Mini review: Prevention of mother–child transmission of HIV: 25 years of continuous progress toward the eradication of pediatric AIDS?

Figures & data

Table 1. Residual transmission risk in mothers with undetectable viral load at delivery based on the timing of treatment initiation French Perinatal Study  (2000-2011)

Treatment start	n	% IC
Before conception	0/2651	0% [0.0–0.1]
1st trimester	1/507	0.2% [0.0–1.1]
2nd trimester	9/1735	0.5% [0.2–1.0]
3rd trimester	4/452	0.9% [0.2–2.3]

All women received a combination of at least three antiretroviral drugs.

Adapted from Ref. [19].

Table 2. General principles regarding the use of antiretroviral (ARV) drugs during pregnancy

1. All pregnant women living with HIV should initiate ARV triple combination as early in pregnancy as possible, regardless of their plasma HIV RNA copy number or CD4 T lymphocyte count. Earlier viral control is associated with lower risk of transmission (see Table 1). An additional 4–6-week monotherapy is given to the neonate.

2. Maternal HIV viral load should be maintained below the limit of detection at all time points of pregnancy including antepartum and intrapartum as well as postnatally in case of breastfeeding to the neonate. Mother is encouraged to maintain the treatment after delivery even if the child is not breastfed.

3. Whenever possible, ARV drug-resistance genotype studies should be systematically performed before starting ARV drug regimens, including in women who are ARV naive, but treatment is initiated before results and adapted secondarily if necessary.

4. Previously treated women should continue their current regimens unless they include drugs known or suspected to be embryotoxic or new molecules for which there are no data on toxicity during pregnancy. Physicians are encouraged to visit updated guidelines. PK of some ARV changes in pregnancy; it may lead to lower plasma levels of drugs and necessitate increased dosages, more frequent dosing, boosting, or more frequent viral load monitoring.

5. In high-income countries, it is recommended to completely avoid breastfeeding, regardless of ART and maternal viral load. In resource-limited settings, maternal ARV treatment reduces the risk of transmission through breastfeeding.

ARV preferred choice (2019)

Mother: Two nucleoside reverse transcriptase inhibitors (NRTIs)^a associated with either a protease inhibitor (PI)^b or an integrase strand transfer inhibitor (INSTI)^c. Alternative choices are possible. In countries with limited health resources, non-nucleodide reverse transcriptase inhibitor (NNRTI)^d as the third drug is still an option.

During delivery: NRTI^e perfusion, only if the maternal viral replication before delivery is not controlled. Pre-labor C section can also be discussed in this specific situation.

Newborn: NRTI^f or NNRTI^g monotherapy during 2–6 weeks. Dual or triple combination if untreated mother or in case of maternal uncontrolled viral replication at delivery (high risk of transmission)^h.

^aABC: abacavir + 3TC: lamivudine or TDF: tenofovir + FTC: emtricitabine.

^brDRV: darunavir or rATZ: atazanavir, both boosted by ritonavir.

^cRTG: raltegravir or DTG: dolutegravir (DTG is contraindicated during the first trimester of pregnancy).

^dEFZ: efavirenz or NVP: nevirapine.

^eIntravenous perfusion of AZT: zidovudine.

^fAZT zidovudine.

^gNVP nevirapine.

^hAZT zidovudine + NVP nevirapine. Expert advice for triple therapy or in case of resistance on maternal viral isolate.

Adapted from Ref. [20–22].

Figure 1. Evolution of the risk of transmission to the child depending on the intensity of antiretroviral treatment in mono, bi, or triple therapy. French Perinatal Study 1985-2017 (unpublished). NRTI: nucleos(t)ide reverserse transcriptase inhibitor

Figure 2. Theoretical cascade of “missed opportunities” for screening and treatment of pregnant women in low-resource countries

Figure 3. Evolution of the proportion of pregnant women tested for HIV-1 in 12 selected countries and evolution of the number of infected children

Source: UNAIDS [30].

Figure 4. Health of exposed non-infected children. Triple potential risk

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