Antiretroviral drugs and breastfeeding
Q.3 What are the differences between the two antiretroviral drug strategies - Option A and Option B1 - for preventing HIV transmission through breastfeeding?
Current evidence indicates that the efficacy and safety of Options A and B to prevent HIV transmission through breastfeeding are equivalent - both will significantly reduce transmission during pregnancy and during breastfeeding, and both are safe. The main differences are in implementation.
Option A is cheaper, and for some women it may be easier to give the infant a single medicine once per day rather than taking medicines herself. If for whatever reason she omits doses to the infant, either because she forgets or because there are stock-outs at the clinics, then the long half-life of neviripine (NVP) will continue to provide some protection. (It takes several days for the level in the body to drop even if NVP is not given again.) The maternal component of Option A is possibly more complex, requiring a postnatal 'tail' of AZT and 3TC and giving NVP to the infant. With Option B, the maternal intervention is the same antenatally and also after delivery.
Option B is more expensive, but may provide some benefit to the mother while she is taking the ARVs during breastfeeding. If the mother does not take the medicines consistently every day, then the protection to the infant will decrease, and it may result also in resistance developing in the mother. More information about the advantages and disadvantages are available in the 2010 WHO prevention of mother-to-child transmission (PMTCT) guidelines. More research evidence will become available in the next few years about other drug options and the safety and benefit of the ARVs recommended in Options A and B.
1 Option A: Mother: Antepartum twice-daily AZT starting from as early as 14 weeks of gestation and continued through pregnancy; at onset of labour, single-dose Nevirapine and initiation of twice-daily AZT + 3TC for 7 days postpartum. Breastfed infant: daily NVP from birth for a minimum of 4 to 6 weeks and until 1 week after all exposure to breast milk has ended. Non-breastfed infant: Daily NVP or sd-NVP + twice-daily AZT from birth until 4-6 weeks of age. Option B: Mother: Triple ARV prophylaxis starting from as early as 14 weeks of gestation and continued until delivery, or, if breastfeeding, continued until 1 week after all infant exposure to breast milk has been ended. ll infants: Daily NVP or twice daily AZT from birth until 4 to 6 weeks of age.
Full details of options: