Journal of Infection (2014) 69, S56eS62

www.elsevierhealth.com/journals/jinf

Mother to child transmission of HIV: What

works and how much is enough?
Jennifer Stevens, Hermione Lyall*

St Mary’s Hospital, Praed Street, London W2 1NY, UK

Accepted 18 July 2014

Available online 17 October 2014

KEYWORDS Summary In 2012, 3.3 million children were living with HIV (Human Immunodeficiency virus),
HIV; of whom 260,000 were new infections. Prevention of mother to child transmission is vital in
Mother; reducing HIV-related child mortality and morbidity. With intervention the risk of transmission
Child; can be as low as 1% and without it, as high as 45%. The WHO (World Health Organisation) rec-
Transmission; ommends a programmatic approach to the prevention of perinatal HIV transmission and has
Prevention; withdrawn option A and introduced option Bþ. This recommends that all HIV positive pregnant
Perinatal; and breastfeeding women receive lifelong triple ARV (antiretroviral) from the point of diag-
Pregnancy; nosis. The infant would then receive 4e6 weeks of ART (antiretroviral therapy) (NVP, nevira-
Anti-retroviral therapy pine or AZT, Zidovudine) regardless of the feeding method. Where resources are not limited
an individualised approach can be adopted. Worldwide, health care needs to be accessible
and HIV testing performed in pregnancy and followed up in a robust but socially sensitive
way so that treatment can be initiated appropriately. In either setting the risk of transmission
is never zero and countries need to decide for themselves what is the most practical and sus-
tainable approach for their setting, so that the maximum impact on maternal and child mor-
tality and morbidity can be achieved.
ª 2014 Published by Elsevier Ltd on behalf of The British Infection Association.

The global picture children were newly infected with HIV in these countries
in 2012.1 Children living with HIV in low and middle income
countries, eligible for ART are less likely than adults to
It is estimated that 35.3 million people are living with HIV
receive it, with ART coverage being 34% for children and
worldwide, with 25 million living in sub-saharan Africa.1 3.3
64% for adults in 2012.2 Prevention of mother to child trans-
million children are living with HIV, of whom 260,000 were
mission is key to reducing the HIV-related child mortality
new infections in 2012.1 In the 22 priority countries in the
and morbidity (see Table 1).
Global Plan, coverage of ART amongst pregnant women
living with HIV reached 62% and approximately 230,000

* Corresponding author. Tel.: þ44 0203 3121013.

E-mail addresses: stevensjae@hotmail.com (J. Stevens), Hermione.lyall@imperial.nhs.uk (H. Lyall).

http://dx.doi.org/10.1016/j.jinf.2014.07.018
0163-4453/ª 2014 Published by Elsevier Ltd on behalf of The British Infection Association.
Mother to child transmission of HIV S57

Table 1 WHO recommendations for prevention of mother to child transmission 2012.

Woman receives: Infant receives:
Treatment (for CD4 count  350 cells/mm ) Prophylaxis (for CD4 count > 350
3

cells/mm3)
Option Aa Triple ARVs starting as soon as diagnosed, Antepartum: AZT starting as early as 14 Daily NVP from birth
continued for life weeks gestation until 1 week after
Intrapartum: at onset of labour, single-dose cessation of all
NVP and first dose of AZT/3TC breastfeeding; or, if not
Postpartum: daily AZT/3TC through 7 days breastfeeding or if
postpartum mother is on treatment,
through age 4e6 weeks
Option Ba Same initial ARVs for bothb: Daily NVP or AZT from
Triple ARVs starting as soon as diagnosed, Triple ARVs starting as early as 14 weeks birth through age 4e6
continued for life gestation and continued intrapartum and weeks regardless of
through childbirth if not breastfeeding or infant feeding method
until 1 week after cessation of all
breastfeeding
Option Bþ Same for treatment and prophylaxisb: Daily NVP or AZT from
Regardless of CD4 count, triple ARVs starting as soon as diagnosed,c continued for life birth through age 4e6
weeks regardless of
infant feeding method
From UNICEF. Options B and Bþ: key considerations for countries to implement an equity-focussed approach. Eliminating new HIV
infections among children and keeping mothers living with HIV alive and well; July 2012.5
Note: “Triple ARVs” refers to the use of one of the recommended 3-drug fully suppressive treatment options. For the drug abbreviations
in the table: AZT (azidothymidine, zidovudine [ZDV]); NVP (nevirapine); 3TC (lamivudine).
a
Recommended in WHO 2010 PMTCT guidelines; single dose NVP and AZT þ 3TC intrapartum and postpartum tail can be omitted if the
mother received more than 4 weeks of AZT during pregnancy; in this case continue maternal AZT twice daily during labour and stop at
delivery.
b
True only for EFV-based first-line ART; NVP-based ART not recommended for prophylaxis (CD4 >350).
c
Formal recommendations for Option Bþ have not been made, but presumably ART would start at diagnosis.

Without intervention the risk of MTCT (mother to child
transmission) ranges from 20 to 45%.3 In non-breastfeeding
populations, with specific interventions the risk of MTCT
can be as low as less than 1% and as low as 2e5% in breast-
feeding populations.4 Target 3 of the United Nations
Programme on HIV/AIDS (UNAIDS) goals for 2015 is to elim-
inate new HIV infections amongst children by 90% and to
substantially reduce AIDS related maternal deaths by
50%.3,5 The millennium development goal 4 is to reduce
the under 5 mortality by two thirds by 2015.4 Goal 5 aims
to reduce maternal mortality by three quarters and have
universal access to reproductive health by 2015.6 Millen-
nium Goal 6 aims for the number of new HIV infections to
have halved by 2015 and for there to be universal access
to treatment by 2010.4 In the context of the UNAIDS goals
and the millennium development goals we are in a critical
position to assess current progress and recommit to
advance our success in tackling this issue both on national
and international levels.
In 2011 the countries with the lowest estimated
coverage of the most effective regimen were North Africa
and the middle east (9%), west and central Africa (26%) and
East, South and South east Asia (20%).7 This compares with
Europe and central Asia (95%) and sub-Saharan Africa
(58%).7 There has been a steady decline of 24% in MTCT in
sub-Saharan Africa from 2009e2011.7 There were modest
declines in the Caribbean and Oceania, with North Africa
and the Middle East yet to show any decline.7 However
different countries will have different priorities depending
on the nature of their epidemic. For example, the Western
Pacific, South East Asia and the Americas focus on the dual
elimination of HIV and congenital syphilis, whereas Eastern
Europe targets the IV drug users and their partners as a pri-
ority population for improving PMTCT (prevention of
mother to child transmission).4 In 2010 the Pan American
Health Organisation and UNICEF (United Nation’s Interna-
tional Children’s Emergency Fund) developed strategies
for the advancement of elimination of MTCT of HIV and
congenital syphilis.6 The aim was to reduce new paediatric
cases of HIV to 0.3 per 1000 live births and to reduce
congenital syphilis to 0.5 cases per 1000 live births by pro-
moting the integration of HIV, sexual and reproductive
health, paediatric, family and community health services.6
It aims to ensure that women have access to rapid diagnos-
tics for both HIV and syphilis and to treatments and moni-
toring. Studies in nine European countries found that HIV
prevalence in women IVDU (intravenous drug users) was
50% higher than among male IVDU.8 MTCT was also found
to be 42% higher in this female group when compared to
HIV positive mothers who were not drug users, in the
Ukraine.8 One step towards combating this problem is the
integration of antenatal services with drug treatment
services.8
So whilst data showing downwards trends is encouraging
we need to ensure that all pregnant women living with HIV
have safe and simple access to ART, with prime focus on
those living in the hardest to reach settings. This refers to
both the difficult to reach geographical and social
S58
environments (ie. marginalised populations). This, coupled
with fragile health care systems heightens the vulnerability
of these women and increases the risks that they are
exposed to, which in turn, impact upon their children. The
answer is multi-faceted but requires flexible, practical and
innovative solutions.
Timing of mother to child transmission
MTCT occurs as a continuum across three time periods; in-
utero (10%), perinatal (15%) and postnatally through
breastfeeding (10%) [3]. Maternal risk factors include;
plasma viral load, CD4 count and the stage of HIV disease.
The risk of transmission ranges from 1% with a viral load of
less than 400 to 32% with a viral load of 100,000.9 At deliv-
ery risk factors include: mode of delivery, premature deliv-
ery, duration of membrane rupture and infection in the
birth canal.9 Post natal risk factors include mixed feeding
and mastitis.9 Interventions for MTCT can be targeted to
these three time periods and can either take a program-
matic or individualised approach (Fig. 1).
Preventative interventions need to be considered within
the context of the environment of the mothereinfant pair.
In resource poor settings, cessation of breastfeeding is
deemed unsafe as the risks of gastroenteritis and malnu-
trition from early weaning outweigh the risk of transmission
of HIV. Termination of breastfeeding before 6 months of
age increases the risk of gastro-enteritis and associated
morbidity and mortality as well as increasing the risk of
malnutrition in the absence of safe and nutritious feeding
alternatives.10 Recent randomised controlled studies have
demonstrated the low risk of breast milk transmission
Figure 1 MCT rates in diagnosed women in UK and Ireland 2000e2011. From Townsend CL, Byrne L, Cortina-Borja M, Thorne C, de
Ruiter A, Lyall H, Taylor GP, Peckham CS, Tookey P. Earlier initiation of ART and further decline in mother to child transmission
rates 2000e2011. AIDS, 2014;28 (7):1049e57.22
J. Stevens, H. Lyall
where the mother is on ART, or the infant is on pre-
exposure prophylaxis.10,11 Therefore in such settings PMTCT
programmes should be designed around breastfeeding
which is the most appropriate way to safely feed infants.10
The combined effect of maternal ART and infant post
exposure prophylaxis has been adopted into programmes in
Africa to reduce MTCT, and so despite breastfeeding the
risk of transmission is 1e2%, this compares to the UK where
the risk of transmission is as low as 0.1% with maternal ART
and formula feeding.
The programmatic approach
The three main objectives of the WHO in their 2010e2015
PMTCT strategic vision is to accelerate global and national
scale-up of effective and comprehensive PMTCT services, to
improve the quality and demonstrate the public health
impact of PMTCT services and to strengthen the linkages
between maternal, newborn and child health services,
reproductive health services and HIV related services to
reduce overall maternal and child mortality.4
The WHO emphasizes the importance of all HIV infected
women having access to life-long treatment if they are
clinically or immunologically eligible for it. For those
pregnant women who did not require it for their own health
there were two options; A and B, see Table (Table 2).4 In
2010 a further option, Bþ was introduced which advocates
life-long treatment for all HIV positive pregnant or breast-
feeding women, irrespective of their clinical stage or CD4
count.4,5
In June 2013, WHO issued new guidance which now
excludes option A and recommends one simplified triple
Mother to child transmission of HIV S59

Table 2 BHIVA recommendations for ART in pregnancy 2012.

Mother requires ART for
herself
Nucleoside backbone
Zidovudine/lamivudine
Abacavir/lamivudine
Tenofavir/emtricitabine
Third agent
Efavirenz or Nevirapine
OR boosted protease
inhibitor
Special considerations
Darunavir needs twice
daily dosing.
Consider 3rd trimester
TDM if on tenofovir and
atazanavir.
From British HIV association guidelines for the management of HIV infection in pregnant women, 2012. HIV Med 2012;13
(Suppl. 2):87e157.11
Mother requires ART for
PMTCT only
Commence by 24 weeks
gestation
Nucleoside backbone
Zidovudine/lamivudine
Abacavir/lamivudine
Tenofavir/emtricitabine
Third agent
Preferably boosted PI
Special considerations
Zidovudine
monotherapy þ C-section if
VL < 10,000 þ CD4>350
Start ART by week 14 if
VL > 30,000
Start earlier if >100,000
Late presenter not on ART Elite controllers
Commence ART CD4>350, VL < 50:
immediately if > 28weeks Zidovudine monotherapy or
gestation ART.
VL > 100,000/unknown use
raltegravir in 3 or 4 drug
regimen.
Presenting in term labour:
stat dose
Nevirapine þ zidovudine,
lamivudine and raltegravir.
If in preterm labour
consider double dose
tenofavir to further load
baby, especially if unable to
feed.

regimen for all pregnant women irrespective of their CD4
count (option Bþ), this would then continue lifelong for all
or just for those who meet the eligibility criteria (option
B).12 This decision was made on the evidence that whilst tri-
als have shown similar efficacy between Option A and B, the
complexities of the former have hindered the up-scaling of
PMTCT in many low-resource countries.12 Countries have
to make a programmatic choice between ‘option B’ and
‘Bþ’, as there is not yet the evidence to detail the overall
impact of lifelong treatment in this scenario.12 Countries
that have the capacity to monitor CD4 count, with concen-
trated epidemics and where the option of alternative
feeding is safe, option B may still be considered (Table 1).12
This WHO programmatic update 2012, suggests that
option B and specifically Bþ are preferable over option
A.13 Both B and Bþ start women on a triple ARV regimen
which carries more assurance that those eligible for treat-
ment will get a fully suppressive regimen. The ability to
use the same regimen for ART and PMTCT simplifies drug
forecasting, procurement, supply and stock monitoring
and is less confusing for the women.13 Option Bþ has
several advantages such as not requiring CD4 counts to
determine eligibility for ART or to decide whether or
when to stop once the risk of MTCT is over.5,13 It also offers
protection for future pregnancies by remaining on ART from
conception as well as offering ongoing protection to sero-
discordant couples.5,13 Early treatment before women
meet the immunological or clinical criteria for ART would
have an advantageous affect on their health (65% reduced
risk of contracting TB whilst on ART irrespective of CD4
count7) and may reduce drug resistance if they are not
starting and stopping ART regularly, especially in areas of
high birth rates.9 It also reinforces the message that ART
is intended for lifelong treatment and therefore may
improve compliance.9
Feedback from the field
Results from Malawi where option Bþ has been imple-
mented since the third quarter of 2011, show that there has
been a dramatic increase in the number of new ART
initiations in pregnant women from the 4th quarter of
2011 through to 2012. Numbers rose from 1 new initiation
per quarter (5% of all new initiations) to 11 per quarter
(35%).7 Of those who initiated ART in the third quarter of
2011 77% remained on treatment, of the 23% that discontin-
ued; 94% were lost to follow-up, 3% died and 3% decided to
stop treatment.14 ART and PMTCT programmes were com-
bined and administered by nurses at primary health facil-
ities where women and children were already accessing
health care; helping to target the hard to reach areas and
reducing stigma.5 This could in turn encourage compliance
and adherence. So revising the national guidelines, moni-
toring and evaluation systems, the supply chain and human

Table 3 BHIVA recommendations for stopping ART postpartum 2012.

Clinical scenario Duration of treatment
AIDS defining illness/CD4 <350 Continue as per adult treatment guidelines
CD4 count 350e500 þ co-infection with Hepatitis B or C Continue as per adult treatment guidelines
CD4 count 350e500 Continue as per adult treatment guidelines
CD4 count >500 þ no discordance þ no hepatitis co-infection Discontinue treatment
From British HIV association guidelines for the management of HIV infection in pregnant women, 2012. HIV Med 2012;13
(Suppl. 2):87e157.11
S60
resources strategies they made significant steps in
providing an effective, equitable service with a broad
health impact.5
Cost
The WHO anticipate B and Bþ to be more cost effective
than A, as first line once daily regimens are less costly now.5
The regimen recommended is Tenofavir, lamivudine or em-
tricitabine and efavirenz, (for ART and PMTCT). It is avail-
able as a single pill, fixed-dose combination and currently
costs $180 per year with declines anticipated.13 Recent
pharmacokinetic data is reassuring on the use of efavirenz
in pregnancy but continued pharmacovigilence is essential.
Simple regimens are needed for the best chance of
success.15
Early concerns
However, option Bþ does raise questions around how to
guarantee long term adherence, retention in treatment,
safe transition to HIV care from antenatal care, develop-
ment of drug resistance, increased drug exposure to the
foetus and newborn, sustainability of service delivery in
fragile primary care settings and the ongoing acceptability
to women.13 Continued application and reflection of and on
this programme will in time reveal resolutions to these
questions.
Infant feeding
The 2010 guidelines for infant feeding have not changed in
the updated WHO 2013 guideline document.12 In countries
where breastfeeding with the mother on ART and the infant
receiving prophylaxis is considered the safest approach to
ensuring survival of the newborn, mothers should exclu-
sively breastfeed for the first 6 months of life and continue
breastfeeding through weaning until 12 months of life.12
They can stop when a safe alternative is guaranteed after
this age.12
The individualised approach
The UK and Ireland adopt an individualised approach to
PMTCT, but it is not without its own complications and the
risk of MTCT still is not totally eliminated. Reasons for this
are drug resistance, poor maternal adherence to treat-
ment, late presenters in pregnancy and sero-conversion in
pregnancy. Tables 2 and 3 give details of the British HIV As-
sociation guidelines for the individualised management of
HIV in pregnancy.11
In the UK and Ireland, from 2005 onwards more than 95%
of women living with HIV are diagnosed antenatally through
universal antenatal screening.15 This compares to a 30%
antenatal diagnosis in the early 90s. Over the last 14 years,
a higher proportion of women are being diagnosed before
their current pregnancy rather than during it.15 Plus, a
higher proportion of women are on ART at conception due
to a prior diagnosis rather than being HIV positive but not
on ART at conception.16
J. Stevens, H. Lyall
With an individualised approach MTCT rates in UK and
Ireland have also shown a steady decline over the last 11
years to 0.5% overall in 2010e2011 (Fig. 1).15
If the HIV test is declined at antenatal screening it
should be offered at subsequent visits and if still declined
at delivery, the infant should be tested at birth.11 For those
late bookers or those un-booked in labour a point of care
test should be offered. A rapid result, if positive, enables
initiation of intrapartum ART, infant PEP (post-exposure
prophylaxis), avoidance of breastfeeding and infant co-
trimoxazole prophylaxis (whilst awaiting the infant HIV
diagnostic results).11
Baseline resistance testing should be undertaken before
starting ART. Vaginal delivery is the preferred delivery
option if the viral load is undetectable (<50 copies/ml) by
36 weeks.11
Timing of PMTCT
Wade et al. published a cohort study in 1998 which looked
at the use of zidovudine monotherapy at different time
points in the peripartum spectrum.17 No prophylaxis car-
ried a transmission rate of 26%, ZDV given antepartum
had a rate of 6%, whilst intrapartum and postpartum pro-
phylaxis had a rate of 10%.17 Postpartum prophylaxis
within 48 h had a rate of 9% whereas after 72 h or more
the rate was 18.4%.17 This highlights that even if interven-
tions can only be achieved intra or postpartum reduction
in transmission can still occur, but by more than 72 h after
birth treatment is not likely to be effective. However, the
high risk infant can still be offered PJP (pneumocystis jir-
oveci) prophylaxis, until HIV diagnostic tests are
completed.
When choosing ART regimens for pregnant women
during delivery it is important to choose drugs which cross
the placenta and load up the infant for delivery and for
the first 7 days of life. For example single dose nevirapine
has a half life of 7 days in the neonate and raltegravir has
a half life of 2 days. By contrast the protease inhibitors
cross the placenta very poorly. The PANNA (Pharmacoki-
netics of newly developed Antiretrovial agents in HIV-
infected pregnant women) study is collecting pharmaco-
kinetic data for anti-retrovirals used in pregnancy.18 Data
so far is variable for the different classes, NRTIs have the
highest plasma:cord ratio as well as raltegravir, with
values around 1.0.18 This is of particular importance in
premature infants who cannot feed orally and would
benefit from in-utero loading. The only drugs that are
licensed for neonates are zidovudine, lamivudine and ne-
virapine, although there are small pharmaco-kinetic
studies of others.11
Monotherapy or combination therapy for neonatal
prophylaxis?
Over that last 13 years there has been an increasing trend in
the use of combination therapy over monotherapy for
neonatal prophylaxis, as represented in this graph lifted
from the EPPIC study, 2013.19
In a randomised controlled trial for PEP infants born to
mothers who did not have treatment in pregnancy,
Mother to child transmission of HIV
Nielson-Saines et al., 2012 have shown that perinatal
MTCT rates halved when 2 or 3 drug regimen was used
intrapartum compared to zidovudine monotherapy (after
excluding in-utero transmission).10 In this study infant
combination therapy with ZDV and NVP was equally effec-
tive as triple therapy with Nelfinavir, lamivudine and zido-
vudine.16 However it is important to point out that
Nelfinavir is very poorly absorbed by neonates and is no
longer available.
The EPPICC study, an observational cohort analysis of
5285 mothereinfant pairs showed an increase in risk of
MTCT of 2.29 times without infant prophylaxis but it did not
show any benefit of combination therapy over monother-
apy.17 27.7% had no antenatal or intrapartum antiretroviral
prophylaxis, 17.3% had only intrapartum prophylaxis and
55% of mothers had a detectable viral load at delivery
despite antenatal antiretroviral prophylaxis.5 Neonatal pro-
phylaxis was administered to 87.5% and of these 23.9%
received combined prophylaxis. Those who received com-
bined therapy were in the higher risk group for MTCT.5
This has to be considered when interpreting the results.
Crude MTCT rates for Western Europe were 3.4%, 6.3%
and 17.7% for one drug, combination therapy and no
neonatal prophylaxis respectively.17
Caesarean section
The European mode of delivery randomised controlled
study 1999, showed that pre-labour elective caesarean
section reduced the MTCT rate from 10% to 9% (vaginal
delivery and emergency caesarean section respectively) to
2%.20 This was pre ART in women with detectable viral loads
and shows that this isolated intervention can have a signif-
icant impact. Data from the UK and Ireland from 2006 has
shown that viral load has the greatest impact on MTCT,
with an undetectable viral load (<50 copies/ml) having a
transmission rate of 0.1%. This compares to a transmission
rate of 0.7% in cases treated with ART and elective
caesarean section but a higher viral load.21
Conclusion
Mother to child transmission is preventable whether you
use an individualised or programmatic approach. The
preference for either is multi-factorial and has to be
considered within the context of the country of implemen-
tation. Sustainability, practicality and the ability to follow
women up are important influencing factors. Countries
need to ensure availability of HIV testing in pregnancy; that
this is taken up and that appropriate interventions are
complied with so that extremely low rates of transmission
may be achieved. However, the risk is never 0% and women
do need to be aware of this. Inaccessible or weak family
planning services, stigma and discrimination impede access
to services and these areas require attention to see
change. Women living with HIV should be empowered to
partnership and leadership in devising and delivering
programmes for women and children of the current and
future generations.
S61
Conflict of interest
The authors have no conflict of interest to report.
References
1. UNAIDS global report on the global AIDS epidemic 2013. Joint
United Nations programme on HIV/AIDS (UNAIDS ).
2. Towards and AIDS-free generation children and AIDS sixth
stocktaking report 2013. Joint United Nations programme on
HIV/AIDS (UNAIDS).
3. UNAIDS Joint United Nations programme on HIV/AIDS, women
out loud; 2012.
4. WHO. Prevention of mother to child transmission. strategic
vision 2010 e 2015. Preventing mother-to-child transmission
of HIV to reach the UNGASS and millennium development goals.
5. UNICEF. Options B and Bþ: key considerations for countries to
implement an equity-focussed approach. Eliminating new HIV
infections among children and keeping mothers living with HIV
alive and well; July 2012.
6. Pan American Health Organisation. 2010 situation analysis:
elimination of mother-to-child transmission of HIV and
congenital syphilis in the Americas.
7. UNAIDS global report on the global AIDS epidemic; 2012.
8. United Nations office on drugs and crime. Delivering HIV ser-
vices to pregnant drug users in low resource settings.
9. Cooper ER, Charurat M, Burns DN, Blattner W, Hoff R. Trends in
antiretroviral therapy and mother-infant transmission of HIV.
The Women and Infants Transmission Study Group. J Acquir Im-
mune Defic Syndr. 2000 May 1;24(1):45e7. <http://www.
ncbi.nlm.nih.gov/pubmed/10877494>.
10. McIntyre J. Use of anti-retrovirals during pregnancy and
breastfeeding in low-income and middle-income countries.
Curr Opin HIV AIDS 2010 January 5;(1):48e53.
11. British HIV Association guidelines for the management of HIV
infection in pregnant women, 2012. HIV Med 2012;13(Suppl. 2):
87e157.
12. WHO. Consolidated guidelines on the use of antiretroviral
drugs for treating and preventing HIV infection. Recommenda-
tions for a public health approach; June 2013.
13. WHO. Programmatic update. Use of anti-retroviral drugs for
treating pregnant women and preventing HIV in infants. Exec-
utive summary; April 2012.
14. Centre for communicable disease. Morbidity and mortality weekly
report; Impact of an innovative approach to prevent mother-to-
child transmission of HIV. Malawi July 2011eSeptember 2012,
vol. 62; March 1, 2013. p. 148e51.
15. National study of HIV in pregnancy and childhood (NSHPC). Ob-
stetric and paediatric surveillance data from the UK and
Ireland; 2011.
16. Nielsen-Saines K, Watts DH, Veloso VG, Bryson YJ, Joao EC,
Pilotto JH, et al. Three postpartum anti-retroviral regimens
to prevent intrapartum HIV infection. N Engl J Med 2012;
366:2368e79.
17. Wade NA, Birkhead GS, Warren BL, Charbonneau TT,
French PT, Wang L, et al. Abbreviated regimens of Zidovudine
prophylaxis and perinatal transmission of the human immuno-
deficiency virus. N. Engl J Med 1998;339:1409e14.
18. PANNA; www.pannastudy.com.
19. Chiappini E, Galli L, Giaquinto C, Ene L, Goetghebuer T,
Judd A, et al. Use of combination neonatal prophylaxis for
the prevention of mother-to-child transmission of HIV in Euro-
pean high-risk infants. For the European pregnancy and paedi-
atric HIV cohort collaboration (EPPIC) study group in
EuroCoord. AIDS 2013;27:991e1000.
S62
20. European mode of delivery collaboration 1999; elective
caesarean-section versus vaginal delivery in prevention of ver-
tical HIV-1 transmission: a randomised clinical trial. Lancet
1999;353:1035e9.
21. Townsend CL, Cortina-Borja M, Peckham CS, de Ruiter A, Lyall H,
Tookey PA, et al. Low rates of mother to child transmission of HIV
J. Stevens, H. Lyall
following effective pregnancy interventions in the UK and
Ireland 2000e2006. AIDS 2008;22(8):973e81.
22. Townsend CL, Byrne L, Cortina-Borja M, Thorne C, de Ruiter A,
Lyall H, et al. Earlier initiation of ART and further decline in
mother to child transmission rates 2000e2011. AIDS 2014;
28(7):1049e57.