Analysis

How evidence based are public health policies for prevention of mother to child transmission of HIV?

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3763 (Published 20 June 2013) Cite this as: BMJ 2013;346:f3763
  1. Philippe Van de Perre, professor 123,
  2. Thorkild Tylleskär, professor4,
  3. Jean-François Delfraissy, professor5,
  4. Nicolas Nagot, researcher123
  1. 1INSERM U 1058 (Infection by HIV and by agents with mucocutaneous tropism: from pathogenesis to prevention), 34394 Montpellier, France
  2. 2Université Montpellier 1, 34090 Montpellier, France
  3. 3CHU Montpellier, Département de Bactériologie-Virologie et Département d’Information Médicale, 34295 Montpellier, France
  4. 4Centre for International Health, University of Bergen, 5020 Bergen, Norway
  5. 5Agence Nationale de Recherches sur le Sida et les Hépatites Virales, Paris, France
  1. Correspondence to: P Van de Perre p-van_de_perre{at}chu-montpellier.fr

WHO is due to issue new guidelines on preventing transmission of HIV from mother to child at the end of June. Philippe Van de Perre and colleagues argue that recommendations have gone ahead of the evidence and call for a more cautious approach

Most public health authorities use recommendations formulated by United Nations agencies when they renew or update national public health guidelines. UN recommendations thus affect the lives of millions of people worldwide and should be based on robust scientific evidence, but that is not always the case. The World Health Organization’s recommendations for the prevention of mother to child transmission of HIV have long been a source of debate, and this has intensified with the forthcoming guidelines expected to advocate lifelong antiretroviral treatment for all HIV infected women, regardless of CD4 count.1 In this article, we discuss WHO’s arguments for adopting this strategy and the concerns we have.

Background of WHO recommendations

WHO has been issuing guidelines for the prevention of mother to child transmission of HIV since the mid-90s, as good evidence has emerged from trials. In 1994, a trial showed that giving zidovudine to selected HIV-1 infected women from the earliest stages of pregnancy with intravenous infusion during labour and delivery, and to their babies, reduced mother to child transmission by nearly two thirds.2 The US rapidly translated this good news into public health recommendations and WHO followed suit shortly after.3 4 However, most health professionals in low resource settings thought the strategy was not feasible and wanted to know whether a short course of oral zidovudine given to mothers during pregnancy and delivery and to exposed newborns would be effective.

By the end of the decade, randomised trials provided compelling evidence that perinatal antiretroviral prophylaxis in mothers and their neonates with zidovudine, nevirapine, or a combination …

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