Protocolo

P re v e n t i o n o f M o t h e r- t o - C h i l d Tra n s m i s s i o n o f H I V: A n t i ret ro v i r a l Strategies
Jennifer S. Read,
KEYWORDS  Mother-to-child transmission  HIV-1  Prevention  Antiretrovirals
MD, MS, MPH, DTM&H

Prevention of mother-to-child transmission of human immunodeficiency virus type 1 (HIV) is just 1 component of the overall management of HIV-1–infectedwomen and their children. Therefore, the use of antiretrovirals or other efficacious interventions for the prevention of mother-to-child transmission of HIV-1 (including cesarean section before labor and ruptured membranes, complete avoidance of breastfeeding) cannot be viewed in isolation from other components of optimal care for women of reproductive age, mothers, and children. The World HealthOrganization’s1 (WHO’s) Strategic Approaches to the Prevention of HIV Infection in Infants includes 4 components: primary prevention of HIV-1 infection; prevention of unintended pregnancies among HIV-1–infected women; prevention of transmission of HIV-1 infection from mothers to children; and provision of ongoing support, care, and treatment to HIV1–infected women and their families. Ideally,primary prevention of HIV-1 infection occurs, for example, an HIV-1–uninfected woman does not acquire HIV-1 infection either before or during pregnancy. To facilitate the prevention of acquisition of HIV-1 infection, individuals should know their own and their sexual partners’ HIV-1 infection status, which is accomplished through the provision of and access to HIV-1 counseling and testing. Next, evenif a woman acquires HIV-1 infection, prevention of unintended pregnancies is crucial. Antiretroviral therapy for women who need treatment of

The author has nothing to disclose. Pediatric, Adolescent, and Maternal AIDS Branch, Center for Research for Mothers and Children, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, ExecutiveBuilding, Room 4B11C, 6100 Executive Boulevard, MSC 7510, Bethesda, MD 20892-7510, USA E-mail address: JENNIFER_READ@NIH.GOV Clin Perinatol 37 (2010) 765–776 doi:10.1016/j.clp.2010.08.007 0095-5108/10/$ – see front matter. Published by Elsevier Inc. perinatology.theclinics.com

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their HIV-1 infection, antiretroviral prophylaxis for women who do not yet need treatment,antiretroviral prophylaxis for infants of HIV-infected mothers, and other interventions to prevent mother-to-child transmission of HIV-1 should be available. Finally, HIV-1–infected women and their children need ongoing support, care, and treatment, including infant feeding, counseling, and support. This review addresses antiretroviral strategies for the prevention of mother-to-child transmission of HIV-1 andis largely based on published US2 and global3 guidelines. Specifically, the review focuses on antiretrovirals for the secondary prevention of HIV-1 infection–prevention of HIV-1 transmission from a pregnant HIV-1–infected woman to her child. The review primarily addresses antiretroviral strategies for nonbreastfeeding, HIV-1–infected women and their infants in resource-rich settings, such as theUnited States.2 Antiretroviral strategies to prevent antepartum, intrapartum, and early postnatal transmission in resource-poor settings3 are also addressed, albeit more briefly.

ANTIRETROVIRAL STRATEGIES TO PREVENT MOTHER-TO-CHILD TRANSMISSION OF HIV-1 IN THE UNITED STATES Mechanisms of Action of Antiretrovirals in Preventing Mother-To-Child Transmission of HIV-1

Antiretrovirals preventmother-to-child transmission of HIV-1 in 3 ways: decreasing the HIV-1 RNA concentration (viral load) in maternal blood and genital secretions4,5; infant pre-exposure prophylaxis; and infant post-exposure prophylaxis. The importance of maternal viral load as a risk factor for mother-to-child transmission has been clearly demonstrated.4,6,7 However, the possibility of other mechanisms of action of...