Final report of a specially commissioned panel tasked with examining the ethics of the PROMISE trials, which study different drug regimens to prevent mother to child transmission of HIV. The trials are sponsored by the US National Institute of Allergy and Infectious Disease, which commissioned the ethics review.
PROMISE ethics panel final report, October 17, 2012
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NIAID Special Ethics Review
of the PROMISE Trials
Final Report of the Expert Review Panel
Submitted to the Divisions of AIDS
October 17, 2012
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Table of Contents
PROMISE Review Panel Roster 3
Acknowledgements 4
Abbreviations 5
Special Ethics Review Agenda 6
REPORT
Background and rationale for special ethics review 7
Questions to the Panel 9
Documents provided to the Panel 9
Synopsis of the presentations to the Panel 10
Gaps in knowledge that PROMISE aims to fill 13
Panel responses to questions 17
Additional comments/considerations 20
Specific recommendations 21
References 23
APPENDICES
Appendix 1: Synopsis of the PROMISE trials design
Appendix 2: Scientific Background for PROMISE
Appendix 3: Scientific Roadmap on Antiretroviral Drugs for PMTCT and Maternal
Treatment
Appendix 4: PROMISE protocol modifications
Appendix 5: WHO Programmatic Update 2012
Appendix 6: Letters received by the PROMISE study teams from the Ministries
of Health of Malawi and Uganda
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Acknowledgements
The Panel would like to thank the staff of the Division of AIDS and NICHD for the extensive
preparatory work that was conducted to facilitate the Panel’s deliberations, along with all the
presenters who provided us with extremely useful information and responded very constructively
to questions from the Panel. As well, we would like to thank the DAIDS support staff for their
assistance with travel and accommodations and hospitality. And finally, the Panel would like to
thanks Dr. Dennis Dixon for his outstanding support and guidance through the process.
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Abbreviations
ART Antiretroviral Therapy (used before defined)
ARV Antiretroviral
AZT Azidothimidine (Zidovudine)
BF Breastfeeding
DAIDS Division of AIDS
EFV Efavirenz
HPTN HIV Prevention Trials Network
IMPAACT International Maternal-Pediatric-Adolescent AIDS Clinical Trials
MTCT Mother to Child Transmission
NIAID National Institute of Allergy and Infectious Diseases
NVP Nevirapine
PEPFAR President’s Emergency Plan for AIDS Relief
PMTCT Prevention of MTCT
PROMISE Promoting Maternal Infant Survival Everywhere
sdNVP Single-dose NVP
TDF Truvada
WHO World Health Organization
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Background and Rationale for the Special Ethics Review
In 2010, after several years of planning and preparation, the NIAID-NICHD sponsored
International Maternal-Pediatric-Adolescent AIDS Clinical Trials (IMPAACT) network began
enrolment into the set of clinical trials known as PROMISE(Promoting Maternal Infant Survival
Everywhere). The PROMISE trials were designed to evaluate the optimal antiretroviral drug
interventions for: the prevention of antepartum and intrapartum mother to child transmission
(MTCT) of HIV; the prevention of postpartum transmission of HIV to breastfed infants; and for
the preservation of maternal health beyond the period of risk for MTCT, either after delivery or
following cessation of breastfeeding.
The design and management of national programs for prevention and treatment of HIV in low
and middle income countries are complex policy challenges. Country guidelinesfor antiretroviral
therapy for pregnant women and the prevention of mother to child transmission (PMTCT) of
HIV infectiongenerally involve criteria for selecting from among available drug regimens and for
starting and stopping regimens based on pregnancy and breastfeeding status and current levels of
CD4 count and HIV viral load. In developing countries, guidelines are mostly adapted from
World Health Organization (WHO) PMTCT and ART guidelines.
When begun, the PROMISE trials were fully compatible with treatment guidelinesin the
participating countries in North and South America, Asia, and Africa. The PROMISE trials, as
designed, are also compatible with the most recent, 2010 revision of WHO guidelines for
antiretroviral drugs for treating pregnant women and preventing HIV infections in infants(1).The
2010 WHO guidelines emphasize the importance for maternal health, and for the PMTCT, of
initiating life-long combination antiretroviral therapy (ART) for HIV-infected pregnant women
with CD4 counts <350 cells/mm3
, or advanced clinical stages of HIV. Women who do not yet
need ART for their own health by these criteria are recommended either of two ARV
prophylaxis options (Option A or Option B) for PMTCT (see Table 1.). The research population
addressed by the PROMISE trials is women who do not yet meet eligibility criteria for
antiretroviral therapy for their own health in the countries in which the study is conducted.
In 2011, new research findings became available indicating that initiating combination ART at
the higher CD4 count threshold of 550 cells/mm3
had the added benefit of significantly reducing
the risk of HIV transmission to an uninfected sexual partner(2). This new information, coupled
with the growing experience of countries facing the challenges of implementing PMTCT
programs, such as difficulty in identifying women who are eligible for ART for their own health,
has led to the consideration of a third option (Option B+). Option B+ would provide lifelong
ART to all HIV positive pregnant women at the time of diagnosis, regardless of their CD4 cell
count or HIV disease stage (see Table 1). Increased availability of drugs in limited resource
settings has generated optimism that wider delivery of ART might be possible. HIV-infected
pregnant women are a logical target for such expanded delivery, since the women who are
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presenting for antenatal care are already linked to health care providers, and their babies remain
at risk of infection through mother-to-child transmission (MTCT).
(From WHO Programmatic Update, 2012 (3, p. 2)
A recent programmatic update from the WHO(3) urges countries to consider adopting Option B+
for reasons of operational and programmatic simplicity in order to achieve the targets set by a
large consortium of member states, international organizations, civil society and private sector
organizations, regional bodies and agencies of the United Nations in ‘The Global Plan towards
the Elimination ofnew HIV infections among children by 2015 and keeping their mothers
alive’(4). The Option B+ approach is already being implemented in Malawi, and the WHO
programmatic update has led other countries to consider it.
The implications of this recent WHO programmatic update for the ethical conduct of the
PROMISE trials are unclear. With the WHO’s recent promotion of Option B+, it is reasonable to
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ask whether trials studying different treatment regimens remain relevant. In an effort to ensure
that the PROMISE trials continue to have relevance and value scientifically and conform to the
highest standards of ethical research, in late 2011 NIAID decided to assemble a panel of
independent experts to review the current ethical status of the trials and offer advice,
accordingly. A meeting for this purpose took place in Bethesda on June 18 and 19, 2012. This is
the report of that meeting.
Questions to the Panel
NIAID’s concerns about the on-going value and ethical quality of the PROMISE trials were
distilled into two main questions for the panel:
1. Given the changing landscape of PMTCT guidelines, could PROMISE be conducted (or
under what conditions can PROMISE be conducted) in a country that has chosen a
national policy for PMTCT that recommends initiation of antiretroviral therapy for life in
all HIV-infected pregnant women regardless of CD4 count (Option B+)?
2. Given diverse implementation challenges and current policy developments in PMTCT
programs, does the study still have sufficient value for informing clinical, policy, or
program decisions now or in the future? If no, is there a design modification that would
provide sufficient value to continue the study?
Background documents provided to the Panel
• A Synopsis of the PROMISE Trial Design (see Appendix 1)
• A comprehensive Scientific Background document for the PROMISE trials including a
detailed review of the relevant clinical science, including references to earlier clinical
trials and other studies that informed the design of the PROMISE trials, and review of
relevant international guidelines, including WHO PMTCT Guidelines, and a range of
other issues related to PROMISE(5). (see Appendix 2)
• Scientific Roadmap on Antiretroviral Drugs for PMTCT and Maternal Treatment. A
summary of other ongoing clinical trials including timelines for completion. (see
Appendix 3)
• Current versions of the PROMISE P1077 protocols. (P1077BF, P1077FF, P1077HS)
• A document highlighting modifications in PROMISE protocols currently in process.
Specifically amendments made to address i) results of HPTN 052 showing that
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antiretroviral treatment can reduce heterosexual HIV transmission, ii) changes in infant
feeding patterns to longer duration (>12 months), iii) increasing use of tenofovir-based
antiretroviral regimens in pregnant women without hepatitis B infection, and iv)
streamlining the protocols to make them less complex for subjects and staff to implement.
(see Appendix 4)
• WHO Programmatic Update: Use of Antiretroviral drugs for treating pregnant women
and preventing HIV infection in infants. April 2012 statement of current thinking at the
WHO, reflecting the importance that operational and implementation issues are likely to
play in the next revision of WHO recommendations expected in 2013(3). (see Appendix
5)
• Letters received by the PROMISE study teams from the Ministries of Health of Malawi
and Uganda supporting continuation of the study as designed. (see Appendix 6)
Synopsis of the presentations to the Panel
Dr. Emily Erbelding
Dr. Erbelding, Deputy Director, Division of AIDS (DAIDS), NIAID, welcomed the panel and
invited presenters to the meeting. To inform its discussions the panel heard presentations on
background, design, and current status of PROMISE, by Dr. Mary Glenn Fowler of the Johns
Hopkins University School of Medicine and PROMISE chair. The broader scientific context of
related ongoing clinical research was presented by Dr. Laura Guay of the Elizabeth Glaser
Pediatric AIDS Foundation, and also a member of the panel. Insights about recent discussions by
WHO and member countries that led to the release of the programmatic update in 2012(3), and
are expected to lead to changes in the Guidelines themselves in 2013, were provided by Dr.
Nathan Shaffer, PMTCT Team Leader, Department of HIV/AIDS,WHO, by teleconference. And
an account of the challenges associated with implementing national guidance for ART for
pregnant women and PMTCT was provided by Dr. Angela Mushavi, National PMTCT
Coordinator, Ministry of Health and Child Welfare, Zimbabwe, also a member of the panel.
Dr. Mary Glenn Fowler
Dr. Fowler presented the design and current status of PROMISE, whose primary and secondary
objectives relate to maternal and infant health outcomes for HIV-infected women who do not
qualify for ART for their own health, according to current WHO and national treatment
guidelines. The three primary research questions being addressed by PROMISE are:
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i) Which is more effective and safe to prevent MTCT during the antenatal period
(pregnancy): ZDV plus intrapartum single dose nevirapine, or a triple-
antiretroviral drug prophylaxis regimen?
ii) Which is more effective and safe to prevent postnatal MTCT through breast milk:
provision of daily nevirapine prophylaxis to the infant, or provision of triple-
antiretroviral drug prophylaxis to the mother for the duration of breastfeeding (up
to 18 months)?
iii) For women who receive triple-antiretroviral drug prophylaxis during pregnancy
and/or breastfeeding, is it better to stop or continue the triple-antiretroviral drug
regimen after risk of MTCT has ceased (i.e., after delivery, if formula feeding, or
after lactation, if breastfeeding)?
In each case the first of the pair of comparators corresponds to current WHO guidelines.
In addition to discussing these three primary comparisons, Dr. Fowler emphasized that
PROMISE will also contribute important new knowledge with respect to regimen adherence,
emergence of antiretroviral drug resistance, safety of Tenofovir (TDF) in pregnant women and
their babies, and any complications of combination ART to mothers, for example those arising
from concurrent hepatitis B infection.
Dr. Laura Guay
Dr. Guay emphasized that there are important limitations in our knowledge about all current
ART regimens (A, B and B+). She summarized a large number of relevant clinical trials and
observational studies, most of them very much smaller than PROMISE and less likely to produce
clear answers, even though in some cases the questions are similar. She pointed out that very
limited information is available regarding the magnitude of the various problems associated with
the implementation any of the PMTCT options, such as the implications of non-adherence. Dr.
Guay presented a summary of potential implementation, operational and clinical advantages and
disadvantages for A, B, and B+. She presented priority research areas that were outlined in the
April 2012 WHO programmatic update, and highlighted in the Scientific Background document
for the panel, particularly around Option B+, for which data are needed, including:
• Service organization/delivery of ART in MCH and primary care settings
• Cost and sustainability
• ARV adherence and retention in care
• Referral mechanisms and transitions from the PMTCT program to HIV care and
treatment programs
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• HIV drug resistance with long-term use of ART initiated in early HIV disease
• Safety of increased exposure to ARVs for the fetus/infant
• Acceptability and equity
Several of these issues are being addressed in the PROMISE study, such as ARV adherence,
drug resistance, safety, and acceptability across the study arms.
Dr. Guay also reviewed some key issues related to the urgent need for evidence about the
acceptability and comparative program advantages of Options A, B and B+, including:
• Operational advantages of providing triple ARVs to all pregnant women (Options B and
B+)
• How best to meet the programmatic and implementation requirements of these
approaches
• The acceptability, effectiveness and prevention impact of Option B+
Dr. Nathan Shaffer
Dr. Shaffer reviewed WHO’s process for updating guidelines for treatment and prevention of
HIV infections. As part of this review, he noted that developing countries have expressed a
preference that WHO guidelines recommend a single option for a given clinical situation, rather
than present alternatives. Based on recent research findings, WHO has determined that the global
goal of decreasing new HIV infections in young children by 90% (from 400,000 to 40,000
annually) and decreasing population-based MTCT rates to <5% in breastfeeding settings (and
<2% in non-breastfeeding settings), and thus virtually eliminating MTCT globally by 2015, is
achievable. One key to the realization of that goal is simplification and harmonization of
guidelines across various segments of the population. One such simplification would be the
elimination of the need for CD4 cell count tests to guide the initiation and interruption of ART,
which would be accomplished with the widespread adoption of B+. B+ would further simply this
process by providing the same ARV regimen to all pregnant HIV infected women.
In the panel’s discussion with Dr. Shaffer, it was highlighted that the PROMISE trial and other
past studies on PMTCT have not evaluated the safety profile of ART regimens containing
Efavirenz (EFZ), which is currently recommended in the WHO programmatic update, even
though it is contraindicated during pregnancy in the U.S. This issue was identified as a
potentially valuable subject for future operational research to address the current lack of
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evidence about the safety of widespread use of Efavirenz in pregnant women in their first
trimester.
Dr. Shaffer emphasized that guidelines have the greatest force when based on the highest quality
evidence, preferably the results of randomized clinical trials. However, with respect to the care
of HIV-infected pregnant women, WHO advocates the adoption of B+ because it seems highly
feasible that the expanded use of combination ART regimens could add benefit without adding
serious harm. Prospective evaluation of B+ may be several years away, and delaying
implementation until these evaluations are complete would limit the expected benefits. Despite
WHO’s promotion of B+ for its programmatic advantages, serious questions remain about the
sustainability of the efficacy and safety of the regimen.
Dr. Angela Mushavi
The panel was anxious to learn more about the process of responding to changes in WHO
guidelines at the national level. Dr. Mushavi gave a thorough description of the current approach
followed in Zimbabwe. There is a standing organization of committees and working groups
established by the Ministry of Health and Child Welfare and made up of expert stakeholders
throughout Zimbabwe, who are charged with assessing the implications of changing national
guidelines. In making their recommendations, these groups consider the five touchstone
principles of avoiding harm, providing equitable access to care, improving quality of care,
maximizing efficient use of resources, and implementing sustainable programs. In the past,
approval of national plans has taken up to 3 years, and full implementation even longer, but the
more systematic approach being followed currently is expected to reduce these times
considerably.
Gaps in knowledge that PROMISE aims to fill
The Scientific Background document prepared for the panel by Dr. Lynne Mofenson(5)
contained a detailed description of the current evidence, and gaps in the evidence, regarding
ARVs for PMTCT. The panel has drawn on this review, supplemented by our own review of
primary sources, where necessary.
92% of maternal mortality and 88% of perinatal and postnatal MTCT occur in pregnant women
who meet current WHO criteria for ART(CD4 count < 350), and current guidelines recommend
lifelong ART for these women. For pregnant women who do not yet meet current criteria for
treatment for their own health, two options for PMTCT are offered, Option A and Option B(5).
The PROMISE protocol was designed to address questions restricted to this group of women—
those who do not meet current eligibility criteria for ART for their own health in the countries in
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which the research is conducted—and will directly compare the full Option A versus Option
B(5). Although there have been no clinical trials to compare the full Option A vs Option B,
available data indicate that the two prophylaxis options have similar efficacy for PMTCT in
women not eligible for treatment(5). In the current WHO guidelines for PMTCT, “more reliable
data comparing Option A and Option B prophylaxis” is identified as a research priority(1, p. 94).
PROMISE therefore offers an important opportunity to build foundational knowledge in the form
of high quality trial evidence about the PMTCT regimens being delivered in the majority of
PMTCT programs in high burden countries.
Specific PROMISE research questions
PROMISE is designed to provide evidence from randomized, controlled trials to address 3
critical questions about the efficacy and safety of ART regimens being offered to HIV-infected
pregnant and postpartum women who do not yet qualify for ART as treatment for their own
health, and to their infants. First, what is the optimal intervention for the prevention of
antepartum and intrapartum HIV MTCT? Second, what is the optimal intervention for the
prevention of postpartum transmission in breastfeeding (BF) infants? And third, what is the
optimal intervention for the preservation of maternal health after the risk period for MTCT ends
(either at delivery or cessation of BF)? More specifically:
i) Will an antenatal maternal triple ARV regimen be more effective than
AZT/sdNVP in reducing the risk of in utero and intrapartum MTCT in women
with higher CD4 count (>350) and will it be safe? (Antepartum Component)
ii) Will a postpartum maternal triple ARV regimen given for the duration of
breastfeeding (to 18 months) be more effective than infant NVP prophylaxis in
reducing the risk of postnatal MTCT in infants of women with higher CD4 count
(>350) and will the interventions be safe? (Postpartum Component)
iii) Will stopping a maternal triple ARV regimen given solely for PMTCT in HIV-
infected women with higher CD4 counts either at delivery or at the cessation of
breastfeeding be deleterious to the mothers’ health and disease progression?
(Maternal Health Component)
The B+ option of initiating ART earlier for all women irrespective of CD4 count and disease
stage (i.e., treating at CD4 >350) was not formally considered for the 2010 revision of the WHO
guidelines due to insufficient evidence and lack of field experience with the regimen(5). At the
same time, the optimal criteria for ART initiation in resource-limited settings remain
controversial and while some observational studies in higher resource settings suggest a benefit
to initiating ART at higher CD4 cell counts (e.g. CD4 <500 cells/mm3
), others do not(6-8).
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However, important new research indicates that initiation of ART in individuals with CD4 <550
cells/mm3
significantly reduces sexual transmission of HIV among discordant couples(2), and in
Malawi, after considering the 2010 WHO recommendations for PMTCT, the country decided to
adopt the B+ option for reasons of programmatic simplicity (e.g., as a way to address the
widespread lack of access to CD4 testing, which is a prerequisite for successful implementation
of Options A and B). Subsequently, a recent programmatic update from WHO advises countries
to consider the B+ option, emphasizing these reasons of programmatic and operational
simplicity.
The Option B+ approach is a third regimen for PMTCT being used in the field that has not been
studied for efficacy in women with high CD4 count. At the time of writing the current WHO
guidelines for PMTCT, the B+ approach was identified as a priority for research(1. p.94).
Despite the current push to the B+ option, there remain important questions about its
sustainability in economic terms, in programmatic terms, and in terms of important clinical
questions, such as ARV drug toxicity for mothers and fetus/child, ARV drug resistance, ART
failure and the availability of alternative ARV drugs.
Variations in breastfeeding practice
Due to variations in practice at different IMPAACT sites globally, not all of the PROMISE trial
specific research questions are relevant at all sites of the network. Therefore, three versions of
the PROMISE protocol have been developed, each containing only those components relevant to
the different settings of the IMPAACT network. One version, P1077BF (BF=Breastfeeding), is
designed for areas of the world where HIV-infected women are advised to breastfeed. Another
version, P1077FF (FF=Formula feeding), is designed for areas of the world where HIV-infected
women formula-feed but where less complex antiretroviral prophylaxis regimens to reduce
mother to child transmission (MTCT) are used; this protocol addresses questions 1 and 3, above.
To date, there have been no direct comparisons between stopping or continuing ART in
breastfeeding populations and very little is known about the relative merits of continuing ARVs
for maternal health after cessation of breastfeeding, or about HIV disease progression and
associated problems, such as the evolution of ARV drug resistance. The PROMISE trial will
provide unique and valuable data about these questions.
Additional key clinical, public health and economic questions
In addition to these main protocols, PROMISE also includes modules for intensive study of
possible bone and renal toxicity, study of Hepatitis B/HIV co-infected women, ARV resistance
in women and in infants who become infected, and a cost effectiveness analysis. PROMISE is
expected to follow women and infants for at least 96 weeks. These additional data from a
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relevant research population will be a valuable contribution to the evidence base for PMTCT
program implementation.
Key programmatic questions
While there are important potential programmatic advantages to the Option B+ approach, there
are also many important unanswered questions and an urgent need for careful monitoring and
evaluation. These questions figured prominently in the presentations to the panel and in the
panel’s deliberations. The Scientific Background document prepared for the panel(5) outlines the
following key questions:
• Acceptability: How acceptable to women who would not otherwise be taking ART is
early treatment for the purposes of prevention of HIV transmission to partners and infants
when the clinical benefit to the woman herself is possible but unconfirmed?
• Adherence: To what extent are women adherent to the regimen throughout the MTCT
risk period, and do they continue to be adherent after the MTCT risk period?
• Retention: How many women remain in care and treatment after the PMTCT period?
• Service delivery: Can non-physician providers (e.g. nurses) provide ART on a large scale
in maternal and child health settings?
• Logistics: What is required to assure a reliable supply chain of ART and to avoid stock-
outs?
• Monitoring: What are the appropriate strategies for clinical monitoring of response to
treatment (including CD4 testing and, potentially, measurement of viral load)?
• Safety: What new evidence can be provided on the safety of EFV and TDF during
pregnancy and breastfeeding? The most reliable data will come from well-supported,
prospective pharmaco-vigilance registries.
• Effectiveness for PMTCT: What is the impact of this intervention on MTCT rates, both
early transmission, at six weeks, and overall rates, at the end of breastfeeding, and on
HIV-free survival?
• Effect on the mother's health: What are the benefits to maternal health in women with
high CD4 counts?
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• Effectiveness for decreasing sexual transmission: What is the amount of benefit for sero-
discordant couples in terms of increased prevention of sexual transmission of HIV and at
the population level if a ‘treatment as prevention’ strategy is implemented?
• Cost and cost-benefit: What are the costs and cost-benefit of this approach?
• Equity: What is the impact of this approach on the ability of the country programme to
serve other adults in need of ART? (5, p. 11)
Although PROMISE will not answer all of these questions comprehensively, it will provide
critical insights about many of them. It is extremely likely that any high quality evidence that can
be generated about any of these questions will prove valuable for PMTCT programs in the
future, regardless of which regimens are adopted. But in the short-term, since PROMISE will
address some of these questions for the regimens (A and B) that are currently being implemented
in the field, the findings will have immediate relevance in terms of optimizing the
implementation of PMTCT.
PANEL Responses to Questions
To more accurately reflect its reasoning, the Panel has decided to respond to Question 2 before
responding to Question 1. We first explain why we think PROMISE continues to have scientific
and social value. We then move to the case of countries that have already adopted B+ and
explain why we believe it is ethically acceptable to continue PROMISE in those countries.
Why PROMISE continues to have scientific and social value
Question 2 to the Panel
Given diverse implementation challenges and current policy developments in PMTCT programs,
does the study still have sufficient value for informing clinical, policy, or program decisions now
or in the future? If no, is there a design modification that would provide sufficient value to
continue the study?
Response to Question 2
Yes, the panel believes that PROMISE poses important and highly relevant questions and
is extremely likely to produce findings that will have value for informing clinical, policy,
or program decisions now or in the future.
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Rationale
The current move from A to B/B+ regimens appears to be driven largely by perceived
“programmatic and operational advantages”(3, p. 4) of the regimens. However, there remain
important gaps in the evidence about the relative merits of A and B and B+. Despite the
momentum in favor of B/B+ regimens, the WHO itself highlights the need for precisely the type
of evidence that PROMISE is designed to produce:
“There is an urgent need to assess country experience and evidence that address the
preferences among options A, B, and B+.”(3, p. 4)
We believe that PROMISE will provide evidence of comparative safety between A, B and B+
and will prove to be valuable for addressing some of the evidence gaps for future clinical, policy
and program decisions, although precisely how and when this value will be realized is difficult to
anticipate, given the current emphasis on the implementation of B/B+ regimens.
In addition to the primary analyses planned in PROMISE, the panel also found that some of the
planned secondary analyses—particularly those related to some key programmatic, operational
and clinical questions occupying the field—were also likely to yield evidence that could be
extremely valuable for the on-going management of program implementation, including B and
B+. For example, PROMISE is designed to provide evidence about various aspects of ARV
adherence and retention in care, HIV drug resistance associated with the various regimens, and
safety of the increased ARV exposure for the fetus/infant.
Is it ethically acceptable to continue PROMISE in countries that have adopted B+?
Question 1 to the Panel
Given the changing landscape of PMTCT guidelines, could PROMISE be conducted (or under
what conditions can PROMISE be conducted) in a country that has chosen a national policy for
PMTCT that recommends initiation of antiretroviral therapy for life in all HIV-infected pregnant
women regardless of CD4 count (Option B+)?
Response to Question 1
Yes, the Panel believes that PROMISE could be conducted ethically in countries that
have chosen B+.
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Rationale
When the Panel convened on June 18 and 19 of 2012 only Malawi had officially adopted B+.
But B+ is also being considered in several other countries, including Kenya, South Africa,
Uganda, Zambia and Zimbabwe. Of these countries, PROMISE trials are actively enrolling
patients in Malawi, South Africa, Uganda, Zambia and Zimbabwe(5, p. 12). Based on the
information provided to the panel, we believe that no intervention arm within PROMISE, as
currently designed, provides a level of care that is known to be inferior to B+. This conclusion
appeared to be well supported in the presentations to the panel and in supporting documentation
provided to the panel. For example, the WHO Programmatic Update of April 2012 states that:
“The two recommended prophylaxis options (A and B) are quite different programmatically,
but were judged to be equally efficacious, if implemented appropriately [emphasis in the
original], in reducing the risk of infant infections for women with CD4 counts >350
cells/mm3
”(3, p. 1)
Similarly, the scientific background document provided to the panel stated that:
“The expected efficacy of Option B+ for PMTCT would be similar to that observed with
option B since both provide a combination ARV regimen during pregnancy and
breastfeeding.”(5, p. 7)
Although the Scientific Background document goes on to acknowledge that there may be
advantages to B+ over B, there are an equal number of questions about the implementation and
sustainability of B+ to warrant the on-going generation of high quality evidence about the
regimens employed in the vast majority of PMTCT programs in high burden countries. Given
these conclusions, and in the absence of any scientific evidence to challenge this claim, the panel
found no reason why randomization in PROMISE should be viewed as unacceptable from the
standpoint of participant rights or welfare.
Additional Considerations for Question 1
Informed Consent
The core concern reflected in the first question to the panel is that PROMISE investigators and
teams may find themselves in the position in which a country adopts B+ as the national policy,
yet women within PROMISE could be randomized to a different drug regimen. Although the
Panel has concluded that there is sufficient uncertainty about the relative merits of the different
options to justify randomization, the very fact that some women will receive a regimen that is
different from the national program regimen could cause confusion and uncertainty about the
implications of the different regimens. To avoid these outcomes, there must be adequate
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assurance that the informed consent procedures implemented across the trial sites take into
account a change in the national policy to B+. Women must be properly apprised of the
implications of their choice to participate in the PROMISE trial, including the fact that they
could be randomized to receive a regimen that is different than that endorsed by the national
program, along with the risks and benefits associated with each option.
Additional Comments/Considerations
There are strong ethical and scientific grounds for continuing the PROMISE studies.
A. There are no randomized clinical trials, aside from the PROMISE trials, that have
addressed the comparative efficacy and safety of the different approaches to PMTCT in
women who are not yet eligible for ART for their own health.
B. The WHO programmatic update is not a formal WHO guideline document and revised
WHO PMTCT guidelines will not be available until 2013. Until these changes come into
effect, from an ethical-regulatory point of view the proper reference guidance for all
PROMISE research sites is the current country guideline. Currently, 21 of the 22 high
burden countries identified in the Global Elimination Plan(4) continue to deliver Option
A or Option B in their national programs. And in Malawi, the only country (and the only
PROMISE country) that has formally endorsed option B+ in its National guidelines, and
where recruitment into the PROMISE study is ongoing, the national policy makers have
endorsed continued recruitment into PROMISE, because of the likelihood that the trials
will produce valuable safety evidence.
C. Countries’ reactions toWHO’s anticipated endorsement of B+ is uncertain. Each country
is likely to follow its own usual process of deciding what is best locally. In the near-term,
this will likely result in a diversity of strategies among countries. And since a widespread
transition to B+ would take a long time, in the meantime, additional data from the
PROMISE trials could be extremely valuable for countries following their own internal
review processes.
D. The Panel also recognized that the concept behind B+ is not universally endorsed. For
example, in India, where PROMISE was not approved at a site in Chennai, there were
significant concerns about the vulnerability of B+ to economic circumstances and
government finance decisions. Also, culturally in many developing countries, in
households where there are more than one person infected with HIV, the woman in the
B+ arm may share her ARVs with her husband and children who may not have ART,
resulting in sub-therapeutic doses for all. These vulnerabilities are not unique to Option
B+ and they reinforce the need to continue the careful and deliberate comparative
21. ! 21!
evaluations of these implementation challenges for Options A and B as well, as is done in
the PROMISE trials.
Specific Recommendations
In addition to our responses to the two main questions framing the mandate of the panel, we also
offer several additional specific recommendations, based on our deliberations following the
presentations and submissions to the panel.
Recommendation 1
PROMISE is not studying the EFV-based B+ regimen that is currently recommended for roll-out
by WHO and is being supported by US government funding through PEPFAR. Hence
NIAID/NIH should explore ways of gathering evidence about the EFV-based B+ regimen
comparable to the lopinavir/ritonavir-based B+ evidence being generated by PROMISE.
Recommendation 2
PROMISE will have limits in terms of its ability to account for the impact of implementation
differences between Options A, B and B+, or to project 'worst case' scenarios when systems fail
for any Option. Therefore, NIAID/NIH, should consider supporting other operational research
studies aimed at key operational and programmatic questions that are not currently planned in the
PROMISE analyses.
Recommendation 3
NIAID/NIH should consider adding some qualitative sub-studies to the PROMISE trial to
address key questions, such as women’s perceptions of, and preferences for, the various options,
especially given that Option B+ requires women who may not necessarily be clinically eligible
for treatment beyond pregnancy and breastfeeding to take treatment for the rest of their lives.
Inadequate understanding of the personal and social implications of B+ could result in missed
opportunities to improve the overall impact of the intervention.
!
Recommendation 4
NIAID/NIH should review the PROMISE communication and dissemination strategies to ensure
that they effectively communicate the goals and potential value of the trials to key stakeholders
22. ! 22!
and optimize the ultimate impact of the findings for reducing MTCT and preserving maternal
health.
23. ! 23!
References
!
1. World Health Organization. Antiretroviral drugs for treating pregnant women and
preventing HIV infections in infants: recommendations for a public health approach:
2010 version. Geneva, Switzerland: World Health Organization.!
!
!
2. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early
antiretroviral therapy. N Engl J Med. 2011 Aug 11;365(6):493-505.!
3. World Health Organization. Programmatic update: use of antiretroviral drugs for treating
pregnant women and preventing HIV infection in infants – executive summary. April
2012. World Health Organization, Geneva, Switzerland, 2012.
4. UNAIDS. Countdown to Zero: The Global Plan towards the Elimination of new HIV
infections among children by 2015 and keeping their mothers alive. World Health
Organization, Geneva, 2011.
5. Mofenson LM. Scientific background, WHO PMTCT Guidelines, and other issues
related to PROMISE. Background document prepared for the PROMISE Expert Review
Panel, June 2012.
6. Kitahata MM, Gange SJ, Abraham AG et al. Effect of early vs deferred therapy for HIV
on survival. N Eng J Med 2009; 360: 1815-26.!
!
7. When to Start Consortium (Sterne JA et al). Timing of initiation of antiretroviral therapy
in AIDS-free HIV-1-infected patients: a collaborative analysis of 18 HIV cohort studies.
Lancet 2009; 373: 1352-63.!
!
8. Wright ST, Carr A, Woolley I, et al. CD4 cell responses to combination antiretroviral
therapy in patients starting therapy at high CD4 cell counts. JAIDS 2011; 58: 72-9.!
25. 1
PROMISE (Promoting Maternal Infant Survival Everywhere) Design
Pregnant/postpartum women who require treatment for their own health (current WHO recommendations:
CD4 <350 cells/ul and/or advanced HIV disease WHO clinical stages 3 or 4) should initiate a
combination antiretroviral (ARV) drug regimen as soon as possible and continue on this regimen for life.
However, there is controversy about how to optimize prevention of mother to child transmission
(PMTCT) as well as maternal/infant health in women who do not currently require treatment for their
own health. Based on currently available data, the WHO recommends two options which appear to be
equally effective for PMTCT – zidovudine (AZT) given during pregnancy with single-dose nevirapine
(sdNVP) at onset of labor and daily infant nevirapine (NVP) if the infant is breastfeeding (BF) for up to
12 months (Option A), or maternal triple combination ARV regimen during pregnancy and continued if
BF for up to 12 months, after which the maternal ARV regimen is discontinued (Option B). Each of these
options has different advantages and disadvantages as well as cost.
The PROMISE protocol (P1077) is a research protocol of the IMPAACT network designed to address in
an integrated and comprehensive fashion four critical questions currently facing HIV-infected pregnant
and postpartum women who do not yet require treatment for their own health, and their infants:
1. What is the optimal intervention for the prevention of antepartum and intrapartum HIV MTCT?
2. What is the optimal intervention for the prevention of postpartum transmission in BF infants?
3. What is the optimal intervention for the preservation of maternal health after the risk period for
MTCT ends (either at delivery or cessation of BF)?
The PROMISE protocol began development in 2008; P1077HS opened to enrollment in January 2010,
1077BF opened to enrollment in March 2011, and P1077FF opened to enrollment in May 2011. The
prolonged development process of PROMISE is reflective of changes in scientific research and in World
Health Organization recommendations during the course of protocol development that resulted in
modifications to the studies and delays in protocol opening. For example, in December 2009, WHO
updated guidance on Option A and B for prevention of mother to child transmission (PMTCT),
recommending new guidance for 6 weeks of infant NVP in infants of mothers receiving triple drug
regimens; as a consequence, P1077BF and P1077FF were delayed to enable incorporation of this new
guidance and infant regimen into the protocol document. The original PROMISE protocol contained a
component (‘Infant Health’ component) to evaluate whether the use of co-trimoxazole in HIV-exposed
uninfected infants who were weaned prior to age 12 months would decrease the morbidity and mortality
associated with early weaning. However, the new WHO guidance recommended at least 12 months of
infant or maternal prophylaxis while breastfeeding, and as a consequence after the study opened it was
observed that breastfeeding duration in the countries in which the study was being performed was now at
least 12 months or longer. Given that few infants are now being weaned early, PROMISE is currently
being revised to drop the Infant Health component of the protocol.
The overall PROMISE protocol has 3 separate interventional components to address each of these
questions. Due to variations in the standard of care for HIV-infected pregnant and postpartum women
and their infants at different IMPAACT sites globally, not all of these questions are relevant at all sites of
the network. Therefore, three versions of the PROMISE protocol have been developed, each containing
only those components relevant to the different settings of the IMPAACT network.
26. 2
One version, P1077BF (BF=Breastfeeding), is designed for areas of the world where HIV-infected
women are advised to BF, and addresses all four questions. Another version, P1077FF (FF=Formula
feeding), is designed for areas of the world where HIV-infected women formula-feed but less complex
antiretroviral prophylaxis regimens to reduce mother to child transmission (MTCT) are used; this protocol
addresses above questions 1 and 3. The third version, P1077HS (HS=HAART Standard”), is designed for
countries such as the U.S., where use of triple drug regimens during pregnancy for PMTCT as well as
formula feeding is standard; this protocol addresses question 3 only.
In addition to these main protocols, PROMISE also includes modules for intensive study of possible bone
and renal toxicity, study of Hepatitis B/HIV co-infected women, ARV resistance in women and in infants
who become infected, and a cost effectiveness analysis. PROMISE is expected to follow women and
infants for at least 96 weeks. The study will provide first-line regimens to all participants either
randomized to triple ARV or who require treatment during the course of follow-up, and has several
second-line regimens available for those who need them.
P1077BF in BF populations, has 3 components to address each of the 3 research questions, and involves
3 sequential randomizations of women with entry CD4 >350 who are first enrolled while pregnant (or
who are late presenters and enroll at delivery). If during the course of study follow-up a woman qualifies
for treatment based on country guidelines, she is provided with treatment and does not undergo further
randomization. Data from P1077BF and P1077FF will be combined for analysis.
Antepartum Component: The primary objectives are to compare the efficacy of maternal antepartum
triple ARV prophylaxis versus antepartum AZT + sdNVP to reduce antepartum and intrapartum HIV
transmission at age 1 week and to assess/compare safety and tolerability of these ARV regimens,
including adverse pregnancy outcomes (e.g., stillbirths, prematurity, low birth weight and birth
defects). Data from the Antepartum Component of P1077BF and P1077FF will be combined for
analysis of this question.
Postpartum Component: The primary objectives are to compare the efficacy of maternal triple ARV
versus infant NVP prophylaxis during BF to reduce cumulative HIV transmission from BF and to
assess the safety/tolerability of these ARV regimens for mother and infant.
Maternal Health Component: The primary objective is to compare the rate of progression to AIDS-
defining illness or deaths between women who received triple ARV prophylaxis during BF, and are
randomized to stop or continue the regimen after cessation of BF. Data from the Maternal Health
Component of P1077BF and P1077FF will be combined for analysis of this question.
27. 3
P1077FF in formula feeding populations, has 2 components to address 2 of the research questions, and
involves 2 sequential randomizations of women with entry CD4 >350 who are first enrolled while
pregnant. If during the course of study follow-up a woman qualifies for treatment based on country
guidelines, she is provided with treatment and does not undergo further randomization.
Antepartum Component: The primary objectives are to compare the efficacy of maternal antepartum
triple ARV prophylaxis versus antepartum AZT + sdNVP to reduce antepartum and intrapartum HIV
transmission 1 week (7-12 days) of age and to assess and compare the safety and tolerability of these
ARV regimens, including adverse pregnancy outcomes (e.g., stillbirths, prematurity, low birth weight
and birth defects).
Maternal Health Component: The primary objective is to compare the rate of progression to AIDS-
defining illness or death between study arms between women who received triple ARV prophylaxis
and are randomized to stop or continue the regimen after delivery of their infants.
28. 4
P1077HS in areas where combination ARV for PMTCT is standard, addresses only the maternal
health question regarding stopping or continuing the ARV regimen after delivery in women with CD4
>400 prior to starting ARV for PMTCT. If during the course of study follow-up a woman qualifies for
treatment by current guidelines, she is provided with treatment and does not undergo further
randomization. Data from P1077HS will be analyzed separately from P1077BF and P1077FF.
Maternal Health Component: The primary objective is to compare the rate of progression to AIDS-
defining illness or death between study arms between women who received triple ARV prophylaxis
and are randomized to stop or continue the regimen after delivery of their infants.
The sample sizes for each component are shown in the slides below:
29. 5
As of April 30, 2012, 1,150 mother/infant pairs have been enrolled into 1077BF and FF:
1013 mother-infant pairs enrolled in 1077BA (antepartum - breastfeeding)
88 mother-infant pairs registered in 1077BL (late presenter - breastfeeding)
544 mother-infant pairs proceeded to 1077BP (postpartum - breastfeeding)
56 mothers proceeded to 1077BM (maternal health - breastfeeding)
30. 6
137 mother-infant pairs enrolled in 1077FA (antepartum – formula feeding)
27 mothers proceeded to 1077FM (maternal health – formula feeding)
Current enrollment into P1077BF and FF is ~115 mother/infant pairs per month, with 12 of 14 sites
actively enrolling (2 additional sites in Tanzania and Zambia will be open soon). Depending on
monthly enrollment, accrual is estimated to be completed by August 2013 (if increase enrollment to
200/month) to June 2014 (if stay at 125/month). The first interim efficacy analysis for Antepartum
Component (combined analysis of Antepartum BF and FF components) is expected in November
2012.
Current enrollment into P1077HS is 610 (of planned 2000 mothers). Enrollment is open at sites in
Argentina, Botswana, Brazil, China, Haiti, Peru, Thailand and the United States. Currently, 42
women per month are being enrolled, with accrual estimated to be completed January 2015. If
accrual increases to 50 women per month, accrual will be completed in August 2014.
32. Scientific Background, WHO PMTCT Guidelines, and Other Issues
Related to PROMISE
Background
To provide background for discussion of the PROMISE protocol, this paper will review the
World Health Organization (WHO) guidelines for prevention of mother to child HIV
transmission (PMTCT), summarize the evidence basis for the 2010 guidelines, discuss the
rationale for a newly proposed approach of life-long antiretroviral therapy (ART) for all pregnant
women (known as “Option B+”) and some of the uncertainties and key questions with this
approach, and discuss current state of country implementation of PMTCT guidelines.
PMTCT is a dynamic and rapidly changing field. In 2010, research developments led to revision
in the WHO guidelines for antiretroviral (ARV) drug use by HIV-infected pregnant and
breastfeeding women for maternal health and PMTCT in resource-limited countries (WHO 2010).
The availability of new highly effective interventions to prevent perinatal and postpartum MTCT
through breast milk led the UNAIDS to announce the Global Plan Towards the Elimination of New
HIV Infections Among Children by 2015 and Keeping Their Mothers Alive - a bold and challenging
new global goal of decreasing new HIV infections in young children by 90% (from 400,000 to
40,000 annually) and decreasing population-based MTCT rates to <5% in breastfeeding settings
(and <2% in non-breastfeeding settings), and thus virtually eliminating MTCT globally by 2015
(UNAIDS 2010)
(http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110609_JC2137_Glob
al-Plan-Elimination-HIV-Children_en.pdf).
The revised 2010 WHO guidelines emphasized the importance of initiation of life-long
combination ART for HIV-infected pregnant women with CD4 counts <350 cells/mm3
or WHO
stage 3 or 4 clinical disease (approximately 40-50% of all HIV-infected pregnant women) for
maternal health as well as for the prevention of infant HIV infection. For women who do not yet
need ART for their own health, a choice of two ARV prophylaxis options is recommended for
PMTCT: antepartum zidovudine (AZT) plus intrapartum single-dose nevirapine (sdNVP) and
daily infant NVP through 12 months of breastfeeding (Option A), or a maternal triple drug
regimen during pregnancy and 12 months of breastfeeding (Option B).
While WHO increased its immunologic threshold for initiation of ART in HIV-infected adults
from CD4 <200 to <350 cells/mm3
in 2010, the optimal criteria for ART initiation in resource-
limited settings remains controversial; some observational studies in higher resource settings
suggest a benefit to initiation of ART at higher CD4 cell counts (e.g., CD4 <500 cells/mm3
)
while others do not (Kitahata MM. NEJM 2009; Sterne JA. Lancet 2009; Wright ST. JAIDS 2011). Important
new research indicates that initiation of ART in individuals with CD4 <550 cells/mm3
significantly reduces sexual transmission of HIV among discordant couples (Cohen MS. NEJM
2011). These data, along with considerations regarding program simplification, have led to a
consideration of a third option, Option B+, which would be to provide life-long ART in all HIV-
infected pregnant women regardless of CD4 cell count. This approach has been adopted in one
country (Malawi) and is being considered in others.
33. 2
However, in resource-limited countries there are significant limitations on the number of
available ARV drugs, and the challenge in these settings is to balance the benefits of starting
ART early in pregnant women with risks of ARV drug toxicity to the mother and fetus/infant in
pregnancy and breastfeeding; costs and health system burden; issues related to adherence,
resistance, ART failure and availability of future treatment options; and assuring treatment
availability for all individuals who meet current treatment guidelines.
There is no debate regarding the need to provide ART to women who meet current WHO criteria
for treatment; 92% of maternal mortality and 88% of perinatal and postnatal MTCT occur in this
group of women (Kuhn L. AIDS 2010). However, there remain critical research gaps about optimal
ARV use for PMTCT in women who don’t meet current WHO ART eligibility criteria. The
PROMISE protocol was designed to address questions restricted to this group of women - those
who do not meet current eligibility for ART for their own health in the countries in which the
research is conducted, and will directly compare the full Option A versus Option B.
Summary of and Evidence Basis for 2010 WHO PMTCT Guidelines
Guidelines for the use of ARV drugs to treat pregnant women and prevent HIV infection in
infants, along with the HIV and infant feeding guidelines, were last revised in 2010, in
coordination with updating of the adult ART guidelines (WHO PMTCT guidelines 2010; WHO adult
ARV guidelines 2010). The 2010 revision reflected new research findings at that time indicating:
the benefits of starting ARV prophylaxis for PMTCT earlier in pregnancy (Hoffman RM.
JAIDS 2010);
decreased HIV transmission when mother or infant receives postpartum ARV
prophylaxis during breastfeeding (Chasela CS. NEJM 2010; Kesho Bora. Lancet Infect Dis.2011);
and
the benefit of ART for improved health and survival when it is started at a CD4 count
<350 cells/mm3
instead of waiting for a decline to <200 cells/mm3
(Severe P. NEJM 2010).
This finding resulted in a change in guidance, calling for initiation of ART in all HIV-
infected individuals with CD4 counts of ≤350 cells/mm3
(or WHO stage 3 or 4 clinical
disease), including pregnant women.
The revised 2010 WHO PMTCT guidelines recommend starting pregnant women eligible for
treatment (i.e. with CD4 counts of ≤350 cells/mm3
) on lifelong ART. The recommendation calls
for giving treatment priority to pregnant women as part of treatment scale-up. ART for pregnant
women meeting the eligibility criteria would address the great majority of mothers and infants at
risk. A study in Zambia found that 68% of the HIV-infected women studied met WHO criteria
for ART, and 92% of maternal mortality and 88% of perinatal and postnatal MTCT occurred in
these women (Kuhn L. AIDS 2010). A study of more than 6,000 women in nine countries, all but
one in sub-Saharan Africa, found that 48% qualified for treatment under current WHO criteria
(Carter RJ. JAIDS 2010). The HIV and infant feeding guidelines recommend that, when the
breastfeeding mother or infant is receiving ARVs, breastfeeding should continue for the infant’s
first 12 months and beyond, with complementary foods introduced at six months.
For women not eligible for ART for their own health (CD4 count >350 cells/mm3
), the 2010
guidelines offer countries a choice of two effective prophylaxis options for PMTCT (Table 1).
34. 3
Option A expands the previous (2006) recommended approach to prophylaxis for women
not eligible for ART, which consisted of maternal zidovudine (AZT) during pregnancy,
single-dose nevirapine (sdNVP) plus AZT plus lamivudine (3TC) at delivery and
continued for one week postpartum. The revised 2010 recommendation extended
prophylaxis with daily NVP to the infant throughout breastfeeding.
Option B introduced a new approach: a maternal triple ARV regimen (with the regimen
based on the country’s recommended first-line ART) given all HIV-infected women
during pregnancy and until cessation of breastfeeding (if CD4 count >350 cells/mm3
) or
for life (if CD4 count ≤350 cells/mm3
).
For both options prophylaxis is recommended to start as early as 14 weeks gestation. If a woman
is breastfeeding, prophylaxis is recommended to continue throughout the breastfeeding period
(infant or maternal antiretroviral prophylaxis with exclusive breastfeeding for the first 6 months
followed by continued breastfeeding with complementary foods through at least 12 months).
Table 1. WHO 2010 Guidelines for Prophylaxis of MTCT (adapted from Table 2 of the 2010 guidelines)
(Note in both options, all women with CD4 <350 cells/mm3
or WHO Stage 3/4 disease should initiate life-long ART)
Option A
Maternal AZT/sdNVP + infant NVP
prophylaxis
Option B
Maternal triple ARV prophylaxis
Mother
Antepartum: AZT starting as early as 14 weeks
of gestation.
Intrapartum*: sdNVP at onset of labour and
initiation of daily AZT/3TC until 7 days
postpartum.
* If maternal AZT was provided for >4 weeks
antenatally, sdNVP and AZT/3TC “tail” can be
omitted, and only AZT given in labour.
Mother
Antepartum: Triple ARV prophylaxis starting as
early as 14 weeks of gestation. Regimen choice:
AZT+3TC+LPV/r or
AZT+3TC+ABC or
AZT+3TC or TDF+3TC (or FTC) + EFV
Intrapartum: Same regimen
Postpartum: Same regimen continued until
1 week after exposure to breast milk has ended.
Infant
Breastfeeding infant
Daily NVP from birth until 1 week after
exposure to breast milk has ended (or a
minimum of 4–6 weeks following birth)
Infants receiving replacement feeding only
Daily NVP or single-dose NVP plus daily AZT
from birth until age 4–6 weeks
Infant
Daily NVP or daily AZT from birth until age 4–
6 weeks (irrespective of mode of infant feeding).
Although there have been no clinical trials to compare the full Option A vs Option B, available
data indicate two prophylaxis options have similar efficacy for PMTCT in women not eligible
for treatment (see below). Countries were advised to choose one of the two options based on
operational and programmatic considerations. The guidelines acknowledged that access to CD4
testing is necessary to determine whether a woman needs prophylaxis or lifelong treatment, and
that the requirement for CD4 testing can be a barrier to successfully implementing Option A.
35. 4
CD4 testing also is needed to determine which women should continue on lifelong treatment if
started on Option B.
Brief Review of Data on Efficacy of Option A versus Option B for PMTCT
While there are not comparative studies of the full antepartum-postpartum Option A vs Option
B, data from studies looking at antepartum component of Option A vs B and other studies
looking at postpartum component of Option A vs B are available.
The Kesho Bora trial compared maternal triple ARV prophylaxis (the Option B approach) with
AZT plus sdNVP prophylaxis (the antepartum component of Option A), both starting at 28
weeks gestation or later in African women with CD4 cell counts of 200–500 cells/mm3
(deVincenzi
I. Lancet Inf Dis 2011). The women randomized to the triple ARV arm continued the drugs until the
early cessation of breastfeeding at six months, while those in the AZT arm did not receive any
postnatal prophylaxis after one week—a departure from the Option A regimen. Transmission
rates at birth, reflecting the efficacy of the interventions for preventing MTCT during pregnancy,
were similar in the two arms—1.8% (95% CI 0.9–3.7%) with the triple drug regimen and 2.5%
(95% CI 1.3–4.6%) with AZT plus sdNVP. Of note, for women with CD4 counts of 350–500
cells/mm3
(women who were not eligible for treatment by current standards), the transmission
rates at delivery were identical—1.7% in each arm.
The two postnatal prophylaxis regimens, infant NVP (postpartum component of Option A) and
maternal triple ARV prophylaxis (postpartum component of Option B) have been compared in
only one trial. In the Malawi Breastfeeding and Nutrition (BAN) trial, women with baseline CD4
counts of >250 cells/mm3
were enrolled at the time of delivery, and breastfeeding mother-infant
pairs were randomized to one of three arms: a control arm of intrapartum sdNVP plus one week
AZT/3TC, or this control regimen plus six months of infant NVP (the postpartum component of
Option A), or maternal triple ARV prophylaxis (the postpartum component of Option B) (Chasela
CS. NEJM 2010). Rates of postnatal MTCT at six months were significantly lower in the infant
NVP and maternal triple drug prophylaxis arms than in the control arm but were similar in the
two experimental arms—2.9% (95% CI 1.9–4.4%) with triple drugs and 1.7% (1.0–2.9%) with
infant NVP, although the study was not designed or powered to compare the two experimental
arms. It was noted that, if maternal prophylaxis with triple ARV regimens is started in the
postpartum period or late in pregnancy, it may be less effective than infant prophylaxis because it
takes several weeks to months before full viral suppression in breast milk is achieved; thus,
efficacy against early breast milk MTCT may be decreased in this situation, if no early infant
prophylaxis is provided.
There are limited published data on implementation of the WHO 2010 guidelines and on
operational evaluations that compare implementation of Options A and B. With roll-out of
Option A, South Africa reported a preliminary population-based early MTCT rate of 3.5% (95%
CI 2.9-4.1%) based on a 2010 national surveillance study of 6-week infants attending
immunization clinics compared to an historical 22% with no ARVs (Goga IAS 2011); these data
provide only an early indication of Option A effectiveness because full implementation of the
Option A program was not in place until 2011. A comparison of MTCT rates before and after
South Africa switched from the 2006 guidelines to the 2010 Option A guidelines found that the
infection rate among infants around six weeks of age dropped from 3.4% (95% CI 2.6–5.0%) to
36. 5
1.5% (95% CI 0.9–2.9%) – similar to that reported with triple ARV drugs (Rundare et al., CROI
2012 Ab 1003). Similar results have been reported in an intensive surveillance and quality
improvement project in Kwazulu-Natal province (Horwood J Trop Med 2010). These studies confirm
the effectiveness of Option A when implemented with high coverage and access to CD4 testing
and ART for eligible women. In contrast, in an analysis of program implementation in Botswana
between February 2009 and April 2010 (93% of infants were formula fed), MTCT rates were
5.5% (95% CI 2.6-10.6%) in the AZT/sdNVP group (without extended infant prophylaxis) and
0.4% (95% CI 0-2.2%) in the triple ART (women with CD4 <250 cells/mm3
) group (Dryden-
Peterson S. JAIDS 2011).
Computer modelling based on Zimbabwe suggests that Options A and B are roughly equivalent
in preventing MTCT (Ciaranello AL. PLosMed 2012). The models estimated rates of MTCT among
infants age 12 months under three different treatment schemes—sdNVP, Option A and Option B.
All models assumed that women identified as eligible for ART were referred for treatment. At a
rate of uptake of PMTCT services of 56%, the actual rate in Zimbabwe in 2009, the projected
transmission rate with the sdNVP regimen was 18% compared with 14.4% with Option A and
13.4% with Option B. The level of PMTCT uptake had greater impact on MTCT rates than the
choice of regimen. In a model in which CD4 assays were not available and treatment eligibility
was based only on clinical assessment, at 95% uptake the projected 12-month transmission rates
were 9.6% with Option A and 5.9% with Option B. In a separate model in which CD4 assays
were available for all women and ART was provided for all women with CD4 <350 cells/mm3
,
at 95% uptake the projected 12-month transmission rates were 7.4% with Option A and 5.8%
with Option B. These results demonstrate CD4 assay availability is more important to optimize
the efficacy of Option A than Option B.
Benefits and Uncertainties/Risks of Option A vs Option B
There are not yet randomized clinical trial data directly comparing the full Option A and Option
B and their relative benefits in terms of efficacy, safety, feasibility and cost-effectiveness.
Choice among these options is complex; there are multiple objectives of ARV use in pregnancy
and lactation that are sometimes conflicting. These include optimizing PMTCT, optimizing
maternal and infant health, minimizing side effects to the woman and her infant, preserving
future ART options for the woman (and infected infants), and maximizing overall benefit to the
population given fixed and limited resources. There are advantages and disadvantages of both
options from program point of view.
Option A is the less costly option in terms of initial drug cost, but it is more complex, is not
harmonized with adult ART guidelines, and requires CD4 counts to differentiate women who
require ART for their own health from those needing only prophylaxis. While point-of-care CD4
testing is a promising new approach, at this point, access to CD4 testing continues to be an
important barrier to identifying and providing ART to women eligible for treatment. In the
absence of CD4 counts, provision of Option A to all pregnant women would inappropriately
provide AZT single-drug prophylaxis women with CD4 <350 cells/mm3
who require treatment.
Option B has higher initial drug costs but provides the potential opportunity to integrate PMTCT
with first-line adult treatment recommendations (if non-NVP ART regimens are used). Since in
37. 6
Option B all pregnant women receive triple ARV regimens, prophylaxis could be initiated
pending (or without) CD4 assay results. Thus, with Option B all women in need of treatment
would receive triple ARVs. However, CD4 assays would still be needed to make decisions
regarding stopping or continuation of the regimen after MTCT risk for women who require ART
for their own health. Additionally, while access to CD4 testing is not required for initiation of
ART, access to testing is optimal to monitor ongoing response to therapy, as for any individual
on treatment.
There is likely similar complexity in program implementation. Baseline evaluations, prescription
of drugs and refills, and adherence counseling are similar. With Option A, maternal CD4 count is
needed to determine whether the woman should receive ART or prophylaxis, although the
regimen could be initiated pending CD4 results. With Option B, maternal CD4 count is needed
to determine whether the woman should continue the triple ARV regimen after risk of MTCT
has ceased, although the regimen could again be initiated pending CD4 results. Option A
requires the additional prescription and administration of intrapartum sdNVP and 1 week
AZT/3TC “tail”, which adds complexity. For Option B, the choice of triple ARV regimen is
complicated by NVP toxicity in women with CD4 >250 cells/mm3
and limited data on safety in
pregnancy and breastfeeding of drugs other than AZT and 3TC, particularly for tenofovir (TDF)
and efavirenz (EFV). In the U.S., pregnant women with CD4 count >250 cells/mm3
receive
protease inhibitor (PI)-based regimens. Postpartum, infant ARV prescription is required for both
options. If the triple drug regimen includes EFV and is continued postpartum, family planning
must be addressed.
A New Approach - Option B+ - Lifelong ART for All Women
A number of countries are moving towards an approach of starting all pregnant women on ART,
irrespective of clinical and immunologic staging, and continuing ART for life—an approach
similar to “test and treat” and known as “Option B+”. Table 2 shows the proposed approach.
Table 2. Option B+: Lifelong ART for all pregnant women
Option B+
Maternal ART for life
Mother
Antepartum and postpartum: ART starting as early as 14 weeks of gestation and continued for life
Regimen choice (proposed to harmonize with adult ART guidelines but avoid the risk of NVP
toxicity in women with high CD4 count; use a simplified, fixed-dose combination regimen):
TDF + 3TC (or FTC) + EFV (one pill, once daily regimen)
AZT + 3TC + EFV
Infant
Daily NVP from birth until age 4 to 6 weeks (irrespective of mode of infant feeding)
The Option B+ approach was first proposed by Malawi, based on their concerns that they could
not effectively implement either Option A or B because of limited access to CD4 testing, high
38. 7
fertility rates—and thus the prospect of repeatedly stopping and starting ARV—and the need to
integrate PMTCT more fully with the national adult ART program, based on one simplified
regimen (Schouten EJ. Lancet 2011). Because of its greater operational simplicity, Option B+
circumvents these problems. While Option B+ was not formally considered in the 2010 WHO
PMTCT guidelines, due to insufficient evidence on clinical benefit of ART in individuals with
CD4 counts >350 cells/mm3
and lack of field experience, it was identified as a high-priority
research question. A recent programmatic update from WHO has more formally endorsed
consideration of this approach (WHO Program Update April 2012).
The expected efficacy of Option B+ for PMTCT would be similar to that observed with Option
B, as both provide triple ARV regimens during pregnancy and breastfeeding. However, Option
B+ may have several advantages over Options A and B: protection of serodiscordant partners,
including protection after MTCT risk has ceased; potential clinical benefit for the women of
starting ART early; avoidance of a pattern of starting, stopping and restarting ARV in women
who become pregnant again soon; and potential protection of subsequent pregnancies from
MTCT from conception.
Treatment as prevention (HPTN 052 and WHO couples HIV testing and counselling
guidance)
The results of HPTN 052 demonstrate the strong benefit of starting ART early (i.e. in those with
CD4 counts of 350 to 550 cells/mm3
) to prevent heterosexual transmission in serodiscordant
couples (Cohen MS. NEJM 2011). Option B+ (as well as Option B during the period of triple ARV
administration) has the potential to prevent sexual transmission as well as to provide a highly
effective intervention for PMTCT. WHO has provided guidance recommending couples HIV
testing and counselling, with support for disclosure, and that infected partners in serodiscordant
couples who do not yet require ART (CD4 >350 cells/mm3
) should be offered ART to reduce
sexual transmission, noting that in situations/countries with limited or inadequate resources,
individuals who require ART for their own health should be given priority (WHO Couples
Testing/Counselling April 2012). In ANC settings, rates of serodiscordance range from 10% to 50%.
It is important to note prevention of sexual transmission depends on maintaining suppression of
viral load. Adherence to the daily ART regimen is essential to maintain suppression. Therefore,
in order to realize the full public health benefits of this approach there must be continuous supply
of drugs without stock out and strong support for adherence.
Clinical benefit of starting ART earlier
Although not conclusive, there is evidence that starting ART earlier could have clinical benefit
(Kitahata MM. NEJM 2009; Sterne JA Lancet 2009; Wright ST. JAIDS 2011; CASCADE Arch Intern Med 2011;
Rhame FS. Curr Infect Dis Rep 2011). For example, in the HPTN 052 study initiation of ART when
CD4 count was <550 cells/mm3
(rather than waiting until CD4 decreased to <250 cells/mm3
)
reduced the incidence of extrapulmonary (but not pulmonary) tuberculosis. There was no
significant difference in mortality between early and deferred ART arms but median follow-up
was only 1.7 years (Cohen MS. NEJM 2011). Randomized clinical trial data on the clinical benefit
of ART initiation in individuals with CD4 >350 cells/mm3
are not yet available. However, the
NIAID-sponsored START (Strategic Timing of Antiretroviral Treatment) Study being conducted
in 35 countries is an ongoing randomized controlled trial comparing initiation of ART when CD4
39. 8
falls to <350 cells/mm3
compared to immediate ART when CD4 is 500 cells/mm3
or above, and
will provide critical data about the benefits and risks of early treatment.
Approximately 48%-68% of HIV-infected pregnant women have CD4 cell count <350 cells/mm3
when they are first seen in antenatal care (Carter RJ. JAIDS 2010; Kuhn L. AIDS 2010). For women
with higher CD4 counts, the time to decline to the current treatment threshold for treatment of
≤350 cell/mm3
after delivery varies based on baseline CD4. In the Kesho Bora study, among
women with CD4 cell count of 350–500 cells/mm3
at study entry in the AZT/sdNVP group, 34%
dropped to a CD4 count of <350 cells/mm3
within two years postpartum (Kesho Bora Study Group.
IAS 2010 Ab.ThLBB105). Similarly, in the HPTN 046 clinical trial of infant NVP to prevent
transmission during breastfeeding, within one year postpartum 36.9% of women with CD4
counts between 400 and 549 cells/mm3
at delivery dropped to CD4 counts of <350 cells/mm3
. In
contrast, at one year postpartum only 7.4% of women with baseline CD4 count >550 cells/mm3
at delivery had dropped to <350 cells/mm3
(Fowler MG. CROI 2012 Ab 1015).
Avoiding stopping and starting ART
Studies of CD4-guided ART interruption found that interruption significantly increased the risk
of opportunistic infections or death as compared with continuous ART in individuals meeting
treatment criteria, largely as a consequence of lowering CD4 count and increased viral load
(SMART Study Group. NEJM 2006). The relevance of these data to women with high CD4 count who
receive triple ARV prophylaxis is unknown. Limited data from clinical trials in which women
with higher CD4 count receive triple ARV for prophylaxis and stop following delivery or
breastfeeding have not shown increased rates of disease progression compared to those receiving
other prophylaxis such as AZT alone (Kesho Bora Study Group. IAS 2010 Ab.ThLBB105, Tungsiripat M
JAIDS 2006).
However, many countries with HIV high burdens also have high fertility rates; women may
become pregnant again soon after they stop breastfeeding. Lifelong treatment under Option B+
would avoid the stop-start pace of prophylaxis. If the woman continues taking ARVs properly,
assuming continued viral suppression, they also will protect the next pregnancy starting at
conception rather than waiting until the woman presents for antenatal care, which in many
countries may be late in pregnancy. However, some data suggest an increase in prematurity or
other adverse pregnancy outcomes in women receiving ART, particularly in women receiving
ART from before conception and continued throughout pregnancy (Powis KM. JID 2011; Cohan D.
CROI 2012 Abs 1027; Chen J. CROI 2012 Abs 1028, Shapiro R. CROI 2012 Abs 1031). Prematurity may be
more problematic in low- than high-resource settings.
It is important to note that many pregnancies in low-resource countries are unintended (Homsy J.
PLosOne 2009; King R. BMC Public Health 2011; Jhangri GS. J Fam Plan Reprod Health Care 2012).
Provision of adequate family planning services is an essential component of efforts to eliminate
perinatal transmission. Modelling by UNAIDS has demonstrated that provision of ART alone
will not reach the goal of eliminating perinatal transmission. To achieve a 90% reduction in new
paediatric infections, the analysis found, programmes must achieve 90% or higher coverage with
effective ARV prophylaxis, reduce the incidence of new infections in women by 50%, meet
40. 9
unmet need for family planning, and limit breastfeeding to 12 months (Mahy M. Sex Transm Infect
2010).
Choice of ART drug regimen
An ideal first-line regimen to provide to all HIV-infected pregnant women is not yet available.
Key requirements include: low cost, available as a fixed-dose combination, safe for pregnant
women and breastfeeding infants, minimal monitoring requirements, low resistance profile, and
compatibility with other drugs included as part of basic care. The choice of ART regimen is
more complex in women with higher CD4 counts (i.e. >350 mm3
). The most common first-line
drug, NVP, is not recommended for use in women with high CD4 counts because of potential
increased hepatic toxicity. In well-resourced countries a protease-inhibitor-based regimen is used
in pregnant women with high CD4 counts. In low-resource settings use of an EFV-based
regimen is proposed. The regimen of TDF, 3TC and EFV is available as a fixed-dose
combination of one tablet a day, is one of the recommended first-line regimens for adults, and
has recently been recommended as the best currently available regimen for treatment
optimization (WHO Tx 2.0 2011). It is also effective against the hepatitis B virus and can be used
without routine laboratory monitoring.
A critical issue for any new regimen for pregnant and breastfeeding women, as well as for
women who might become pregnant, is safety. To date, there are limited data on EFV and TDF
use in pregnancy. Early data suggesting neural tube birth defects in primates with in utero EFV
exposure and some isolated case reports and retrospective clinical data in humans have led to
concern about use of EFV in women of childbearing age. Both the US Food and Drug
Administration and the European Medicines Agency classify EFV as a potential teratogen, and
while recognizing that the teratogenic risk is low and primarily early in pregnancy, advise
against its use in pregnant women unless the potential benefits outweigh the risk (Bristol-Myers
Squibb FDA EFV drug label Dec 2011, EMA EFV drug label). However, a computer simulation model
projected improved survival among women initiating EFV-based instead of NVP-based ART in
Cote d’Ivoire, with a small potential number of birth defects (Ouattara EN. AIDS 2012). Evaluation
of prospectively collected data on infants born to mothers taking EFV in the first trimester in
humans is reassuring (Ford N. AIDS 2011). The number of first trimester EFV exposures in
prospective studies remains too small, however, to allow a definitive conclusion regarding the
risk of rare outcomes such as neural tube defects in women who conceive while on EFV,
although it is clear that the relative risk, if any, is low. Women who desire pregnancy could be
offered an alternative ART regimen while attempting to conceive and until the second trimester
of pregnancy. This would increase the complexity of the Option B+ approach, however.
Additionally, as noted, the majority of pregnancies in resource-limited settings are unplanned.
The optimal triple ARV regimen in pregnancy and breastfeeding and the safety of these regimens
in women and infants need to be determined. The risk of toxicity or congenital defects may be
affected by nutritional deficiency and other conditions more common in developing than
developed countries. ART use has been associated with adverse birth outcomes in studies in
Botswana and Uganda (Cohan D et al. CROI 2012 Abs 1027; Chen J et al. CROI 2012 Abs 1028, Shapiro R et
al. CROI 2012 Abs 1031). With increasing use of the triple ARV regimen in pregnant and lactating
41. 10
women, at a minimum a pharmacovigilance surveillance system needs to be in place to evaluate
pregnancy outcomes and birth defects.
Adherence, acceptability, and retention in care
There is evidence that women receiving ART may require special assistance with adherence and
retention in care postpartum; recent studies have shown a significant decrease in ART adherence
during the postpartum period and also possibly an increased risk of loss-to-follow-up following
delivery (Nachega J CROI 2012 Ab 1006, Myer L CROI 2012 Ab 22, Clouse K CROI 2012 Ab 1004). In a meta-
analysis of 51 studies on ART adherence among pregnant and postpartum women in high-, mid-
and low-resource countries, only 73.5% (95% CI 69-78%) of women had adequate adherence to
their ART regimen (defined as >80% adherence); the point estimate of the proportion of women
with >80% ART adherence was 75.7% (95% CI 72-80%) during the antepartum period and
50.3% (95% CI 33-73%) during the postpartum period (p=0.009) (Nachega J. CROI 2012).
Virtually no data are published on patient acceptability of various PMTCT regimens outside of a
clinical trial setting.
Loss-to-follow-up is a major obstacle to effective delivery of PMTCT programs in diverse
contexts. In a study of 925 patients in a South African ART clinic, pregnant women with
baseline CD4 counts <200 cells/mm3
initiating ART were six times more likely to be lost to
follow-up than men (Wang B. S Afr Med J 2011). In another South African study, pregnant women
were substantially more likely to be lost to follow-up than non-pregnant women for both pre-
ART care and while on ART (Kaplan R. AIDS 2008).
Studies reporting on individual barriers to accessing PMTCT care cite issues such as
transportation, lack of partner support, lack of awareness, stigma, and delivery outside of health
care facilities (Peltzer K. BMC Public Health 2011, Peltzer K. Afr J Reprod Health 2007, Mbonye AK. Sex Trans
Infect 2009, Mbonye AK. J Biosoc Sci 2010). There are no comparative data on which programmatic
PMTCT approach might be more acceptable or accessible to patients.
Resource allocation considerations concerning access to ART
Given that resources for treatment remain limited and that worldwide 10 million people who
require treatment still lack access to ART, public health decisions on PMTCT need to be part of
broader country HIV programming (WHO Progress Report 2011). To optimally decrease MTCT and
reduce maternal mortality, the highest priority should be to ensure that women who currently
require ART for their own health receive it. Countries making decisions about increasing use of
ART will need to consider how best to increase access for those needing ART for their own
health while at the same time assuring sustainable access for those started on ART early.
Analyses of budgetary impact and cost-effectiveness that compare Options A and B (and B+)
and address short- and long-term benefits and costs for both mothers and infants will be an
important subjects for future research. Operational research will need to validate the cost-
effectiveness of specific approaches in their settings, particularly in countries implementing
Option B+.
42. 11
Operational aspects of Option B+
Constraints on health systems and human resources will need to be addressed to accommodate an
Option B+ approach. Task-shifting and possibly expansion of health staff to allow provision of
ART in primary health care facilities, where the great majority of women receive AMNC care,
and integration of ART and PMTCT programmes (for initiation, maintenance and retention on
treatment) will be needed. Maintaining the drug supply chain and uninterrupted provision of
ART to women during pregnancy and breastfeeding will be crucial. Additionally, strong support
to women for continuous adherence to the regimen and retention in care and treatment after the
perinatal and breastfeeding period needs to be assured.
Key questions and monitoring and evaluation needs for Option B+
While there are important potential programmatic advantages as well as health benefits to the
Option B+ approach, there are also many important unanswered questions and an urgent need for
careful monitoring and evaluation. Key questions include:
• Acceptability: How acceptable to women who would not otherwise be taking ART is
early treatment for the purposes of prevention of HIV transmission to partners and
infants when the clinical benefit to the woman herself is possible but unconfirmed?
• Adherence: To what extent are women adherent to the regimen throughout the MTCT
risk period, and do they continue to be adherent after the MTCT risk period?
• Retention: How many women remain in care and treatment after the PMTCT period?
• Service delivery: Can non-physician providers (e.g. nurses) provide ART on a large
scale in MCH settings?
• Logistics: What is required to assure a reliable supply chain of ART and to avoid
stock-outs?
• Monitoring: What are the appropriate strategies for clinical monitoring of response to
treatment (including CD4 testing and, potentially, measurement of viral load)?
• Safety: What new evidence can be provided on the safety of EFV and TDF during
pregnancy and breastfeeding? The most reliable data will come from well-supported,
prospective pharmacovigilance registries.
• Effectiveness for PMTCT: What is the impact of this intervention on MTCT rates
(both early transmission, at six weeks, and overall rates, at the end of breastfeeding,
and on HIV-free survival?
• Effect on the mother's health: What are the benefits to maternal health in women with
high CD4 counts?
• Effectiveness for decreasing sexual transmission: What is the amount of benefit for
serodiscordant couples in terms of increased prevention of sexual transmission of
HIV and at the population level if a ‘treatment as prevention’ strategy is
implemented?
• Cost and cost-benefit: What are the costs and cost-benefit of this approach?
• Equity: What is the impact of this approach on the ability of the country programme
to serve other adults in need of ART?
43. 12
PMTCT Implementation
After the release of the Rapid Advice and the 2010 PMTCT ARV guidelines, regions and
countries moved quickly to adapt and update their guidelines. In general, in lower prevalence
settings and in settings with more developed infrastructure, Option B was chosen. High-burden
countries, particularly in sub-Saharan Africa, have favoured Option A, driven in large part by
concerns about the increased drug cost of Option B and the lack of capacity to delivery triple
ARVs in the MNCH care setting, and a desire for continuity with existing approaches. However,
many of these countries are reassessing their initial choice based on programme experience and
the rapidly changing context. Both low-prevalence and high-prevalence countries are moving
towards Option B, and a number of countries are considering Option B+. More mature
programmes (e.g. Botswana) and lower prevalence countries in West Africa have tended to
choose Option B. Table 3 provides a list of 22 priority countries and national PMTCT policies
as of end of 2011.
Table 3. The 22 priority countries for the Global Elimination Plan, the PMTCT national policy chosen as of
the end 2011, and current considerations
Country
ANC HIV
Prevalence
high (>15%)
medium (5-15%)
low (<5%))
PMTCT option
chosen at the End of
2011
Updates on PMTCT option, March 2012
(if changed from end of 2011)
Angola Low B
Botswana* High B
Burundi Low B
Cameroon Low A
Chad Low ?
Côte d'Ivoire Low B
DRC Low A
Ethiopia Low A
Ghana Low B
India* Low A Moving to B
Kenya Medium A Considering B+
Lesotho High A
Malawi* Medium B+ Implementing B+
Mozambique High A
Namibia High A
Nigeria Low A and B
South Africa* High A Considering B+
Swaziland High A
Tanzania* Medium A
Uganda* Medium A Considering B+
Zambia* Medium A Considering B+ but funding/human
resource issues
Zimbabwe* High A
* Countries with sites enrolling into PROMISE. Botswana is conducting P1077HS protocol, all other countries
are conducting P1077BF and/or FF protocols.
44. 13
Summary
Option B and Option B+ have a number of benefits in addition to PMTCT that might make either
of them a preferred option in some settings. These additional benefits include the following:
Implementation may be easier and more effective in areas where the availability of
CD4 assays is limited.
These options assure that women who present in ANC in need of treatment for their
own health receive appropriate ART without delay.
The same ARV regimen is administered to all pregnant women and continued during
pregnancy, labour and postpartum.
The regimen may be able to be harmonized with those recommended for ART in non-
pregnant individuals.
A triple ARV regimen may improve a woman’s health (for women with higher CD4
counts) while she is taking it.
With good adherence and maintenance of viral suppression, the triple ARV regimens
may reduce sexual transmission of HIV to sexual partners.
Despite these important advantages, which are now motivating some countries to move towards
Option B or B+, there are still complex public health considerations for resource-limited
countries. These include the limited availability of antiretroviral drugs; costs and health system
burden; weighing the benefits of starting pregnant women on ART early against the risks of
ARV drug toxicity to the mother and fetus/infant; issues related to adherence, resistance, ART
failure and the availability of future treatment options; as well as assuring treatment for all
individuals who meet current treatment guidelines.
Countries are in various stages of national PMTCT scale-up, have varying burdens of HIV
infection and have different MCH infrastructure, resources and support from external partners.
Countries with limited resources will ultimately have to determine how to best use ARVs and
allocate resources for those who need treatment for their own health and to maximize the
effectiveness of their PMTCT programmes.
WHO is not changing its 2010 PMTCT recommendations at this time, but with their interim
program update (WHO Program Update April 2012) note that the Option B and the new Option B+
strategy may be able to link treatment and prevention on a large scale. Countries that are
successfully implementing Option A and achieving their goals towards elimination were not told
to plan an immediate change to Option B. However, WHO encouraged all countries, including
those implementing Option A, to reassess their own situations in light of the changing
understanding of benefits and uncertainties of the different options and approaches. They also
noted that further data on feasibility, impact and cost-effectiveness, as well as better
pharmacovigilance data to determine the safety of first-line regimens during pregnancy and
breastfeeding, are needed to better inform country decision-makers.
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