Temporal Reduction of HIV Type 1 Viral Load in Breast Milk by Single-Dose Nevirapine during Prevention of MTCT

Short-course zidovudine (ZDV) with or without a single dose of nevirapine (sdNVP) is widely used to prevent mother-to-child HIV transmission (PMTCT). However, more data on viral load in breast milk following pMTCT regimens are needed. In a randomized PMTCT study in Botswana, in which half of the women received sdNVP in labor, stored samples from mothers assigned to breastfeed were analyzed for HIV-1 RNA in breast milk supernatant. A total of 527 samples from 282 women, collected at delivery, 2 weeks, 2 months, and 5 months postpartum were available for testing. Cell-free breast milk HIV-1 RNA was detectable (>40 copies/ml) in 44.8% (236/527) of samples analyzed. Women randomized to sdNVP + ZDV were more likely to have undetectable breast milk viral loads at 2 weeks postpartum compared with those who received ZDV alone (67.8% vs. 38.5%, p = 0.002). By 2 months postpartum the difference between study arms disappeared, and 43.8% of women who received sdNVP + ZDV had undetectable HIV-1 RNA compared to 53.8% of the ZDV alone group (p = 0.19) and 60.5% vs. 64.5%, respectively, at month 5 (p = 0.61.) The addition of sdNVP to antenatal short-course AZT resulted in significantly reduced breast milk viral loads at 2 weeks postpartum suggesting a reduced risk of MTCT during the early postpartum period. However, viral loads in both study arms were comparable at 2 and 5 months postpartum, suggesting that the receipt of sdNVP in labor may defer rather than blunt the postpartum viral load rebound seen in breast milk after the discontinuation of ZDV