South African Study Recommends Changes to WHO Regulations on PMTCT

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The World Health Organization’s (WHO) guidelines on Prevention of Mother to Child Transmission (PMTCT) recommends that all HIV exposed uninfected infants (HEUs) born to HIV positive mothers receive cotrimoxazole (CTX) prophylaxis, commencing at four to six weeks of age and continuing until HIV infection can be excluded. A recent study by UKZN and the South African Medical Research Council (SAMRC) recommends changing these guidelines, which would result in global policy changes in the management of HEUs.

Emeritus Professor Anna Coutsoudis of the Department of Paediatrics and Child Health said: ‘The results of our study are exciting and will facilitate a change in the WHO and our own country’s guidelines with regard to the treatment of HEUs. The results indicate that there is no benefit in administering daily CTX to HEU breastfed infants, whose mothers are accessing a PMTCT programme and adhering to lifelong Antiretroviral Therapy (ART) in a non-malaria area. We therefore recommend that it is removed from the PMTCT programme in non-malaria countries.’

The study was conducted over five years from 2013 to 2018 at the Lancers Road and Cato Manor clinics in Durban. The city is regarded as the epicentre of the HIV epidemic. A cohort of 1219 HEUs were enrolled, with 611 receiving CTX and 608 not receiving it. All the participants, who included 653 male and 566 female HEUs were healthy, breastfeeding infants born to HIV positive mothers that were actively involved in PMTCT follow-up. The infants were HIV negative prior to the six-week enrollment visit and were followed up until 12 months of age.

Interestingly, a sub-study that examined the microbiome of infants found that those taking CTX prophylaxis had significantly higher resistance gene abundance than infants not taking CTX prophylaxis. Furthermore, infants taking CTX had decreased inter-individual microbiome diversity. These alterations to the microbiome are considered to be unfavourable and may have negative health impacts.

Coutsoudis added: ‘The findings on the increased resistance to CTX are serious since some evidence exists that CTX resistance coincides with resistance to other important antibiotics used during childhood for common illnesses. Since antibiotic resistance is a growing threat, and since the study showed that CTX prophylaxis increases antibiotic resistance genes while showing no clinical benefit for HEU infants in non-malaria countries, these data reiterate the call to revise the current CTX guidelines for HEU infants when mothers are actively receiving ART.

‘The other benefits of removing CTX as a routine treatment for HEUs include cost savings, a reduction in poor health among the infants and a likely increase in their quality of life. We believe that CTX prophylaxis should not be started in HEUs that have a negative HIV test at birth and whose mothers are receiving and adherent to lifelong ART.’

Words: MaryAnn Francis

Photograph: Supplied