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Previous Volume 351:217-228 July 15, 2004 Number 3 Next

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ABSTRACT

Background Although zidovudine prophylaxis decreases the rate of transmission of the human immunodeficiency virus (HIV) type 1 substantially, a large number of infants still become infected. We hypothesized that the administration, in addition to zidovudine, of a single dose of oral nevirapine to mothers during labor and to neonates would further reduce transmission of HIV.

Methods We conducted a randomized, double-blind trial of three treatment regimens in Thai women who were receiving zidovudine therapy during the third trimester of pregnancy. In one group, mothers and infants received a single dose of nevirapine (nevirapine–nevirapine regimen); in another, mothers and infants received nevirapine and placebo, respectively (nevirapine–placebo regimen); and in the last, mothers and infants received placebo (placebo–placebo regimen). The infants also received one week of zidovudine therapy and were formula-fed. The end point of the study was infection with HIV in the infants, established by virologic testing.

Results Between January 15, 2001, and February 28, 2003, a total of 1844 Thai women were enrolled. At the first interim analysis, the independent data monitoring committee stopped enrollment in the placebo–placebo group. Among women who delivered before the interim analysis, the as-randomized Kaplan–Meier estimates of the transmission rates were 1.1 percent (95 percent confidence interval, 0.3 to 2.2) in the nevirapine–nevirapine group and 6.3 percent (95 percent confidence interval, 3.8 to 8.9) in the placebo–placebo group (P<0.001). The final per-protocol transmission rate in the nevirapine–nevirapine group, 1.9 percent (95 percent confidence interval, 0.9 to 3.0), was not significantly inferior to the rate in the nevirapine–placebo group (2.8 percent; 95 percent confidence interval, 1.5 to 4.1). Nevirapine had an effect within subgroups defined by known risk factors such as viral load and CD4 count. No serious adverse effects were associated with nevirapine therapy.

Conclusions A single dose of nevirapine to the mother, with or without a dose of nevirapine to the infant, added to oral zidovudine prophylaxis starting at 28 weeks' gestation, is highly effective in reducing mother-to-child transmission of HIV.

Source Information

From Epidémiologie Clinique, Santé Maternelle et Infantile et Sida, Institut de Recherche pour le Développement, Paris (M.L., G.J., S.L., N.N.-G.-H.); the Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston (M.L., G.J., N.N.-G.-H.); Institut National d'Etudes Démographiques, Paris (S.L.); INSERM, Erm 0321, Paris (J.Y.M.); the Family Health Research Center, Mahidol University, Bangkok, Thailand (S. Koetsawang); the Ministry of Public Health, Bangkok, Thailand (S. Kanshana, V.T.); and Children's Hospital and the Department of Pediatrics, Harvard Medical School — both in Boston (K.M.).

Address reprint requests to Dr. Lallemant at the Perinatal HIV Prevention Trial — Institut de Recherche pour le Développement, Unité 54, 29/7-8 Samlan Rd., Soi 1 Prasing Muang, Chiang Mai 50200, Thailand, or at marc{at}phpt.org.

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