I’d like to call attention to an important set of articles in the recent HIV/AIDS themed issue of The Lancet. Erik Schouten of Malawi Basic Support for Institutionalizing Child Survival (BASICS) has published a commentary (free registration required) about Malawi’s push to be the first country to implement a “B+” approach to reducing mother to child transmission.
Erik and colleagues argue that the current World Health Organization Prevention of Mother to Child Transmission (PMTCT) guidelines are inadequate to truly address vertical transmission of HIV in Malawi and likely other resource-constrained countries as well. At its core, the B+ approach argues for a “test and treat” approach in which pregnant women are tested for HIV and, if positive, offered lifelong triple therapy irrespective of CD4 count versus the staggered mono- or dual-treatment regimens that are the norm with existing PMTCT programs.
Women on triple therapy would reduce their viral load to undetectable levels in most cases, and the risk of transmission to the unborn child would approach that seen in Western countries, less than 2%. In addition, by treating the mothers with effective triple therapy, their risk of morbidity and mortality from their own HIV disease would shrink as well. While it’s true that this approach would carry new challenges, notably increasing costs of starting women on antiretroviral therapy earlier than they would have if current CD4 cutoff levels for treatment are used, the relative costs of B+ and the presumed benefits of earlier treatment and much reduced vertical transmission rates would very likely offset these additional costs.
With this week’s International AIDS Society Conference in Rome, and the likely announcement by US AIDS Ambassador Eric Goosby and UNAIDS chief Michel Sidibe of initiatives to ensure elimination of mother to child transmission by 2015, Erik’s work is particularly timely.
I urge you to read the Lancet article and the accompanying article by writer John Donnelly discussing the decision of the Malawi government to move forward with B+. As mentioned before, this could be a game changer in our struggle to care for HIV infected persons and their children.