Use of Post‐Natal Antiretroviral Prophylaxis for Prevention of Mother‐to‐Child Transmission of HIV Is Increasing in Italy

To the Editor—Decreasing use and duration of post-natal antiretroviral prophylaxis in infants born to human immunodeficiency virus (HIV)-positive mothers in Europe, with a South to North gradient, have been recently reported, possibly reflecting concerns over the safety of the prophylaxis [1]. Attitude toward the use of combined post-natal prophylaxis (CPP) with 2 or 3 antiretroviral drugs was not analyzed [1]. We would like to report data from a study involving 3670 infants born to HIV type 1 (HIV-1)-infected mothers from 1998 through 2008, who were enrolled in the Italian Register for HIV Infection in Children from birth, with an ascertained infectious status. Fifty-seven infants (1.5%) had received CPP. Details regarding data collection and status definitions have been described elsewhere [2]. In contrast to the results of England et al [1], decreasing use of post-natal prophylaxis over time was not evident in our cohort (both considering any type of course or courses ⩾6 weeks), despite a partial overlap of patients between the 2 cohorts [3] (Table 1). Conversely, we observed an increase in the use of CPP over time (Table 1). A logistic regression analysis was performed to assess factors associated with receipt of CPP with 2 or 3 drugs, considering antenatal antiretroviral use, mode of delivery, birth period, prematurity, maternal viral load, and CD4+T lymphocyte count (retained on the basis of Akaike's Information Criterion). Maternal detectable viral load at delivery (adjusted odds ratio [aOR], 4.35; 95% confidence interval [CI], 1.66–11.42; P=.003), lack of antenatal antiretroviral prophylaxis (aOR, 5.28; 95% CI, 1.21–26.00; P=.027), and birth period after 2001 (aOR, 4.06; 95% CI, 1.14–14.44; P=.030) were significantly associated with the use of CPP. CPP was well tolerated in all infants. In logistic regression analysis (considering sex, antenatal antiretroviral use, mode of delivery, period of delivery, prematurity, maternal viral load, and CD4+T lymphocyte count), no significantly different transmission rate was evidenced between children receiving a 6-week course of zidovudine and those receiving CPP (P=.459). However, considering the subgroup of children who were at high transmission risk (no antenatal therapy and no elective Caesarean delivery), a trend toward a lower transmission rate was observed (1 [11.1%] of 9 infants receiving CPP vs 19 [21.1%] of 90 infants receiving only a 6-week zidovudine course; P=.486). Use of Antenatal and Postnatal Prophylaxis and Rates of Mother-to-Child Transmission of Human Immunodeficiency Virus (HIV), by Birth Period CPP has been proposed for use in high-risk infants in Western countries [4–6]. Concerns include possible increased toxicity and occurrence of viral resistance in infected infants [4]. The greatest efficacy of CPP in preventing mother-to-child transmission of HIV-1, compared with monoprophylaxis, is not proven [4–7]. In conclusion, our data do not confirm a decrease in the use of neonatal prophylaxis in infants born to HIV-1-infected mothers in Italy. In contrast, an increase in the use of CPP was documented. CPP was well tolerated and might be a reasonable option in high-risk infants. This approach was also considered to be the most rational in a recent United Kingdom consensus statement [6]. Unfortunately, in our study, no data were available regarding the occurrence of viral mutations in HIV-infected children, and we lacked the statistical power to assess the effectiveness of different regimens in high-risk infants. Larger collaborative studies are needed to evaluate the effectiveness of CPP in the prevention of mother-to-child transmission of HIV in high-risk infants. Luigina Boscardini (Viterbo); Rosalia Da Riol (Udine); Letizia Cristiano (Taranto); Stefania Bernardi; Orazio Genovese, Anna Maria Casadei (Roma); Elisa Anastasio (Catanzaro); Antonietta Giannattasio, Luigi Tarallo (Napoli); Alessandra Vigano, Filippo Salvini, Rita Lipreri (Milano); Amelia Romano; Ernesto Dalle Nogare (Palermo); Anna Maccabruni (Pavia); Carlo Giaquinto (Padova); Danilo Cosso, Elisabetta Bondi, Raffaella Rosso (Genova); Antonio Mazza (Trento); Antonio Pellegatta (Varese); Maurizio Dedoni (Cagliari); Domenico Larovere (Bari); Francesco Baldi; Giacomo Faldella; Massimo Masi; Matilde Ciccia (Bologna); Icilio Dodi (Parma); Fortunati Paolo (Verona); Marco Rabusin (Trieste); Michele Quercia (Bari); Maurizio Ruggeri (Bergamo); Luisa Abbagnato (Como); Patrizia Osimani (Ancona); Raffaele Badolato (Brescia); Rita Consolini (Pisa); Elisa Fiumana (Ferrara); Carlo Amoretti (Imola); Leonardo Felici (Pesaro); Antonia Aliffi (Catania). Potential conflicts of interest. All authors: no conflicts.