Coyarmment and lopinavir/ritonavir). The authors found that pathogen-specific COMMENTARY: BEYOND PREVENTION OF IgG levels were similar at entry and declined similarly by deliv- VERTICAL HIV TRANSMISSION—IMPROVING ery in both arms, suggesting no impact of ART on maternal sero- OUTCOMES OF HIV-UNINFECTED INFANTS BORN protection. However, the cord blood levels—reflecting placentally Divya Bharathi TO MOTHERS WITH HIV INFECTION transferred IgG—for rotavirus and measles (but not pneumococcal) IgGs were higher in the ART arm. Furthermore, in multivariable George K. Siberry, MD, MPH PIDJ analysis, after adjustment for maternal total IgG and pathogen- Accepted for publication November 28, 2017. specific IgG levels, maternal ART use was associated with signifi- From the Office of the U.S. Global AIDS Coordinator (S/GAC), U.S. Department cantly higher levels of cord blood measles and pneumococcal sero- PIDJ-217-974 of State, Washington, DC. type IgGs and with a trend (P = 0.06) for higher level of cord blood The author has no funding or conflicts of interest to disclose. rotavirus IgG. In short, maternal ART in late pregnancy appeared Address for correspondence: George K. Siberry, MD, MPH, 1800 G Street NW, Washington, DC. E-mail: firstname.lastname@example.org. Beyond Prevention of Vertical HIV TransmissionSiberry to be more effective than zidovudine alone in enhancing the trans- Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. placental transfer of pathogen-specific IgG to HEU infants even DOI: 10.1097/INF.0000000000001854 though there was no evidence of increased maternal levels of these specific antibodies. Higher levels of maternally derived pathogen-specific anti- bodies play a major role in protecting infants against pneumonia Pediatr Infect Dis J IV infection in pregnant women in Africa is associated with and other infectious illnesses in the first months of life, before Hpoorer health and survival outcomes for their children, includ- immunizations can provide full protection. Thus, the current policy Lippincott Williams & Wilkins ing their children who were spared HIV infection. Such HIV- and programmatic efforts to ensure that all pregnant women with exposed but uninfected (HEU) infants fare better than their peers HIV receive ART to protect women’s health and prevent infant HIV with HIV infection but experience higher rates of morbidity and Hagerstown, MD infection will likely also improve the protection against infectious mortality than infants born to women without HIV infection, or disease morbidity in the first months of life of their HEU infants. HIV-unexposed and uninfected infants. In particular, HEU infants With successful prevention of HIV infection in infants, the num- XXX suffer higher rates and more severe episodes of pneumonia and ber of infants with HIV infection is already dwarfed by the num- other infectious illnesses in the first few months of life because ber of HEU infants, highlighting the importance of learning how to 1,2 of encapsulated bacteria and other common pediatric pathogens. improve the health outcomes of this growing population of children. Factors that have been linked to higher risk of infectious disease We still have a lot of work to do to optimize maternal ART and death in HEU infants infectious disease and death include and other interventions to further reduce the number of infants advanced maternal HIV disease, lack of maternal antiretroviral infected perinatally and throughout the breastfeeding period. It will (ARV) treatment, preterm delivery and lack of exclusive infant also be important to develop further evidence that effective mater- breastfeeding (often as a strategy to reduce infant HIV transmission nal ART—including the use of newer ARV regimens—continues risk). However, potential biologic and psychosocial mechanisms to reduce the differences between HEU and HIV-unexposed and underlying such associations are complex and incompletely under- uninfected infants in survival, in infectious disease morbidity and stood. Furthermore, while routine ARV therapy (ART) for pregnant in other important health outcomes such as growth and neurodevel- women with HIV infection dramatically reduces the risk of vertical opment. As we strive to get women with HIV started on ART even HIV transmission and improves women’s health status, it is less before conception, it will be critical to understand how such early clear how and to what extent maternal ART may reverse biologic 0891-3668 treatment might enhance the type of beneficial effect reported by effects linked to poorer health outcomes in HEU infants. Bosire et al while ensuring that we also understand the potential In this issue of Pediatric Infectious Disease Journal, Bosire increase in undesirable outcomes such as preterm delivery. 10.1097/INF.0000000000001854 et al present an elegant analysis that advances our understanding of how maternal ART may mediate more robust immunoprotec- REFERENCES tion against infectious disease in the first months of life in HEU 1. Desmonde S, Goetghebuer T, Thorne C, et al. Health and survival of HIV The Pediatric Infectious Disease Journal infants. The authors measured total immunoglobulin G (IgG) and perinatally exposed but uninfected children born to HIV-infected mothers. Curr Opin HIV AIDS. 2016;11:465–476. IgG specific to several common pathogens (measles, rotavirus and 2. Slogrove AL, Esser MM, Cotton MF, et al. A prospective cohort study of 37 virulent pneumococcal serotypes) in women during pregnancy and common childhood infections in South African HIV-exposed uninfected and at delivery as well as in cord blood, using stored specimens from HIV-unexposed infants. Pediatr Infect Dis J. 2017;36:e38–e44. Kenyan participants in the Kesho Bora trial (2013–2015). In this 3 3. Bosire RK, Farquhar C, Nduati, et al. Higher transplacental pathogen- trial, pregnant women with HIV and CD4 counts of 200–500 were specific antibody transfer among pregnant women randomized to triple randomized in late pregnancy (28–36 weeks’ gestation) to receive antiretroviral treatment versus short course zidovudine. Pediatri Infect Dis zidovudine alone or ART (composed of zidovudine, lamivudine J. 2018. March The Pediatric Infectious Disease Journal • Volume 37, Number 3, March 2018 www.pidj.com | 245 Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Pediatric Infectious Disease Journal – Wolters Kluwer Health
Published: Mar 1, 2018
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