondrial toxicity.

Design: Published MTCT and mitochondrial toxicity data were used in a decision analytic model of MTCT among women in sub-Saharan Africa.

Methods: We investigated the HIV and mitochondrial toxicity risks associated with no antiretroviral prophylaxis and five recommended regimens ranging from single-dose nevirapine to three-drug antiretroviral therapy (ART). Sensitivity analyses varied all parameters, including infant feeding strategy and the disability of mitochondrial toxicity relative to HIV.

Results: Provision of no antiretroviral drugs is the least effective and least toxic strategy, with 18-month HIV risk of 30.4% and mitochondrial toxicity risk of 0.2% (breastfed infants). With increasing drug number and duration, HIV risk decreases markedly (to 4.9% with three-drug ART), but mitochondrial toxicity risk also increases (to 2.2%, also with three-drug ART). Despite increased toxicity, three-drug ART minimizes total adverse pediatric outcomes (HIV plus mitochondrial toxicity), unless the highest published risks are true for both HIV and mitochondrial toxicity, or the disability from mitochondrial toxicity exceeds 6.4 times that of HIV infection.

Conclusion: The risk of pediatric mitochondrial toxicity from effective regimens to prevent mother-to-child transmission is at least an order of magnitude lower than the risk of HIV infection associated with less-effective regimens. Concern regarding mitochondrial toxicity should not currently limit the use of three-drug ART to prevent mother-to-child transmission where it is available.

Author Information

aDivision of Infectious Disease, USA

bDivision of General Medicine, Department of Medicine, Massachusetts General Hospital, USA

cDivision of Infectious Disease, Brigham and Women's Hospital, USA

dCenter for AIDS Research, Harvard Medical School, USA

eDepartment of Epidemiology, USA

fDepartment of Health Policy and Management, USA

gDepartment of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, USA.

Received 15 May, 2008

Revised 29 August, 2008

Accepted 5 September, 2008

Correspondence to Andrea L. Ciaranello, MD, Division of Infectious Diseases, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114, USA. Tel: +1 617 724 8445; fax: +1 617 726 2691; e-mail:

Copyright © 2008 Wolters Kluwer Health, Inc.