Country adaptation of the 2010 World Health Organization recommendations for the prevention of mother-to-child transmission of HIV
Elena Ghanotakis, Lior Miller & Allison Spensley
Volume 90, Number 12, December 2012, 921-931
Table 3. Factors considered by Lesotho and Malawi when selecting their antiretroviral therapy (ART) regimens for the prevention of mother-to-child transmission (PMTCT) of HIV
| Factor | Lesotho (Option A) |
Malawi (Option B+a) |
Preferred | |||
|---|---|---|---|---|---|---|
| Option A | Option B | Option A | Option B | |||
| WHO recommendation | Strong | Strong | – | – | Equivalent | |
| Efficacy of intervention | Comparable | Comparable | – | – | Equivalent | |
| Acceptability |
Similar to regimen already in use and familiar to mothers and providers | Unknown to mothers | – | – | Option A |
|
| Can be initiated while awaiting CD4+ lymphocyte count |
Providers less familiar with this approach | – | – | |||
| Can be initiated without CD4+ lymphocyte count | – | – | ||||
| Eliminates the need for minimum package | – | – | ||||
| Cost |
US$ 238 881 | Option B EFV: US$ 2 128 157 | Drug regimen less expensive | Drug regimen more expensive; however, reductions in number of infections, morbidity and mortality in children and adults will lower costs in the long run | Option A |
|
| Requires additional individual ARVs (AZT for mothers and NVP infants) | Requires additional ART (mothers) and NVP (infants) | Management costs for all options likely to be the same | Management costs for all options likely to be the same | |||
| Additional PCRs necessary during breastfeeding | Additional PCRs necessary during breastfeeding | – | – | |||
| Additional laboratory monitoring necessary (mothers: Hb before delivery and infants: LFTs throughout breastfeeding) | Additional laboratory monitoring necessary (mothers: Hb, LFTs, Cr before delivery; mothers: Hb, LFTs, Cr throughout breastfeeding). | – | – | |||
| Feasibility |
Additional refresher training necessary | More extensive training necessary | More complicated than Option B, but not much different from the existing 2006 PMTCT guideline regimen | Would require extensive retraining, but could be easier in concept for both health care providers and mother/baby pairs once training takes place | Option A |
|
| ARVs already available in ANC facilities |
Requires making ART available in antenatal clinics | Necessary to teach proper dosing of NVP | – | |||
| Requires increased laboratory capacity | – | – | ||||
| Health delivery infrastructure | – |
– |
CD4+ lymphocyte test needed to initiate and for early access to ART | CD4+ lymphocyte test needed to know when to take off ART | – |
|
| Necessary for follow up and support of mother/baby pair for ongoing adherence | Necessary for laboratory monitoring of Hb levels | |||||
| Necessary to emphasize clinical review ± PCR for signs of infection | Necessary for follow up and support of mother and infant for ongoing adherence | |||||
| Referral systems for infants who transmit | Would require additional HAART classes at ANC | |||||
| – | Necessary to emphasize clinical review, with or without PCR, for signs of infection | |||||
| – | Referral systems for infants to whom HIV has been transmitted | |||||
| Health risk | Risk of anaemia for mothers (AZT) | Risk of anaemia (AZT), hepatotoxicity (NVP) and elevated Cr (TDF) for mothers | Concern of drug adherence for infants | Impact on maternal health of interrupted ART | Equivalent | |
| Risk of hepatotoxicity in infants (NVP) | Risk of hepatotoxicity for infants (NVP) | No ongoing safety data for extended infant NVP beyond 1 year | Side-effects of ART | |||
| Potential maternal resistance after delivery | Potential maternal resistance when stopping ART | No indication of adverse effect on pregnancy outcome | Concern over hepatotoxicity precludes use of NVP-based regimen | |||
| Potential infant resistance during breastfeeding (through exposure to infant NVP) | Potential infant resistance during breastfeeding (through exposure to maternal ART) | – | Concern over EFV-based teratogenicity if mother gets pregnant while breastfeeding | |||
| Limits future ART options for HIV+ children | Limits future ART options for HIV+ children | – | ||||
ANC, antenatal care; ART, antiretroviral therapy; ARVs, antiretrovirals; AZT, zidovudine; Cr, creatinine; EFV, efavirenz; HAART, highly active antiretroviral therapy; Hb, haemoglobin; HIV, human immunodeficiency virus; HIV+, HIV-positive; LFT, liver function tests; NVP, nevirapine; PCR, polymerase chain reaction; TDF, tenofovir; US$, United States dollars.
a For maternal prophylaxis, all HIV+ pregnant women to be put on lifelong ART; for infant prophylaxis, AZT or NVP until 4–6 weeks of age to all HIV-exposed infants.13,14
Note: Information in table obtained from reference.13