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April 21, 2015

Infant HIV-1 Vaccines: Supplementing Strategies to Reduce Maternal-Child Transmission

Author Affiliations
  • 1Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
  • 2Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina
JAMA. 2015;313(15):1513-1514. doi:10.1001/jama.2015.1382

Despite the success of maternal antiretroviral therapy (ART) to prevent mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1), more than 200 000 children continue to acquire HIV-1 annually. Infants account for roughly 10% of new HIV-1 infections globally despite making up less than 2% of the world’s population. Moreover, the decline in infant HIV-1 acquisition with implementation of wide-scale maternal-infant ART prophylaxis has not been as steep as predicted, and efforts will not meet the World Health Organization goal to eliminate mother-to-child transmission by 2015. This slow decline in infant HIV-1 infections is partly due to suboptimal coverage at each step of the ART “prevention cascade” (Figure). Yet even if the goal of 90% ART coverage can be achieved, it is estimated that 138 000 infants will still become infected with HIV-1 annually1 because of several situations in which maternal ART prophylaxis is ineffective, including maternal late presentation for care, nonadherence, and acute maternal infection during breastfeeding. In low- and middle-income countries, only half of pregnant women attend the recommended 4 prenatal visits. Late initiation of ART results in high rates of mother-to-child transmission, with one South African study reporting a tripling of transmission rates in pregnant women who received less than 4 weeks of ART prior to delivery compared with women who received 16 to 32 weeks of treatment.2 Furthermore, a high number of women disengage from care after childbirth (Figure), leaving infants vulnerable to HIV-1 infection. Also of great concern is the increasing incidence of HIV-1 infection in young women; an estimated 620 000 women aged 15 to 49 years from areas of high HIV-1 prevalence acquired HIV-1 in 2013. Acute HIV-1 infection among mothers accounts for up to 34% of mother-to-child transmission3 and will not be curbed by maternal ART-based strategies. Because of these established gaps in the prevention of mother-to-child transmission, there is a critical need to develop safe, feasible supplemental strategies to be used with the current ART-based strategies, such as a universal infant HIV-1 vaccine.

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