World Health Organization PMTCT guidelines

[12:47 PM, 10/23/2019] Jones Muna: The World Health Organization (WHO) promotes a comprehensive approach to PMTCT programmes which includes:

preventing new HIV infections among women of reproductive age

preventing unintended pregnancies among women living with HIV

preventing HIV transmission from a woman living with HIV to her baby

providing appropriate treatment, care and support to mothers living with HIV and their children and families.8

Guidelines for pregnant women living with HIV

In September 2015 WHO released guidelines recommending that all pregnant women living with HIV be immediately provided with lifelong treatment, regardless of CD4 count (which indicates the level of HIV in the body). This approach is called Option B+.9 By 2015, the implementation of Option B+ had resulted in 91% of the 1.1 million women receiving antiretroviral (ARV) drugs as part of PMTCT services being offered lifelong ART.10

A year later, WHO released guidelines recommending a ‘treat all’ approach, meaning all people diagnosed with HIV should be offered immediate treatment. This has increased the number of women of reproductive age who are receiving ART, regardless of whether they are pregnant or not.11 All but two of the 23 countries deemed a priority for PMTCT by UNAIDS have moved to implement these guidelines.12

Guidelines on infant feeding for mothers living with HIV

WHO bases its recommendations on infant feeding for mothers living with HIV on the comparative risk of infants acquiring HIV through breastfeeding with the increased risk of infants dying from illnesses such as malnutrition, diarrhoea and pneumonia, which increases if they are not breastfed.

In 2016, WHO released guidelines recommending that mothers living with HIV who are on treatment and are being fully supported to adhere to it should exclusively breastfeed their infants for the first six months of life, then introduce appropriate complementary foods while continuing to breastfeed for at least 12 months and up to 24 months or longer (similar to the general population).

When ARV drugs are not immediately available, the WHO guidelines still recommend mothers exclusively breastfeed for the first six months of an infant’s life and continue, unless environmental and social circumstances are safe for, and supportive of, replacement feeding. This decision should be based on international recommendations and consideration of:

the socioeconomic and cultural contexts of the population groups served by maternal and child health services

the availability and quality of health services

the local epidemiology (which diseases are common and who they affect), including HIV prevalence among pregnant women

the main causes of under-nutrition among mothers and children, and infant and child mortality.

When ARV drugs are unlikely to be available, such as in acute emergencies, mothers living with HIV are still recommended to breastfeed their infants to increase their chances of survival.13

Does an undetectable viral load prevent HIV transmission while breastfeeding?

People on antiretroviral treatment who maintain an undetectable viral load (which is when HIV in the body has been suppressed to such a low level that blood tests cannot detect it) are not at risk of transmitting HIV to sexual partners. This has led to the question of whether women living with HIV who are undetectable can breastfeed without fear of passing HIV to their infant.

Research on breastfeeding women living with HIV that includes viral load data is limited. What evidence does exist indicates that an undetectable viral load provides significant protection from HIV transmission. However, there have been cases of HIV transmission among breastfeeding women with undetectable viral loads.14

Currently, most high-income countries recommend women living with HIV do not breastfeed whether they are virally suppressed or not. This is because formula feed and clean, boiled water are widely accessible. So any risks around dirty water or malnutrition have been eliminated. In low- and middle-income countries this risk is far greater, leading WHO’s advice on infant feeding to differ.

Guidelines for HIV-exposed infants

If an HIV-exposed infant is given ART within the first 12 weeks of life, they are 75% less likely to die from an AIDS-related illness.15

This is one of the reasons WHO recommends that infants born to mothers living with HIV are tested between four and six weeks old. This is often referred to as ‘early infant diagnosis’.16

WHO further recommends that another HIV test is carried out at 18 months and/or when breastfeeding ends to provide the final infant diagnosis.17 As proportionally more infant infections are now occurring during breastfeeding these tests are becoming increasingly important.

According to WHO guidelines, all infants who test positive for HIV should be immediately initiated on treatment. The treatment should be linked to the mother's course of ARV drugs and would vary according to the infant feeding method as follows:

breastfeeding: the infant should receive once-daily nevirapine from birth for six weeks

replacement feeding: the infant should receive once-daily nevirapine (or twice-daily zidovudine) from birth for four to six weeks.18

[12:50 PM, 10/23/2019] Jones Muna: With little fanfare, the World Health Organization (WHO) recently published a “Programmatic Update” on the use of antiretrovirals (ARVs) to treat pregnant women and prevent mother-to-child transmission of HIV (PMTCT) that identifies Option B and Option B plus as preferable to Option A.  Both Option B and Option B+ call for the administration of triple combination antiretroviral therapy (ART) to all pregnant HIV-infected women.  Under Option B, antiretroviral therapy would be stopped after the breast feeding period for women with CD4 counts above 350 while Option B + would continue ART in these women for life.

“Option B and specifically B+ seem to offer important programmatic and operational advantages and thus could accelerate progress towards eliminating new pediatric infections,” according to the update. “If option B+ can be supported, funded, scaled up at the primary care level and sustained, it will also likely provide the best protection for the mother’s health, and it offers a promising new approach to preventing sexual transmission and new HIV infections in the general population.”

The guidance also calls for standardization of the ART regimens utilized to allow for better integration with ART clinics post-partum. Limited access to CD4 testing, and consequently, the inability to identify women in need of treatment for their own health is one reason identified for the preferential view of Option B and Option B+.

The WHO summary lists  advantages to the Option B+ approach, such as protection against mother-to-child transmission of HIV in future pregnancies and avoiding stopping and starting of ARVs. Other rationale for the update include the results of the HIV Prevention Trials Network (HPTN) 052 trial demonstrating that antiretroviral therapy reduces a person’s risk of transmitting HIV to an uninfected sexual partner by 96 percent;  reassuring data on the safety of efavirenz during pregnancy; and the decreasing cost of ARV drugs. A number of countries have already adopted this approach, according to the WHO.

The WHO treatment guidelines were last updated in 2010 and prioritized starting all women with CD4 counts at or below 350 or with WHO-defined Stage 3 or 4 of disease on ART for life. Those with CD4 above 350 were recommended to receive ART early on in pregnancy and, in breastfeeding settings, to either the mother or child during the postpartum risk period.

“The move toward getting all HIV-positive pregnant women on HIV treatment for life makes sense on every level–it’s better for the mothers, better for their babies and much easier to put into practice in places where we work, where women often have multiple pregnancies and are hard to reach with care to begin with,” said Nathan Ford, medical director of the Medicines Sans Frontieres Access Campaign. “But the frustrating side is that countries wanting to provide this better care face an uphill battle because of the serious cash crunch at the Global Fund and bilateral donors pulling back treatment support. Donors need to provide the support to ensure that more child infections can be prevented, and that transmission of the virus in general can be stopped through treatment itself.”  MSF is already providing option B+ to pregnant women in Malawi and is planning to pilot the option in Uganda, South Africa and Swaziland.

According to the executive summary, the WHO has started a comprehensive revision of all ARV guidelines, to include ARVs for pregnant women, which it plans to release in early 2013.

Another area of the overall treatment guidance that might need some tweaks is treatment for HIV-infected children. In the April 1 issue of Clinical Infectious Diseases, “Ruel et al present a case-control study that demonstrates neuro-cognitive and motor dysfunction in ‘asymptomatic’ HIV-infected children six to 12 years of age who do not qualify for ART,” according to Drs. Thor A. Wagner and Lisa M. Frenkel who penned an editorial commentary on the study in the same journal. “Their findings suggest that the WHO guidelines do not capture early neurologic disease and provide a rationale to explore whether earlier ART would benefit these children.”