Letters to the Editor
To the Editors:
Dr. Amman's comprehensive and succinct editorial (August 15, 2009)1 is a long overdue reprieve for all whose lives have been affected by HIV. One hopes that his words will mark the beginning of an international rescue effort to protect women living with HIV from exposure to suboptimal antiretroviral (ARV) treatment and prophylaxis regimens.
Still, much remains unsaid. Almost 15 years into the current era of effective lifesaving HIV treatment, we continue to take the abrupt disappearance of the AIDS orphan crisis in resource-rich regions for granted. The inescapable truth remains hidden in plain sight: support of maternal health that includes HIV and reproductive health services is the only way to shield children from AIDS and from the social, medical, nutritional, developmental, and psychological devastation of being orphaned.
The “curious twist in the history of medical research” aptly noted by Dr. Amman (whereby pediatric HIV prevention research has persistently focused on minimizing maternal ARV prophylaxis regimens in the face overwhelming evidence of the advantages of early, optimal, and uninterrupted treatment) may prove to be a very troublesome knot to untie. Physicians in regions where single dose nevirapine strategies have been “rolled out” already struggle with treatment alternatives for single dose nevirapine-exposed women and infected children.
With a few recent exceptions2, clinical trials and program implementation are largely devoid of maternal health outcomes analysis. Validated methodologies to measure impact of vertical transmission prevention protocols outside of research settings do not exist. International consensus on the safety of specific ARVs in women of reproductive age has not been reached.
Almost 12 years ago, clinicians throughout the world first noticed that HIV-infected women receiving optimal HIV treatment during pregnancy did not transmit the virus to their babies.3,4 Today, we, along with our clients, must continue to base treatment decisions during pregnancy on data from largely male or pediatric cohorts. Questions from the 1990s remain unanswered: What combinations are easiest to take during pregnancy? What are the safest for mother and baby? What strategies are associated with the highest adherence, especially in the postpartum period? When and how should we employ 2nd and 3rd line strategies? And finally, what treatment, prophylaxis and nutritional interventions are associated with the longest AIDS-free maternal and HIV-exposed child survival?
We urgently require the answer to these and many other questions. Let us all join with Dr. Amman in the strongest possible advocacy and support for the incorporation of evidenced based principles that define optimal HIV treatment and prophylaxis strategies into all vertical transmission prevention trials as well as national prevention and treatment agendas.
Karen P. Beckerman, MD
Department of Obstetrics & Gynecology and Women's Health
Albert Einstein College of Medicine
1. Amman AJ. Optimal vs suboptimal treatment for HIV-infected pregnant women and HIV-exposed infants in clinical research studies. J Acquir Immune Defic Syndr
2. Kuhn L, Semrau K, Ramachandran S, et al. Mortality and virologic outcomes after accessing antiretroviral therapy among a cohort of HIV-1 infected women who received single-dose nevirapine in Lusaka, Zambia. J Acquir Immune Defic Syndr
3. Marazzi MC, Palombi L, Nielsen-Saines K, et al. Favorable pregnancy outcomes with reduction of abortion, stillbirth, and prematurity rates in a large cohort of HIV+ women in Southern Africa receiving HAART for PMTCT. Presented at: 5th Conference on HIV Pathogenesis, Treatment and Prevention; July 2009; Cape Town, South Africa. Abstract TUAC102.
4. Beckerman K, Benson M, Dahud S, et al. Control of Maternal HIV disease during Pregnancy. Presented at: 12th World AIDS Conference; July 1998; Geneva, Switzerland. Abstract 41.