Joan Robinson is correct in pointing out the discrepancy between the Canadian consensus guidelines for the management of pregnancy, labour and delivery and for postpartum care in HIV-positive women and their offspring1 and the CDC guidelines for prophylaxis after needle-stick exposure.2 However, the issue of how best to manage infants born to HIV-positive women who probably have incompletely suppressed plasma viral load at term requires further study. We attempted to develop evidence-based guidelines, and currently there are good data supporting the use of zidovudine and nevirapine in the infant; hence our recommendation. Other approaches, such as the use of more extensive combination therapies in the infant, may eventually prove helpful in specific high-risk situations, but at present, in our opinion, there is insufficient safety or efficacy data to warrant such a recommendation.
It is noteworthy that the CDC guidelines for the management of occupational exposure2 are based largely on expert opinion, with very limited supporting data. It is also noteworthy that, with respect to this issue, the US Public Health Service Task Force guidelines for prevention of perinatal HIV transmission3 are identical with the Canadian consensus guidelines.1 With the currently recommended approach, vertical transmission of HIV has been reduced from about 25% to less than 1%.4 Although it would clearly be desirable to improve further on these results, we believe that an evidence-based approach is imperative in any such efforts, especially given the increasing concerns about the safety of these medications.
More research is needed into the precise role of and optimal approach to the infant component of perinatal prophylaxis for HIV infection. However, until more data become available, we remain comfortable with the current recommendations.
David R. Burdge Deborah M. Money John C. Forbes Oak Tree Clinic Children's and Women's Health Centre of British Columbia University of British Columbia Vancouver, BC Lindy M. Samson Division of Infectious Diseases Department of Pediatrics Children's Hospital of Eastern Ontario Ottawa, Ont. Sharon L. Walmsley Division of Infectious Diseases Department of Medicine Toronto Hospital University Health Network Toronto, Ont. On behalf of the Canadian HIV Trials Network Working Group on Vertical HIV Transmission
Footnotes
-
Competing interests: David Burdge, Deborah Money, John Forbes and Sharon Walmsley have all received speaker fees and/or educational grants from various pharmaceutical companies manufacturing drugs mentioned in the original article. Burdge, Forbes and Walmsley have received travel assistance from various pharmaceutical companies to attend meetings within the past 2 years. No competing interests were declared for Lindy Samson.
References
- 1.
- 2.
- 3.
- 4.