MSH  in The Lancet: Dr. Erik Schouten Writes About Malawi’s Bold Decision of  Lifelong ART for HIV-Infected Pregnant Women

Today, the British medical journal The Lancet published a viewpoint (registration required) by MSH HIV & AIDS advisor Erik Schouten, who has been working  with Malawi’s Ministry of Health on an approach to preventing mother to child transmission  (PMTCT)of HIV called “B+” that offers all HIV-infected pregnant women lifelong  anti-retroviral treatment (ART). The article appeared in The Lancet’s special themed issue on HIV & AIDS, released in time for the 6th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention that begins this weekend in Rome, Italy (17-20 July ).

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.

Dr. Schouten et al write about Malawi’s triple therapy regiment for pregnant women infected with HIV (tenofovir,lamuvidine and efavirenz—available in a fixed-dose combination of one tablet per day that can be safely use with anti-TB drugs, is effective against hepatitis B virus and can be used without routine laboratory monitoring of toxic effects). “This regiment avoids zidovudine-induced side effects, especially anemia, which is common in pregnancy in Malawi.  It also will be a strategy that does not rely soley on CD4 counts.” Malawi is preparing to revise its policies for prevention of mother-to-child transmission of HIV and for antiretroviral therapy (ART) in response to WHO’s 2010 guidelines. 

According to The Lancet editors of the issue, “The goal of elimination of pediatric infections is hindered by WHO guidelines specifying that CD4 cell count testing be required for uptake. In the absence of these [testing]facilities, Malawi has chosen to offer all HIV-infected pregnant women lifelong antiretroviral therapy, an approach supported by Erik Schouten and colleagues in a Viewpoint and described further in a World Report. Malawi should be commended for taking such a bold public health approach.”

 “This strategy takes into account the weaknesses in the Malawi health system yet should increase the coverage notably from the current 35%. It should also narrow the gap among the estimated 95,000 people living with HIV infection between the 225,000 currently receiving ART and the 440,000 who are eligible,” note Schouten et al.   

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