The median length of antenatal treatment was 21 days with ZDV, 29 with ZDV + NVPsd and 50 with ZDV + 3TC + NVPsd (Table 2). The proportion of women taking the ARV labour dose increased from 83% with ZDV alone to 93% with the two-drug combinations (P < 10–4). The postpartum ARV prophylaxis was generally taken. This component could not be compared between the groups as it differed (Table 2). There was no statistical difference between the three groups for place of delivery and frequency of Caesarian section, an infrequent practice (Table 2). The proportion of women who chose to breastfeed from birth was 54–66% in the two groups receiving ARV combinations, whereas it was 97.6% in the ZDV group (Table 2).
There were 79 of 1010 neonates for whom the diagnosis of paediatric HIV infection was made (Table 1). For 29 of them, in utero transmission was considered. In 28 instances, transmission was classified as intrapartum or early postnatal, the 22 other infections remaining of unknown timing. The overall 6-week probability of transmission was 6.5% (95% CI, 3.9–9.1%) with ZDV + NVPsd and 4.7% (95% CI, 2.4–7.0%) with ZDV + 3TC + NVPsd (P = 0.34 after adjustment on maternal CD4 count, plasma HIV-1 RNA, WHO clinical stage, primigravida, duration of prepartum treatment, intrapartum treatment intake, low birthweight and breastfeeding). When using ZDV alone as reference (12.5% transmission at 6 weeks), the protective effect of the two-drug combinations was strong, with an adjusted effectiveness of 72% (95% CI, 45–86%) for ZDV + NVPsd and 76% (95% CI, 52–88%) for ZDV + 3TC + NVPsd (P < 0.0002 and 0.0001, respectively after adjustment for maternal CD4 cell count, WHO clinical stage, moderate anaemia, age, primigravida, low birthweight, duration of prepartum treatment, intrapartum treatment intake, Caesarian section and breastfeeding) (Table 4). There was neither an interaction between treatment and maternal CD4 cell count (P = 0.68) nor between treatment and infant feeding (P = 0.57). There was no statistical difference in the crude and adjusted risks of transmission at 6 weeks according to the infant feeding exposure. This adjustment factor never reached statistical significance in multivariate analyses (P = 0.10, Table 4). Thus, in comparison with ZDV alone, the relative effectiveness of the two drug combinations among the 703 breastfed children was 70% for ZDV + NVPsd (P < 0.002) and 77% for ZDV + 3TC + NVPsd (P < 0.003).
We stratified the sample according to the 2003 WHO criteria for HAART indication (P = 0.65 for the interaction of this variable with treatment). Among the 212 HAART-eligible women, the 6-week probability of peripartum infection was 23.6% with ZDV alone, 13.6% with ZDV + NVPsd and 9.1% with ZDV + 3TC + NVPsd (P = 0.28 and 0.10, respectively for the two comparisons using ZDV as reference). Among the 774 women who had no HAART indication, the 6-week peripartum transmission probability was 10.9% with ZDV alone, 3.6% with ZDV + NVPsd and 3.5% with ZDV + 3TC + NVPsd (P < 0.03 for both comparisons using ZDV as reference).
We could not investigate the relationship between the ARV regimens and the timing of acquisition of paediatric HIV infection as the majority of cases in the ZDV cohort were HIV RNA positive for the first time at ≥ day 7 (Table 1). Finally, the time period of enrolment was not investigated as the study of each drug regimen followed the previous one without any overlap. We verified however that the transmission rate did not vary by calendar year for each period of enrolment (data not shown).
We have demonstrated a high effectiveness for the ZDV + NVPsd regimen, which reduced peripartum MTCT by 72% compared with ZDV alone [3–6]. We cannot demonstrate an additional benefit of adding 3TC to ZDV + NVPsd although starting ZDV + 3TC a month earlier than ZDV. It is now internationally recognized that triple-drug combinations used together and not sequentially further reduce MTCT, especially for women who need HAART for themselves . However, we identified with ZDV + NVPsd a peripartum regimen that is particularly effective when HAART is not indicated, with comparable results to industrialized countries before the HAART era [9,21]. The 6-week residual risk was independent of the breastfeeding exposure. The prolonged duration of NVP levels in both the mother and the child over the first weeks of life may have reduced early transmission by breastmilk, an added benefit of NVPsd combined with ZDV or ZDV + 3TC. Two-year follow-up is under way to estimate the additional postnatal transmission risk and the cumulative effectiveness of our peripartum and postpartum packages .
Comparing the different ARV MTCT regimens directly is difficult. The first African placebo-controlled trials evaluated individual drug regimens [3,4,7,10]. Then, equivalence trials were designed . Three key parameters have varied from trial to trial and impair the direct comparison of published results. The median maternal CD4 cell count varied between 545 × 106 cells/l in West Africa ZDV studies  to 370 × 106 cells/l with ZDV + NVPsd (Table 2), 461 × 106 cells/l in the Uganda NVPsd trial  and 482 × 106 cells/l in the ZDV + 3TC trial . The frequency of Caesarian section was 30% in South Africa , 3–6% in our cohort and exceptionally elective. We introduced alternatives to prolonged and predominant breastfeeding whereas no neonatal intervention had been proposed in the ZDV reference cohort. Our estimate of the 6-week transmission risk includes early postnatal transmission, possibly partly controlled by the neonatal ZDV + NVPsd prophylaxis but impaired by other risk factors, low maternal CD4 cell count and low frequency of Caesarian section. These three factors were controlled for in all analyses. In doing so, our ZDV + NVPsd regimen had the lowest estimate of the residual transmission risk compared to ZDV alone [3,4], NVPsd , ZDV + 3TC, except its longest regimen with a residual transmission of 5.7% .
The DITRAME PLUS regimens were made of several components, each of them selected on the basis of previous evidence. We did not design the study to investigate their respective contribution as recently done in Thailand in a randomized trial . Indeed, their results strengthen our approach of adding NVPsd to a short-course ZDV regimen. This trial suggests also that the neonatal ZDV + NVPsd prophylaxis has an added value, with a 2.0% residual transmission versus 2.8% in the absence of neonatal NVPsd, although the difference remained below statistical significance . Neonatal NVPsd together with 1 week of ZDV has recently been shown to prevent more intrapartum transmission than NVPsd in Malawi when no ARV could be given before delivery/birth . This was not the case however when maternal NVPsd had been administered prior to delivery . Based on this evidence, the WHO recommends as first-line regimen the combination of a short course of ZDV for pregnant women at ≥28 weeks and children, for at least 1 week, with NVPsd for both .
We chose a non-randomized approach to estimate the treatment effect as we considered there was a priori lack of equipoise between ZDV + NVPsd and ZDV alone. Indeed, ethical principles and time constraints can legitimize the use of non-randomized designs . The Thai trial conducted at the same time as our study stopped its ZDV alone arm after its first interim analysis as it was already inferior to the two arms evaluating ZDV + NVPsd combinations . We acknowledge that beyond the important confounding factors systematically controlled for, such as the clinical and immunological stage of HIV disease, the breastfeeding exposure and the duration of the ARV prophylaxis, unconsidered factors could not be taken into account by our design. Of note, the uptake in the cohorts remained constant over time .
The ZDV + 3TC + NVPsd regimen we evaluated was selected at a time when access to HAART was too limited in Côte d’Ivoire to be considered during pregnancy. Our choice was based on the demonstrated efficacy of short-courses of ZDV + 3TC in the ANRS 075 cohort in France  and in the PETRA trial in Africa . We did not demonstrate an enhanced effectiveness of this regimen in comparison with ZDV + NVPsd, although our study had limited statistical power, an uneven distribution of confounding variables between the two groups (controlled for in the analysis) and was terminated mid-2003 as soon as HAART became available on site.
The ZDV + NVPsd MTCT prophylactic regimen we evaluated is now part of the list of internationally recommended drug regimens by WHO . Once the benefit (effectiveness)/risk (resistance) ratio of the ZDV + 3TC + NVPsd combination is known, this regimen may also be considered. Four areas now require further research consideration. First, the uptake of ARV peripartum interventions is critical to obtain a public health impact. ZDV and NVPsd are not easy to use in Africa [35–37]. Their combined use will not be necessarily more complex but the challenge is to improve coverage . Second, the reduction of the risk of postnatal transmission should be addressed, either with infant feeding strategies  or with ARV-based approaches . Third, alternatives to NVPsd-containing regimens should be investigated as viral resistance and impaired response to subsequent ARV treatment is a serious concern. Finally, the residual transmission we observed with ZDV + NVPsd cannot be considered fully satisfactory. HAART is now universally recommended for pregnant women who fulfil this indication for themselves . We demonstrate in a large African cohort, as in a randomized trial in Thailand, that a short-course peripartum ZDV regimen combined with NVPsd is more effective than previously used single drug regimens and will greatly contribute to the prevention of paediatric HIV infection if rapidly and widely used.
François Dabis was the director and co-primary investigator of the entire project, supervized the epidemiological aspects of the study and wrote the manuscript. Laurence Bequet was the study co-ordinator of all aspects of the project on site. Didier Koumavi Ekouevi was the chief data manager and participated in the data analysis and manuscript writing. Ida Viho was the clinical director and monitored the entire study. François Rouet was responsible for all laboratory aspects of the project on site and contributed to the writing of the manuscript. Charlotte Sakarovitch and Laurence Dequae-Merchadou prepared and conducted data analysis. Apollinaire Horo clinically supervized the antenatal and obstetric phases of the study. Renaud Becquet contributed to data monitoring and was particularly in charge of surveillance of adverse events. Patricia Fassinou supervized the paediatric phase of the project clinically. Christiane Welffens-Ekra was the obstetrician primary investigator of the project. Christine Rouzioux supervized the laboratory component of the project and ensured quality control. Valériane Leroy was the co-primary investigator of the project, was responsible for evaluation of postpartum interventions and participated in the manuscript writing.
The primary sponsor of the DITRAME PLUS project was the French Agence Nationale de Recherches sur le Sida (ANRS), France. Laurence Bequet and François Rouet were supported by the French Ministry of Foreign Affairs. Didier K. Ekouevi was a fellow of the French Charity Ensemble contre le Sida. Renaud Becquet was a fellow of the French Ministry of Education, Research and Technology. The authors wish to acknowledge the support of the Developing Country Unit of the ANRS, particularly Drs Brigitte Bazin and Séverine Blesson, and Mrs Chantal Canon and Névada Mendes. Zidovudine and lamivudine were provided by Glaxo Smith Kline International. Dr Guillaume Walckenaer and Mrs Cecile Thiaux (Glaxo Smith Kline France) facilitated the zidovudine and lamivudine drug supply throughout the study. Pr Marie-Claude Saux, Mrs Dominique Breilh and Mr Bruno Fallour (Pharmacie Centrale, Hôpital du Haut-Lévêque, Pessac, France) were in charge of drug packaging. Euclidis (Pessac, France) ensured quality control of the study drug preparation and was responsible for shipment from France to Côte d’Ivoire. The Board of the Formations Sanitaires Urbaines Communautaires participating as study sites actively supported the project. Special thanks to Marie-Pierre Martin, Isabelle Bely, Bertin Kouadio and Philippe Lepère for the administrative management of the study. Finally, we would like to thank Drs Philippe Msellati and Nicolas Meda for their contribution to the ANRS 049 DITRAME reference study and the women and children who agreed to participate to the DITRAME PLUS project.
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Composition of the ANRS 1201/1202 DITRAME PLUS Study Group
Writing committee: François Dabis, Laurence Bequet, Didier Koumavi Ekouevi, Ida Viho, François Rouet, Apollinaire Horo, Charlotte Sakarovitch, Renaud Becquet, Patricia Fassinou, Laurence Dequae-Merchadou, Christiane Welffens-Ekra, Christine Rouzioux, Valériane Leroy.
Principal investigators: François Dabis, Valériane Leroy, Marguerite Timite-Konan, Christiane Welffens-Ekra.
Coordination in Abidjan: Laurence Bequet, Didier Koumavi Ekouévi, Besigin Tonwe-Gold, Ida Viho.
Clinical team: Clarisse Amani-Bosse, Ignace Ayekoe, Gédéon Bédikou, Nacoumba Coulibaly, Christine Danel, Patricia Fassinou, Apollinaire Horo, Ruffin Likikouet, Hassan Toure.
Laboratory team: Dominique Bonard, André Inwoley, Crépin Montcho, François Rouet, Ramata Touré.
Biostatistics and data management: Gérard Allou, Renaud Becquet, Katia Castetbon, Laurence Dequae-Merchadou, Charlotte Sakarovitch, Dominique Touchard.
Psycho-social team: Hortense Aka-Dago, Herman Brou, Annabel Desgrées du Loû, Alphonse Sihé, Benjamin Zanou.
Scientific committee: Stéphane Blanche, Jean-François Delfraissy, Philippe Lepage, Laurent Mandelbrot, Christine Rouzioux, Roger Salamon.