UKZN’s Emeritus Professor Remains World Expert on Vertical Transmission Prevention of HIV from Mother to Child
Emeritus Professor in Paediatrics, Professor Anna Coutsoudis, was recently invited by the European AIDS Clinical Society to attend its 19th European AIDS Conference in Warsaw to present a paper on the challenges faced in South Africa with respect to breastfeeding for mothers infected with HIV.
Coutsoudis, together with the late Emeritus Professor Hoosen (Jerry) Coovadia and Dr Nigel Rollins, produced a groundbreaking study in 2007 which found that exclusive breastfeeding for all children up to six months old significantly reduced the transmission of HIV from mother to child. This finding resulted in the review of global health policies.
The World Health Organization (WHO), United Nations Children’s Fund, Joint United Nations Programme on HIV and AIDS, and many countries including South Africa adopted the new health policy on exclusive breastfeeding for children up to the age of 6 months. Coutsoudis said the conference presented her with the opportunity to share success stories from South Africa in terms of exclusive breastfeeding and adherence of mothers to antiretroviral drugs during breastfeeding. ‘This was very pertinent for the European AIDS society as they, and other Western countries, are currently re-considering their very strict guidelines which discourages breastfeeding for mothers infected with HIV,’ said Coutsoudis.
At the end of the conference, she was invited by Professor Aleksandra Wesolowska, Head of the Laboratory of Human Milk and Lactation Research at the Medical University of Warsaw, to visit their institute and present a workshop on learning from South African experiences to help shape the guidelines for HIV positive mothers in Poland who choose to breastfeed. The University is working closely with the Ministry of Health to develop guidelines and support mechanisms for breastfeeding mothers.
Discussions also ensued around a groundbreaking change in policy by the South African health ministry. In 2000, WHO guidelines recommended that all HIV exposed breastfeeding infants should receive daily prophylaxis with an antibiotic, cotrimoxazole (CTX) from 6 weeks of age until 6 weeks after cessation of breastfeeding. Coutsoudis said, ‘For the past 10 years, I have been a member of the WHO Cotrimoxazole Prophylaxis Guideline Development Group and have voiced concern about the dangers of antibiotic resistance and the influence of antibiotics on the gut of infants but WHO was waiting for more evidence before it could change the guidelines.’
Through scholarship funding for postdoctoral fellows, Coutsoudis was able to initiate a study to examine whether there was indeed any benefit of CTX in this present time with all the other interventions already on board to improve infant’s health. The studies were undertaken by Dr Brodie Daniels (the study co-PI); Dr Eshia Moodley-Govender; Dr Helen Mulol and Dr Beth Spooner (PhD student).
Moodley-Govender, together with colleagues from the University of Washington, examined the impact of the antibiotic on the infant’s gut microbiome and its impact on antibiotic resistance, using state of art microbiome analysis work whilst a similar study was conducted in Botswana which confirmed the South African results which showed conclusively that CTX prophylaxis to children who are HIV exposed but uninfected does not reduce mortality or morbidity.
Despite strong evidence of lack of benefit of CTX prophylaxis, the WHO decided in their 2021 guideline group meeting that no clear changes to their policy would be made. Daniels and the team wrote an article highlighting the fact that the finalisation of the 2021 guidelines did not include ethical and public health considerations. Coutsoudis commented, ‘This was particularly problematic for South Africa because of the high numbers of infants born to HIV infected mothers (HIV-exposed infants-HEU). Approximately 310 000 (190 000 to 400 000) infants annually in South Africa would receive a drug with no benefit and several potential harms, with obvious costs to the health service.’
Coutsoudis and her research team advocated to the national Department of Health’s Technical Working Group for Prevention of Mother-Child HIV Transmission (PMTCT) to reconsider the policy, at least for South Africa. After examining the evidence, the working group was ecstatic to find no benefit of CTX to infants who are HEU, and acknowledged that instead, there are harms due to increased antibiotic resistance and microbiome disruption.
These new guidelines for CTX prophylaxis in South Africa now clearly state that:
• Infants who are HIV-exposed are not eligible for routine CTX prophylaxis.
• CTX prophylaxis is reserved for infants with confirmed HIV infection to be used in conjunction with suitable antiretroviral regimens.
Coutsoudis thanked the Department of Health for making this bold change to policy. She said, ‘The Department of Health is to be congratulated on these prudent changes to the guidelines. Complete discontinuation of the CTX prophylaxis programme for all those who are not HIV infected will free up resources spent on procuring, transporting, storing, and administering CTX which could rather be channeled towards other strategies with proven reduced risk of infectious disease morbidity in HEUs namely, access to early HIV diagnosis of infants, linkage to care for infants and children living with HIV, improved maternal health, and continued support for child health services that are of benefit regardless of HIV status such as immunisations and breastfeeding support. Importantly, it will remove the burden from mothers of daily administration of an unnecessary drug to the infant.’
Words: MaryAnn Francis