Abstract

Maternal highly active antiretroviral treatment (HAART): does it improve child survival?
By: T. Taha¹, J. Kumwenda², G. Kafulafula², M.G. Fowler³, S. Chen¹, Q. Li¹, D. Hoover⁴, M. Thigpen⁵, N. Kumwenda¹, L. Mofenson⁶

Background: We previously reported that antiretroviral post-exposure prophylaxis for infants (PEPI) to age 14 weeks can substantially reduce postnatal HIV-1 transmission. In this analysis we assess the association of maternal HAART with child HIV-free survival.
Methods: In the PEPI-Malawi trial, HIV-uninfected infants were randomized at birth into 3 arms: i) control single-dose NVP+1 week ZDV; ii) control plus NVP only to age 14 weeks; or iii) control plus NVP+ZDV to age 14 weeks. Infant and maternal HAART data were collected at regular visits out to 24 months. Women with CD4 < 250 cells/mm³ were referred to a government ARV treatment program. Association of maternal HAART with the risk of child HIV infection or death was analyzed using proportional hazard regression with a time-dependent covariate adjusting for infant prophylaxis treatment group. Maternal HAART use was categorized into three stages: a) HAART-ineligible [HI] (CD4 ≥250); b) HAART-eligible, untreated [HEUT] (CD4 < 250; no HAART); and c) HAART-eligible, treated [HET] (CD4 < 250; received HAART). Cumulative HIV-free survival by maternal HAART (not adjusting for infant prophylaxis) was estimated using a truncated Kaplan-Meier analysis.
Results: Table shows the association of maternal HAART with child HIV infection or death among 2976 infants HIV-uninfected at birth.

Variable	Hazard Ratio (Adjusted for infant prophylaxis treatment)	95% CI	P-value
HEUT	1.00 (reference)
HET	0.46	0.30-0.72	<0.001
HI	0.49	0.40-0.59	<0.001

[Table]

The Kaplan-Meier cumulative HIV-free survival estimates (95% CI) at 24 months were: HEUT 68% (64-73%); HET 81% (71-93%); HI 82% (80-84%).
Conclusions: These observational data suggest that providing HAART to women with low CD4 counts could improve infant HIV-free survival. The survival rates of children with high maternal CD4 counts is similar to that of children with low maternal CD4 counts who receive HAART.