Test and treat for all pregnant women in low and middle income countries?

An opinion piece, published ahead of print in JAIDS by Maria Zolfo and colleagues, argues for a universal test and treat strategy in all HIV-positive women in high burden countries.

They cite the WHO/UNAIDS/Unicef statistics showing that in low and middle income countries, only 21% of pregnant women tested for HIV while they were pregnant, only 24% HIV-positive pregnant women had a CD4 test to determine their eligibility for ART, only 45% received antiretrovirals and only 32% of infants of positive mothers received post natal prophylaxis.

They compare this to the extremely low rates of MTCT in industrialised countries.

They note that provider initiated testing strategies have reached 60-80% amongst pregnant women in 6 out of 10 counties with the highest burden of HIV among pregnant women suggesting that the majority will access services if they are available.

They suggest that the WHO recommended option, of a two tiered antiretroviral strategy in pregnancy of treatment for women indicated for their own health (at clinical stages 3 and 4 and < 350 cells/mm3), and antiretroviral prophylaxis (either short course AZT plus single dose nevirapine or a triple combination regimen stopped after breast feeding) for mothers not indicated for treatment, may not be feasible in settings with limited infrastructure. Not least when there is limited access to CD4 tests.

In some high burden countries, they write, a low tech test-and-treat intervention for all HIV-positive women not yet on ART regardless of the CD4 count and clinical stage will be a more feasible option to reach large numbers of women. They suggest that this should be life-long and not discontinued after breastfeeding.

Based on current evidence this strategy would mean about 50% of women would be eligible for treatment for their own health and 25% would start with CD4 between 350 and 500 cells/mm3. More controversial would be the group that starts treatment with CD4 counts above 500 cells/mm3.

In their arguments they note that the SMART study showed the disadvantages of stopping and starting treatment in non-pregnant adults, even at higher CD4 counts. Additionally lack of availability of CD4 tests may increase the risk of undetected disease progression in women stopping treatment. There is also the likelihood of a subsequent pregnancy.

There are concerns, however, about the sustainability of long term adherence and this may be particularly difficult for healthy women who do not require treatment for their own health.

The IMPAACT PROMISE study is being conducted to look at these questions and others, but results will not be available until 2014 at the earliest.

In the meantime the authors advocate for a universal test and treat strategy to be rapidly implemented in HIV-positive women in high burden countries.

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One of the authors of this article, Erik Schouten, from the Department of HIV and AIDS, Ministry of Health, Malawi gave a presentation in a satellite session at IAS 2010, explaining changes to their national programme for pregnant women. They have decided that the best option for Malawi is exactly as described above, to start all pregnant women on one universal regimen for treatment and prevention continuing for life.

In Malawi, they take a public health approach to treatment. Universal access to reliable CD4 count will not be reached within a few years. Additionally their fertility rate is high 5.6, and breastfeeding is recommended.

Although they acknowledge the challenges, they believe the advantages to this strategy outweigh the disadvantages and this is, The only realistic option for Malawi.

Ref: Zolfo M et al. Time for test and treat in prevention of mother-to-child transmission programmes in low- and middle-income countries. J Acquir Immune Defic Syndr. Published ahead of print 2010.