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Mother-to-Child Transmission of HIV: Pathogenesis,

Mechanisms and Pathways

Article  in  Clinics in perinatology · December 2010

DOI: 10.1016/j.clp.2010.08.004 · Source: PubMed

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M o t h e r- t o - C h i l d
Tra n s m i s s i o n o f H I V:
Pathogenesis,
Mechanisms
and Pathways
a,b, c,d
Athena P. Kourtis, MD, PhD, MPH *, Marc Bulterys, MD, PhD

KEYWORDS

Human immunodeficiency virus
Mother-to-child transmission

Infant
Mechanisms

Without doubt, one of the greatest medical and public health achievements has
been the significant reduction in mother-to-child transmission (MTCT) of human
immunodeficiency virus (HIV), especially in the developed world. Transmission rates
lower than 1% to 2% have been achieved,1,2 even in some resource-limited
settings,3 compared with transmission rates of 14% to 42% without any interven-
tion.4 This has been achieved with the use of antiretroviral drug combinations during
pregnancy, labor/delivery, and neonatal prophylaxis, as well as with elective
caesarean delivery and avoidance of breast feeding. Modalities to prevent
mother-to-child transmission of HIV are highly dependent on the timing and mech-
anisms of HIV transmission. The mechanisms and timing of MTCT of HIV, however,
have not been fully elucidated, are likely multifactorial, and many of their aspects
remain unclear.

The findings and conclusions in this article are those of the authors and do not necessarily
represent the views of the Centers for Disease Control and Prevention.
a
Division of Reproductive Health, National Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS-K34,
Atlanta, GA 30341, USA
b
Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
c
Division of HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention,
Atlanta, GA 30333, USA
d
CDC Global AIDS Program, China, Suite #403, Dongwai Diplomatic Office, 23 Dongzhimenwai
Dajie, Beijing, China
* Corresponding author. Division of Reproductive Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford
Highway, NE, MS-K34, Atlanta, GA 30341.
E-mail address: [email protected]

Clin Perinatol 37 (2010) 721–737

doi:10.1016/j.clp.2010.08.004 perinatology.theclinics.com
0095-5108/10/$ – see front matter. Published by Elsevier Inc.
722 Kourtis & Bulterys

TIMING AND MECHANISMS OF MTCT OF HIV

MTCT can occur:

In utero by direct hematogenous transplacental spread or ascending infection of

the amniotic membranes and fluid
At the time of delivery by mucocutaneous contact of the infant with maternal blood,
amniotic fluid, and cervicovaginal secretions during passage through the birth
canal; ascending infection from the cervix; or maternal–fetal transfusion from
uterine contractions at labor and delivery
During breastfeeding.

There is not complete concurrence about the relative contribution of these different
periods in transmission of HIV to the infant.5 Approximately one-third of infant HIV
infections in nonbreastfeeding populations are detected in the first 2 days of life,
and two-thirds are detected after the first week of life and by 6 weeks of age, leading
some to argue that one-third of transmission occurs during pregnancy and the remain-
ing two thirds during labor in nonbreastfeeding populations.6–8 Indeed, the working
definition of in utero versus intrapartum HIV infection is based on virologic detection
of infection in the infant’s first 2 days of life versus after the first week.6 By synthesizing
results from many prevention studies using antiretroviral agents at various stages
during pregnancy, as well as the preventive benefits of cesarean section when per-
formed before the onset of labor,9 the authors have argued that approximately one-
half of MTCT of HIV occurs late in pregnancy, possibly in the days before delivery,
as the placenta begins to separate from the uterine wall.10 Only a small proportion
of MTCT (<4%) seems to occur in the first trimester,11 and less than 20% by 36 weeks
of gestation.10 Indeed, several studies using highly sensitive polymerase chain reac-
tion PCR techniques have found very little or no HIV positivity in lymphoid tissues of
first or second trimester human fetuses.12–14 A large study with twins did not find
that the birth order of twins was associated with risk for HIV-1 infection,15 supporting
the idea that birth canal exposure is not the major contributor to the baby’s risk; the
authors believe that about one-third of MTCT occurs during delivery.10
Postexposure infant prophylaxis, through administration of antiretroviral drugs to
the infant within hours of birth, protects against cell-free or cell-associated virus
that might have obtained access to the fetal/infant systemic circulation through
maternal–fetal transfusion or through systemic dissemination of virus swallowed by
the infant during passage through the birth canal.16 This approach likely provides
benefit when the virus remains unintegrated in quiescent cells.17,18 With the use of
a PCR that detects viral long terminal repeats (LTR) rather than gag, thus a partly
reverse-transcribed HIV-1 genome, it was found that about 18% of uninfected infants
born to HIV-1 infected mothers had evidence of unintegrated virus in their peripheral
blood mononuclear cells.18 The unintegrated viral intermediate is biologically active,
but in the absence of appropriate activation it decays with time.17 These findings
support the notion that HIV-1 might enter a fetus, but in the absence of appropriately
activated lymphocytes it might not integrate and establish infection until a later time, if
at all. Support for the efficacy of infant postexposure prophylaxis also comes from
studies in macaques.19 If indeed HIV-1 cannot complete reverse transcription until
cell activation occurs, then viral entry might not equal transmission, which arguably
occurs only at the time of viral integration and thus the establishment of infection.
Accepting this premise, most instances of MTCT must occur around the time of birth
(when extensive lymphocyte activation starts to occur), even though viral entry could
have occurred days or weeks earlier. Of interest, significant reduction in the in utero
 Mechanisms of Mother-to-Child Transmission of HIV-1 723

transmission rate of HIV-1 was shown when nevirapine at labor was added to a zido-
vudine regimen started at 28 weeks of gestation.2 An explanation for this is that peri-
natal nevirapine may delay infant PCR positivity or even prevent infection from virus
that entered the fetus during the last few weeks of gestation, a conclusion consistent
with the hypothesis presented.
Breast feeding is also a time of major risk for MTCT of HIV in settings where safe
feeding alternatives are not available. The postnatal transmission rate is estimated
to be as high as 15% if women engage in prolonged breast feeding of about 2
years.20–22 This represents a substantial proportion (over one-third) of MTCT of HIV,
and indeed the period of highest risk if antiretroviral prophylaxis is given during preg-
nancy and peripartum.5,23
It is believed that the risk of breast feeding transmission of HIV to the infant is higher
during early lactation because of increased breast milk viral load in colostrum. The risk,
however, continues throughout breast feeding and is associated with low maternal CD4
count, longer duration of breast feeding, higher maternal viral load, mastitis, and mixed
feeding.24–28 The Breastfeeding and HIV International Transmission meta-analysis
calculated the risk of postnatal HIV transmission after 4 weeks of age to be 8.9 trans-
missions per 100 child–years of breast feeding, with a generally constant rate of trans-
mission between 1 and 18 months of infant age.29 Maternal breast pathologies, such as
mastitis (including subclinical mastitis, identified through elevated breast milk sodium
levels), nipple lesions and breast abscess26,29 and infant oral candidiasis30 also have
been identified as risk factors for MTCT of HIV in the breastfed infant.

FACTORS INFLUENCING MTCT OF HIV

Many factors may influence the risk of MTCT of HIV (Box 1). The risk of HIV transmis-
sion is higher for mothers with clinical and immunologic indicators of advanced
disease, and with increased viral load.31,32

Viral Factors of MTCT of HIV

Amount of virus
A higher maternal viral RNA load in the peripheral blood is associated with a higher risk
of MTCT for HIV,1,33 with the risk increasing as viral load increases.34–36 However,
overlap in HIV RNA copy number has been observed in women who transmitted
and those who did not transmit the virus to their infants. Although the risk of transmis-
sion of HIV from mothers with peripheral blood viral loads below the limit of detection
is very low, no threshold of peripheral blood viral load has been identified below which
transmission does not occur.37 Receipt of highly active antiretroviral therapy by the
mothers, which decreases viral load, has achieved very low MTCT rates. Antiretroviral
drugs decrease maternal viral load in the blood and genital secretions when given
antenatally. However, this is not the only mechanism by which they exert their benefit.
Antiretroviral drugs have been shown to reduce the risk of transmission even among
women with HIV RNA levels less than 1000 copies/mL.38 Additionally, the level of HIV
RNA at delivery and receipt of antenatal antiretroviral therapy are each independently
associated with the risk of transmission, suggesting that antiretroviral prophylaxis
does not work solely through its effects in viral load.1,39 Primary maternal HIV infection
during pregnancy or postpartum in the nursing mother, associated with higher viral
load, is also associated with an increased risk of MTCT.11,40 Indeed, the observed
increase in MTCT of HIV when mothers had frequent unprotected sexual intercourse
during pregnancy might be related to increased risk of primary HIV infection during
724 Kourtis & Bulterys

Box 1
Factors influencing mother-to-child transmission of HIV
Viral factors
Viral load in plasma, genitourinary tract, breast milk
Viral characteristics: genotype, phenotype, tropism, resistance to antiretroviral agents, capacity
for immune escape
Host factors
Immunologic factors
Maternal CD4 count–stage of HIV disease
Maternal immune factors (such as neutralizing antibodies)
Breast milk immune factors
Fetal/neonatal immune response (such as cytotoxic lymphocyte [CTL] responses)
Genetic factors (fetal HLA type, maternal-fetal HLA concordance, single nucleotide
polymorphisms [SNPs] for chemokines/chemokine receptors/innate immune factors)
Tissue/mucosal integrity
Chorioamnionitis/placental pathology/maturational stage
Maternal genitourinary (GU) lesions/sexually transmitted diseases (STDs)
Cracked or bleeding nipples/breast abscess/clinical or subclinical mastitis
Barrier integrity (neonatal skin and mucosal membranes)
Infant gastrointestinal (GI) maturity
Vitamin A/other micronutrient deficiency
Obstetric factors
Mode of delivery
Timing of delivery
Invasive monitoring/obstetric procedures
Duration of membrane rupture

pregnancy, or to the acquisition of other STDs increasing HIV viral load in those
already infected with HIV.41,42
In addition to peripheral blood viral load, a higher maternal genital tract viral load is
independently associated with a higher risk of MTCT of HIV.29 However, intrapartum
cleansing of the genital canal with virucidal agents such as benzalkonium chloride (eval-
uated in a small study in West Africa),43 or 0.25% chlorhexidine (evaluated in Malawi),44
and 0.2% and 0.4% chlorhexidine (evaluated in Kenya)45,46 did not show a benefit in
decreasing MTCT of HIV. A trial of 1% chlorhexidine, thought to be the highest tolerated
concentration,47 has been proposed. The viral load of HIV in the breast milk of the
nursing mother is associated with risk of postnatal transmission to the infant.24

Type of virus
It is likely that transmitted HIV has an advantage in either crossing mucosal barriers,
infecting or replicating in target cells, or evading immune responses compared with
the nontransmitted variants.48 Most evidence supports restricted viral heterogeneity
in the blood near the time of infection in most infected infants, with only one or very
 Mechanisms of Mother-to-Child Transmission of HIV-1 725

few viral variants transmitted from mother to child.49,50 However, transmission of

multiple variants to infants also has been described.51–53 Transmission at the time
of delivery has been primarily associated with a single viral quasispecies,53–55 usually
a minor maternal variant,53 whereas in utero transmitters were more likely to transmit
single or multiple major maternal viral variants.51,53,56 The authors recently compared
the viral sequences from the blood and cervicovaginal fluid of three mothers who
transmitted HIV to their infants with those in their infants. Results indicate the presence
of more than one HIV variant in the neonate’s plasma that are derived from
the maternal blood and from the vaginal compartment, pointing to more than one
episode of transmission with more than one viral strain from different maternal
compartments.57 The authors’ findings also show transmission of cell-associated
maternal virus. This result concurs with those of several other studies, where higher
cell-associated HIV-1 DNA levels in blood and genital secretions or breast milk signif-
icantly increased risk of transmission to the infant.24,29,39,58–60 Even though early
studies of MTCT of HIV had identified plasma cell-free RNA viral load at delivery as
the most significant predictor of transmission,20,39,53 cell-free HIV-1 RNA in plasma
may only be a surrogate marker for the source of virus that is transmitted. Taken
together, the results of studies suggest that, in addition to levels of cell-free virus in
blood and genital secretions, cell-associated virus can independently predict vertical
transmission risk in utero, intrapartum, and via breast feeding.
HIV subtype differences in MTCT have been observed in some cohorts but not
others.48,60–64 Some have suggested that subtype C is preferentially transmitted in
utero compared with subtypes A and D.62 A predominance of CCR5 utilizing, macro-
phage-tropic, nonsyncytium-inducing viruses is noted in perinatal transmission.65
Restricted N-linked glycosylation of the infant viral envelopes (Env) compared with
the maternal Env is another characteristic of newly transmitted viruses.65,66 Most
studies have concentrated on the variable regions of the viral envelope surface protein
gp120, as this region defines viral tropism and contains major targets of the neutral-
izing antibody response. A study recently reported, however, that the replication
capacity of the polymerase gene from transmitting mothers was greater than that of
nontransmitters, suggesting that factors outside of the envelope may play a role in
transmission.67

Host Factors of MTCT of HIV

Immunologic factors
Innate immune parameters Chemokines, the natural ligands of viral coreceptors,
may inhibit HIV-1 infection; the b-chemokines CCL3, CCL4, and CCL5 are natural
ligands for CCR5, and their overexpression in exposed uninfected infants suggests
a possible role in mediating inhibition of MTCT.68 The role of a single strand poly-
morphism (or SNP) in the conserved 30 untranslated region of the cell-derived factor
–1 (SDF-1) gene, which encodes an a chemokine ligand of the CXCR4 viral corecep-
tor, is still unclear, as there are significant geographic and ethnic variations in the
frequency distributions of a and b chemokines and chemokine receptor
polymorphisms.69–71
Defensins are an important family of antimicrobial peptides in people, and they may
play a role in protection from HIV infection. In an Italian study, SNP –44G/G of b defen-
sin 1 seemed to protect against MTCT of HIV,72 and in a Brazilian study where this
SNP was rare, SNPs –52A/A and –20G/G were associated with a lower risk of
MTCT.73 Homozygosity for –550G/G, the SNP of mannose-binding protein MBL2,
which plays a role in activation of the complement pathway and in phagocytosis,
was associated with protection against MTCT of HIV.74
726 Kourtis & Bulterys

Adaptive immune parameters HIV-specific humoral and cellular immune responses

may be important in influencing MTCT. Early studies had shown that higher levels of
maternal HIV-specific immunoglobulin (Ig)-G did not protect against MTCT.11 Such
studies, however, did not measure neutralizing activity. Neutralizing antibodies in
maternal serum have been correlated with protection from perinatal HIV transmission
in some studies,75–77 but not others.77,78 Perinatally transmitted envelope variants
were found to be neutralization-resistant but with relatively few glycosylation sites,67
indicating that maternal neutralizing antibody imposes a selective pressure on the
transmitted virus. Interestingly, a lack of maternal autologous neutralizing antibody
has been associated with in utero but not intrapartum infection in some studies,78,79
indicating that immune protection may differ by the route of infection.
HIV-specific CTL responses have been detected in uninfected, HIV-exposed individ-
uals, including uninfected infants of HIV-infected mothers.80,81 Their role in viral clear-
ance and prevention of infection is not fully elucidated. HIV-specific immune responses
among uninfected infants born to HIV-infected mothers have been detected in several
cohorts, and in some of them they were associated with protection against transmis-
sion during delivery and breast feeding,82,83 but the significance of these responses
remains generally unclear.48,84 One study suggested that higher levels of suppressive
regulatory T cells were associated with HIV-specific immune responses among
exposed uninfected infants.85 Another study suggested that reduced maternal
immune activation was associated with HIV-1 specific cellular immune responses
among exposed uninfected children.86 The authors have found that infants whose
HIV PCR becomes positive after the first week of life have lower levels of plasma-
soluble L-selectin, and thus immune activation levels,87 suggesting that higher levels
of immune activation in the fetus and newborn promote HIV replication. Thus, higher
levels of immune activation may promote HIV transmission from mother to child.48
Breast milk contains a multitude of factors with antimicrobial and immunomodula-
tory properties, both innate and adaptive, that may modulate the risk of MTCT of
HIV. Such factors include lactoferrin, lysozyme, epidermal growth factor, interleukins,
defensins, chemokines, secretory leukocyte protease inhibitor, specific antibodies, as
well as T lymphocytes, NK cells and macrophages that may provide protection to the
infant via different mechanisms.88

Genetic factors
Strong associations between infant gender and in utero transmission have been
reported in several cohorts.11,89,90 Female infants have a two-fold increased risk of
infection at birth when compared with male infants, perhaps because in utero mortality
is higher for male HIV-1 infected infants or because the Y antigens, present in male but
not female fetuses, activate maternal lymphocytes and either cause release of cytokines
with anti-HIV effects or limit maternal HIV-infected lymphocyte survival in male infants.90
CCR5 is the coreceptor for R5-type isolates, predominantly transmitted from
mother to child.69 A 32 base pair deletion (D32) within the CCR5 coreceptor generates
a truncated protein that is not expressed on the cell surface, and D32 homozygosity
confers resistance to infection by R5-type HIV isolates.91 Mothers who transmit infec-
tion to D32 heterozygous infants have a significantly higher viral load than mothers
who transmit infection to wild-type homozygous infants.92
Antepartum transmission of HIV is unique in that it occurs in a setting where the child
shares at least half of his or her major histocompatibility (MHC) genes with the mother,
and while the mother tolerates the paternally-derived fetal histocompatibility mole-
cules. Antepartum MTCT is potentially related to HLA class 1 alleles of the MHC
because of their role both in determining maternal–infant compatibility and in regulating
 Mechanisms of Mother-to-Child Transmission of HIV-1 727

the CD8 T cell response to virally infected cells that results in either their killing or in the
production of factors that interfere with viral replication. In addition, HLA class 1 mole-
cules interact with natural killer cell receptors, a part of the innate immune system. The
HLA region includes 128 genes, and has considerable allele variation among individ-
uals. The breadth of HLA diversity is beneficial for the immunologic response.
The fetus or infant of an HIV-positive mother is exposed to both free HIV virions
and HIV-infected cells that display maternal MHC. Either fetal or newborn anti-
MHC antibodies or alloreactive T cell responses, resulting from HLA discordance,
could protect against infection from the mother. A higher risk of transmission has
been observed in infants whose class I HLA alleles more closely resembled their
mothers’, thus possibly limiting the effectiveness of infant immune responses against
HIV with a history of immune escape in the mother.48,78,93 In addition, maternal-infant
HLA concordance has been associated with clinical disease progression in HIV–
infected infants.94
Several studies suggest that HLA discordance and specific maternal HLA polymor-
phisms (such as B4901, B5301, A2/6802 and B18) are associated with a reduced risk
of MTCT, while others are associated with increased such risk.95–99 Certain
polymorphisms in chemokine receptors (CCR5–59356-T)100 and chemokine ligands
(SDF1–30 A)70 also have been associated with MTCT in African populations. The
HLA-G molecule is of particular interest, as it is a nonclassical MHC class 1 molecule
highly expressed in the placental trophoblasts at the maternal–fetal interface. HLA-G
has several SNPs that have been associated with a decreased risk of perinatal HIV
infection.98 The field of host genomics and associations with susceptibility to HIV
infection and with rate of disease progression is rapidly expanding as the means to
study the human genome have been revolutionized.

Tissue and mucosal integrity: placenta, infant skin and GI tract, maternal GU tract
and breast pathology
Detection of HIV in the placenta does not correlate with infant infection.101,102 As
placental morphology changes during gestation, it is possible that placental cells
with different susceptibility to HIV infection may appear at different times, and thus
the degree of risk of HIV infection of the placenta may differ throughout gestation.
Virus transmission also might occur by passage of cell-free virus through the placental
barrier. Maternal infections associated with chorioamnionitis could perturb the integ-
rity of the placental barrier. If the placental membranes of an HIV-infected woman have
a bacterial infection, maternal white blood cells infected with HIV could enter the amni-
otic fluid, resulting in chorioamnionitis. Chorioamnionitis and funisitis have been asso-
ciated with an increased risk of MTCT.103,104 A randomized, placebo-controlled trial of
antibiotic treatment during pregnancy to prevent chorioamnionitis-associated MTCT
of HIV was discontinued after interim analyses suggested no effect, however.105 Cho-
rioamnionitis also can mediate premature delivery and premature rupture of the
membranes, both factors associated with a higher risk of MTCT of HIV.106 A contrib-
uting factor in the case of a premature infant is the immaturity of his or her skin and
mucosal membranes, resulting in higher permeability to HIV.
Inflammation of the maternal genital tract mucosa, as occurs in genital ulcer
disease, has been shown to increase MTCT of HIV independent of maternal plasma
HIV load,29 and a clinical diagnosis of herpes simplex type 2 infection during preg-
nancy increased MTCT of HIV in several studies.19,107,108 Genital lesions increase local
inflammation and genital shedding of HIV.11
A study showed a marked correlation of maternal vitamin A deficiency with elevated
risk of MTCT of HIV in Africa.109 This observation led to a study investigating vitamin A
728 Kourtis & Bulterys

supplementation to decrease MTCT of HIV. Four such studies have been

completed.110–113 Collectively, these studies showed no benefit of vitamin A supple-
mentation in decreasing MTCT of HIV, with the study from Tanzania showing an
increased risk.112 Other data suggest that deficiencies of other micronutrients (such
as selenium) may be associated with increased risk of MTCT, through increased
genital shedding of HIV and mastitis.114,115 A recent study from Tanzania indicated
a higher risk of MTCT of HIV, perinatally and through breast feeding, in women with
low vitamin D level.116 Vitamin D has immunomodulatory properties and contributes
to the development of the fetal immune system, mechanisms possibly mediating
the observed effect.
With regards to breastfeeding transmission of HIV to the infant, integrity of the
infant’s GI mucosa may be an important factor in determining transmission, and
breaches to such integrity when inflammation occurs may facilitate passage of
HIV.22 Similarly, oral candidiasis in the infant has been associated with increased
risk of postnatal HIV transmission.30 Mastitis and elevated sodium-to-potassium ratio
in breast milk, thought to be a marker of subclinical mastitis, is associated with higher
risk of HIV transmission to the infant, with an increased risk as the mother’s plasma
HIV load increases.117

Obstetric Factors
Although several studies have noted an increased rate of MTCT with preterm delivery,
it remains unclear whether preterm delivery is a result or cause of HIV infection.118–121
Prolonged rupture of the amniotic membranes before delivery can increase MTCT of
HIV.119,122–124 In an analysis of 4271 deliveries with duration of ruptured membranes of
24 hours of less (vaginal deliveries as well as cesarean deliveries after ruptured
membranes or onset of labor), the risk of MTCT of HIV increased approximately 2%
with an increase of 1 hour in the duration of ruptured membranes.125 Amniocentesis
is linked to increased risk of MTCT, as are use of scalp electrodes, forceps, and
vacuum extractors during birth.126,127
Elective cesarean section prior to onset of labor and rupture of the amniotic
membranes has been shown in clinical trials to decrease risk of MTCT of
HIV.9,34,128,129 Potential mechanisms include avoidance of microtransfusions of
maternal blood to the fetus during labor contractions and of direct contact of the
fetus’s skin and mucosal membranes with infected secretions or blood in the maternal
genital canal. An individual patient data meta-analysis incorporating data from 8533
mother–infant pairs showed that the likelihood of MTCT of HIV was approximately
87% lower if a cesarean section was performed before labor and delivery and if anti-
retroviral therapy was provided antepartum, intrapartum, and postpartum, as
compared with other modes of delivery and the absence of such therapy.125

THE ROLE OF COINFECTIONS: CYTOMEGALOVIRUS, HUMAN HERPESVIRUS,

HEPATITIS B AND C, MALARIA, TUBERCULOSIS

The role of other systemic maternal infections influencing MTCT of HIV is unclear.
HIV-infected mothers seem to transmit human herpesvirus (HHV)-6, cytomegalovirus
(CMV), and hepatitis B and C to their babies more frequently than uninfected
women.130–132 MTCT of HIV appears to be more frequent among newborns with
congenital CMV infection.133 A study of perinatally HIV-infected infants from Thailand
showed that the rates of HHV-6 infection were lower in HIV-infected children, but that
HHV-6 coinfection correlated with faster progression of HIV disease.134
 Mechanisms of Mother-to-Child Transmission of HIV-1 729

Malaria infects the placenta and leads to adverse pregnancy outcomes.135 This is
especially true in primigravidae, among whom malaria tends to be more severe.136,137
Several earlier studies have failed to reveal an interaction between malaria and MTCT
of HIV.135,138 More recent data, however, indicate that malaria increases HIV load, and
treatment of malaria reduces HIV load.139 A few recent studies have suggested an
increased risk of MTCT of HIV in pregnant women with malaria,140–142 while others
have not shown a significantly increased risk.137,143,144 In a study in Western Kenya
of women who were dually infected with HIV-1 and malaria, higher parasitemia levels
(>10,000 parasites/mL of blood) were associated with an increased risk of MTCT of HIV
compared to lower levels of parasitemia.145 Inconsistencies in study results may be
due, at least in part, to the epidemiology of malaria in different settings, which could
affect maternal immunity. Another very recent study suggested that maternal tubercu-
losis was associated with increased odds of MTCT of HIV independent of maternal HIV
viral load and CD4 count or of antiretroviral therapy.146

CONCLUSIONS AND FUTURE DIRECTIONS

The accumulated evidence so far suggests that the most comprehensive antiretroviral
regimens for preventing MTCT of HIV are those initiated early in pregnancy and
continued throughout the first weeks of neonatal life and, in a breastfeeding mother,
continued during breast feeding.147,148 Early initiation of antiretroviral prophylaxis
during pregnancy is important, as it takes several weeks for optimal HIV suppression.
Neonatal prophylaxis is also important, both in the case the mother did not receive
optimal prophylaxis during pregnancy, and when she did receive prophylaxis, as it
might suppress low-level viremia; it is critical when the baby has to breast feed.
Approaches aimed at targeting early steps of viral entry and integration, taking advan-
tage of innate resistance to infection or a vaccine against HIV might provide future
advances in preventing MTCT of HIV that would minimize antenatal exposure to
multiple antiretroviral agents, the long-term effects of which on child health have yet
to be fully identified.

REFERENCES

1. Cooper ER, Charurat M, Mofenson LM, et al. Combination antiretroviral strate-

gies for the treatment of pregnant HIV-infected women and prevention of peri-
natal HIV-1 transmission. J Acquir Immune Defic Syndr Hum Retrovirol 2002;
29:484–94.
2. Lallemant M, Jourdain G, Le Coeur S, et al. Single-dose perinatal nevirapine
plus standard zidovudine to prevent mother-to-child transmission of HIV-1 in
Thailand. N Engl J Med 2004;351:217–28.
3. Zhou Z, Meyers K, Li X, et al. Prevention of mother-to-child transmission of HIV-1
using highly active antiretroviral therapy in rural Yunnan, China. J Acquir
Immune Defic Syndr 2010;53:S15–22.
4. Kourtis AP, Duerr A. Prevention of perinatal HIV transmission: a review of novel
strategies. Expert Opin Investig Drugs 2003;12:1–10.
5. Kourtis AP, Lee FK, Abrams EJ, et al. Mother-to-child transmission of HIV-1:
timing and implications for prevention. Lancet Infect Dis 2006;6:726–32.
6. Bryson YY, Luzuriaga K, Sullivan JL, et al. Proposed definitions for in utero
versus intrapartum transmission of HIV-1. N Engl J Med 1992;327:1246–7.
7. Kuhn L, Abrams EJ, Chincilla M, et al. New York City Perinatal HIV transmission
collaborative study group. Sensitivity of HIV-1 DNA polymerase chain reaction in
the neonatal period. AIDS 1996;10:1181–2.
730 Kourtis & Bulterys

8. Kalish LA, Pitt J, Lews J, et al. Defining the time of fetal or perinatal acquisition of HIV-1
infection on the basis of age at first positive culture. J Infect Dis 1997;175:712–5.
9. The European Mode of Delivery Collaboration. Elective caesarean section versus
vaginal delivery in prevention of vertical HIV-1 transmission: a randomized clin-
ical trial. Lancet 1999;353:1035–9.
10. Kourtis AP, Bulterys M, Nesheim SR, et al. Understanding the timing of HIV
transmission from mother to infant. JAMA 2001;285:709–12.
11. Lehman DA, Farquhar C. Biological mechanisms of vertical HIV-1 transmission.
Rev Med Virol 2007;17:381–403.
12. Papiernick M, Brossard Y, Mulliez N, et al. Thymic abnormalities in fetuses
aborted from HIV-1 seropositive women. Pediatrics 1992;89:297–301.
13. Pascual A, Bruna I, Cerrolaza J, et al. Absence of maternal–fetal transmission of
HIV-1 to second trimester fetuses. Am J Obstet Gynecol 2000;183:838–42.
14. Brossard Y, Aubin J, Mandelbrot L, et al. Frequency of early in utero HIV-1 infec-
tion: a blind DNA polymerase chain reaction study on 100 fetal thymuses. AIDS
1995;9:359–64.
15. Biggar RJ, Cassol S, Kumwenda N, et al. The risk of HIV-1 infection in twin pairs
born to infected mothers in Africa. J Infect Dis 2003;188:850–5.
16. Mandelbrot L, Burgard M, Teglas JP, et al. Frequent detection of HIV-1 in the gastric
aspirates of neonates born to HIV-infected mothers. AIDS 1999;13:2143–9.
17. Zack JA, Haislip AM, Krogstad P, et al. Incompletely reverse-transcribed HIV-1
genomes in quiescent cells can function as intermediates in the retroviral life
cycle. J Virol 1992;66:1717–25.
18. Lee FK, Scinicariello F, Ou CY, et al. Partially reverse transcribed HIV genome in
uninfected HIV-exposed infants. Presented at the 11th Conference on Retrovi-
ruses and Opportunistic Infections. San Francisco (CA), February 8–12, 2004.
19. Van Rompay KK, Miller MD, Marthas ML, et al. Prophylactic and therapeutic
benefits of short-term PMPA administration to newborn macaques following
oral inoculation with simian immunodeficiency virus with reduced susceptibility
to PMPA. J Virol 2000;74:1767–74.
20. Fawzi W, Msamanga G, Spiegelman D, et al. Transmission of HIV-1 through
breastfeeding among women in Dar es Salaam, Tanzania. J Acquir Immune
Defic Syndr 2002;31:331–8.
21. Miotti PG, Taha TE, Kumwenda N, et al. HIV transmission during breastfeeding:
a study in Malawi. JAMA 1999;282:744–9.
22. Kourtis AP, Butera ST, Ibegbu C, et al. Breast milk and HIV-1: vector of transmis-
sion or vehicle of protection? Lancet Infect Dis 2003;3:786–93.
23. Bulterys M, Wilfert CM. HAART during pregnancy and during breastfeeding
among HIV-infected women in the developing world: has the time come?
AIDS 2009;23:2473–7.
24. Rousseau CM, Nduati RW, Richardson BA, et al. Longitudinal analysis of HIV-1
RNA in breast milk and its relationship to infant infection and maternal disease.
J Infect Dis 2003;187:741–7.
25. John G, Nduati R, Mbori-Ngacha D, et al. Correlates of mother to child HIV-1
transmission: association with maternal plasma HIV-1 RNA load, genital HIV-1
DNA shedding, and breast infections. J 63. Infect Dis 2001;182:206–12.
26. Semba RD, Kumwenda N, Hoover DR, et al. HIV-1 load in breast milk, mastitis,
and mother to child transmission of HIV-1. J Infect Dis 1999;180:93–8.
27. Willumsen J, Filteau SM, Coutsoudis A, et al. Breastmilk RNA viral load in HIV-1
infected South African women: effects of subclinical mastitis and infant feeding.
AIDS 2003;17(3):407–14.
 Mechanisms of Mother-to-Child Transmission of HIV-1 731

28. Coutsoudis A, Pillay K, Kuhn L, et al. Method of feeding and transmission of HIV-1
from mothers to children by 15 months of age: prospective cohort study from Dur-
ban, South Africa. AIDS 2001;15:379–87.
29. The Breastfeeding and HIV International Transmission Study (BHITS) Group.
Late postnatal transmission of HIV-1 in breast-fed children: an individual patient
data meta-analysis. J Infect Dis 2004;189:2154–66.
30. Embree JE, Njenga D, Datta P, et al. Risk factors for postnatal mother–child
transmission of HIV-1. AIDS 2000;14:2535–41.
31. Newell ML, Thorne C. The safety of antiretroviral drugs in pregnancy. Expert
Opin Drug Saf 2005;4:323–35.
32. Mofenson LM, McIntyre JA. Advances and research directions in the prevention
of mother to child HIV-1 transmission. Lancet 2000;355:2237–44.
33. Mayaux MJ, Dussaix E, Isopet J, et al. Maternal virus load during pregnancy
and the mother to child transmission of HIV-1: the French Perinatal Cohort
Studies. J Infect Dis 1997;175:172–5.
34. The European Collaborative Study. Maternal viral load and vertical transmission
of HIV: an important factor but not the only one. AIDS 1999;13:1377–85.
35. Garcia PM, Kalish LA, Pitt J, et al. Maternal levels of plasma human immunode-
ficiency virus type 1 RNA and the risk of perinatal HIV transmission. N Engl J
Med 1999;341:394–402.
36. Mofenson LM, Lambert JS, Stiehm ER, et al. Risk factors for perinatal transmis-
sion in HIV-infected women and infants receiving zidovudine prophylaxis.
N Engl J Med 1999;341:385–93.
37. Read JS. Prevention of mother-to-child transmission of HIV. In: Zeichner S,
Read J, editors. Textbook of pediatric HIV care. Cambridge (UK): Cambridge
University Press; 2005. p. 111–33.
38. Ioannidis JP, Abrams EJ, Ammann A, et al. Perinatal transmission of HIV-1 by
pregnant women with RNA viral loads <1000 copies/mL. J Infect Dis 2001;
183:539–45.
39. Sperling RS, Shapiro DE, Coombs RW, et al. Maternal viral load, zidovudine treat-
ment, and the risk of transmission of HIV-1 from mother to infant. Pediatric AIDS
Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1996;335:1621–9.
40. Dunn D, Newell ML. Vertical transmission of HIV. Lancet 1992;339:364–5.
41. Bulterys M, Landesman S, Burns DN, et al. Sexual behavior and injection drug
use during pregnancy and vertical transmission of HIV-1. J Acquir Immune Defic
Syndr Hum Retrovirol 1997;15:76–82.
42. Matheson PB, Thomas PA, Abrams EJ, et al. Heterosexual behavior during
pregnancy and perinatal transmission of HIV-1. AIDS 1996;10:1249–56.
43. Msellati P, Meda N, Leroy V, et al. Safety and acceptability of vaginal disinfection
with benzalkonium chloride in HIV-infected pregnant women in West Africa:
ANRS 049b phase II randomized, double-blinded placebo-controlled trial. Sex
Transm Infect 1999;75:420–5.
44. Biggar R, Miotti P, Taha T, et al. Perinatal intervention trial in Africa: effect of
a birth canal cleansing intervention to prevent HIV transmission. Lancet 1996;
347:1647–50.
45. Gaillard P, Mwanyumba F, Verhofstede C, et al. Vaginal lavage with chlorhexi-
dine during labor to reduce mother-to-child HIV-1 transmission: clinical trial in
Mombasa, Kenya. AIDS 2001;15:389–96.
46. Mandelbrot L, Msellati P, Meda N, et al. 15-month follow-up of African children
following vaginal cleansing with benzalconium chloride of their HIV-1 infected
mothers during late pregnancy and delivery. Sex Transm Infect 2002;78:267–70.
732 Kourtis & Bulterys

47. Wilson C, Gray G, Read J, et al. Tolerance and safety of different concentrations
of chlorhexidine for peripartum vaginal and infant washes: HIVNET 025. J Acquir
Immune Defic Syndr 2004;35:138–43.
48. Walter J, Kuhn L, Aldrovandi GM. Advances in basic science understanding of
mother-to-child HIV-1 transmission. Curr Opin HIV AIDS 2008;3:146–50.
49. Kliks S, Cogtag CH, Corliss H, et al. Genetic analysis of viral variants selected in
transmission of HIV to newborns. AIDS Res Hum Retroviruses 2000;16:1223–33.
50. Zhang H, Orti G, Du Q, et al. Phylogenetic and phenotypic analysis of HIV type 1
env gp120 in cases of subtype C mother-to-child transmission. AIDS Res Hum
Retroviruses 2002;18:1415–23.
51. Renjifo B, Chung M, Gilbert P, et al. In utero transmission of quasispecies among
HIV type 1 genotypes. Virology 2003;307:278–82.
52. Scarlatti G, Leitner T, Halapi E, et al. Comparison of variable region 3 sequences
of HIV-1 from infected children with the RNA and DNA sequences of the virus
population of their mothers. Proc Natl Acad Sci U S A 1993;90:1721–5.
53. Dickover RE, Garratty EM, Plaeger S, et al. Perinatal transmission of major,
minor, and multiple maternal human immunodeficiency virus type 1 variants in
utero and intrapartum. J Virol 2001;75:2194–203.
54. Wolinsky SM, Wike CM, Korber BT, et al. Selective transmission of HIV-1 variants
from mothers to infants. Science 1992;255:1134–7.
55. Ahmad N, Baroudy BM, Baker RC, et al. Genetic analysis of HIV-1 envelope V3
region isolates from mothers and infants after perinatal transmission. J Virol
1995;69:1001–12.
56. Kwiek JJ, Russell ES, Dang KK, et al. The molecular epidemiology of HIV-1
envelope diversity during HIV-1 subtype C vertical transmission in Malawian
mother–infant pairs. AIDS 2008;22:863–71.
57. Kourtis AP, Amedee AM, Bulterys M, et al. Various viral compartments in HIV-1-
infected mothers contribute to in utero transmission of HIV-1. AIDS Res Hum
Retrovir 2010, in press.
58. Montano M, Russell M, Gilbert P, et al. Comparative prediction of perinatal HIV-1
transmission using multiple virus load markers. J Infect Dis 2003;188:406–13.
59. Tuomala RE, O’Driscoll PT, Bremer JW, et al. Cell-associated genital tract virus
and vertical transmission of HIV-1 in antiretroviral experienced women. J Infect
Dis 2003;187:375–84.
60. Koulinska IN, Villamor E, Chaplin B, et al. Transmission of cell-free and cell-asso-
ciated HIV-1 through breastfeeding. Virus Res 2006;120:191–8.
61. Eshleman SH, Church JD, Chen S, et al. Comparison of HIV-1 mother-to-
child transmission after single-dose nevirapine prophylaxis among African
women with subtypes A, C, and D. J Acquir Immune Defic Syndr 2006;42:
518–21.
62. Renjifo B, Gilbert P, Chaplin B, et al. Preferential in utero transmission of HIV-1
subtype C as compared to HIV-1 subtype A or D. AIDS 2004;18:1629–36.
63. Yang C, Li M, Newman RD, et al. Genetic diversity of HIV-1 in western Kenya:
subtype-specific differences in mother-to-child transmission. AIDS 2003;17:
1667–74.
64. Eshleman SH, Becker-Pergola G, Deseyve M, et al. Impact of HIV-1 subtype on
women receiving single-dose nevirapine prophylaxis to prevent HIV-1 vertical
transmission (HIV network for prevention trials 012 study). J Infect Dis 2001;
184:914–7.
65. Derdeyn CA, Hunter E. Viral Characteristics of transmitted HIV. Curr Opin HIV
AIDS 2008;3:16–21.
 Mechanisms of Mother-to-Child Transmission of HIV-1 733

66. Wu X, Parast AB, Richardson BA, et al. Neutralization escape variants of HIV-1
are transmitted from mother to infant. J Virol 2006;80:835–44.
67. Eshleman SH, Lie Y, Hoover DR, et al. Association between the replication
capacity and mother-to-child transmission of HIV-1, in antiretroviral drug-naı̈ve
Malawian women. J Infect Dis 2006;193:1512–5.
68. DeRossi A. Virus–host interactions in paediatric HIV infection. Curr Opin HIV
AIDS 2007;2:399–404.
69. John GC, Rousseau CM, Dong T, et al. Maternal SDF1-30 A polymorphism
is associated with increased perinatal HIV-1 transmission. J Virol 2000;74:
5736–9.
70. Tresoldi E, Romiti ML, Boniotto M, et al. Prognostic value of the stromal cell-
derived factor 1 30 A mutation in pediatric HIV-1 infection. J Infect Dis 2002;
185:696–700.
71. Gonzales E, Dhanda R, Bamshand M, et al. Global survey of genetic variation in
CCR5, RANTES, and MIP-1alpha: impact of the epidemiology of HIV-1
pandemic. Proc Natl Acad Sci U S A 2001;98:5199–204.
72. Braida L, Boniotto M, Pontillo A, et al. A single nucleotide polymorphism in the
human beta-defensin 1 gene is associated with HIV-1 infection in Italian chil-
dren. AIDS 2004;18:1598–600.
73. Milanese M, Segat L, Pontillo A, et al. DEFB1 gene polymorphisms and
increased risk of HIV-1 infection in Brazilian children. AIDS 2006;20:1673–5.
74. Boniotto M, Crovella S, Pirulli D, et al. Polymorphisms in the MBL2 promoter
correlated with risk of HIV-1 transmission and AIDS progression. Genes Immun
2000;1:346–8.
75. Kliks SC, Wara DW, Landers DV, et al. Features of HIV-1 that could influence
maternal–child transmission. JAMA 1994;272:467–74.
76. Scarlatti G, Albert J, Rossi V, et al. Mother to child transmission of HIV-1: corre-
lation with neutralizing antibodies against primary isolates. J Infect Dis 1993;
168:207–10.
77. Tranchat C, Van de Perre P, Simonon-Sorel A, et al. Maternal humoral factors
associated with perinatal HIV-1 transmission in a cohort from Kigali, Rwanda,
1988–94. J Infect 1999;39:213–20.
78. Hengel RL, Kennedy MS, Steketee RW, et al. Neutralizing antibody and perinatal
transmission of HIV-1. New York City Perinatal HIV Transmission Collaborative
Study Group. AIDS Res Hum Retroviruses 1998;14:475–81.
79. Dickover R, Garratty E, Yusim K, et al. Role of maternal autologous neutralizing
antibody in selective perinatal transmission of HIV-1 escape variants. J Virol
2006;80:6525–33.
80. DeMaria A, Cirrilo C, Moretta L. Occurrence of HIV-1 specific cytolytic T cell
activity in apparently uninfected children born to HIV-1 infected mothers.
J Infect Dis 1994;170:1296–9.
81. Rowland-Jones S, Nixon DR, Aldhous MC, et al. HIV-1 specific cytotoxic T cell
activity in an HIV-exposed but uninfected infant. Lancet 1993;341:860–1.
82. Clerici M, Sison AV, Berzovsky JA, et al. Cellular immune factors associated with
mother-to-infant transmission of HIV. AIDS 1993;7:1427–33.
83. Kuhn L, Coutsoudis A, Moodley D, et al. T-helper cell responses to HIV envelope
peptides in cord blood: protection against intrapartum and breastfeeding trans-
mission. AIDS 2001;15:1–9.
84. Farquhar C, John-Stewart G. The role of infant immune responses and genetic
factors in preventing HIV-1 acquisition and disease progression. Clin Exp Immu-
nol 2003;134:367–77.
734 Kourtis & Bulterys

85. Legrand FA, Nixon DF, Loo CP, et al. Strong HIV-1 specific T cell responses in
HIV-1 exposed uninfected infants and neonates revealed after regulatory
T cell removal. PLoS One 2006;1:e102.
86. Schramm DB, Meddows-Taylor S, Gray GE, et al. Low maternal viral loads and
reduced granulocyte–macrophage colony-stimulating factor levels characterize
exposed, uninfected infants who develop protective HIV-1 specific responses.
Clin Vaccine Immunol 2007;14:348–54.
87. Kourtis AP, Nesheim S, Thea D, et al. Correlation of virus load and soluble L-se-
lectin, a marker of immune activation, in pediatric HIV infection. AIDS 2000;14:
2429–36.
88. Kuhn L. Milk mysteries: why are women who exclusively breastfeed less likely to
transmit HIV during breastfeeding? Clin Infect Dis 2010;50:770–2.
89. Taha TE, Nour S, Kumwenda NI, et al. Gender differences in perinatal HIV acqui-
sition among African infants. Pediatrics 2005;115:e167–72.
90. Biggar RJ, Taha TE, Hoover DR, et al. Higher in utero and perinatal HIV infection
risk in girls than boys. J Acquir Immune Defic syndr 2006;41:509–13.
91. Liu R, Paxton WA, Choe S, et al. Homozygous defect in HIV-1 coreceptor
accounts for resistance of some multiply exposed individuals to HIV-1 infection.
Cell 1996;86:367–77.
92. Ometto L, Zanchetta M, Mainardi M, et al. Co-receptor usage of HIV-1 primary
isolates, viral burden, and CCR5 genotype in mother-to-child HIV-1 transmis-
sion. AIDS 2000;14:1721–9.
93. MacDonald KS, Embree J, Njenga S, et al. Mother–child class I HLA concor-
dance increases perinatal HIV-1 transmission. J Infect Dis 1998;177:551–6.
94. Kuhn L, Abrams EJ, Palumbo P, et al. Maternal versus paternal inheritance of
HLA class I alleles among HIV-infected children: consequences for clinical
disease progression. AIDS 2004;18:1281–9.
95. MacDonald KS, Embree J, Nagelkerke NJ, et al. The HLA A2/6802 supertype is
associated with reduced risk of perinatal HIV-1 transmission. J Infect Dis 2001;
183:503–6.
96. Winchester R, Chen Y, Rose S, et al. Transmission of HIV-1 from an infected
woman to her offspring during gestation and delivery was found to be influ-
enced by the infant’s major histocompatibility complex class II DRB1 alleles.
Proc Natl Acad Sci U S A 1995;92:12371–8.
97. Winchester R, Pitt J, Charurat M, et al. Mother to child transmission of HIV-1:
strong association with certain maternal HLA-B alleles independent of viral
load implicates innate immune mechanisms. J Acquir Immune Defic Syndr
2004;36:659–70.
98. Aikhionbare FO, Hodge T, Kuhn L, et al. Mother-to-child discordance in HLA-G
exon 2 is associated with a reduced risk of perinatal HIV-1 transmission. AIDS
2001;15:2196–8.
99. Farquhar C, Rowland-Jones S, Mbori-Ngacha D, et al. Human leukocyte antigen
(HLA) B*18 and protection against mother-to-child HIV type 1 transmission.
AIDS Res Hum Retroviruses 2004;20:692–7.
100. Kostrikis LG, Neumann AU, Thompson B, et al. A polymorphism in the regulatory
region of the CC-chemokine receptor 5 gene influences perinatal transmission
of HIV-1 to African-American infants. J Virol 1999;73:10264–71.
101. Mattern CF, Murray K, Jensen A, et al. Localization of HIV core antigen in term
human placentas. Pediatrics 1992;89:207–9.
102. Spector SA. Mother-to-infant transmission of HIV-1: the placenta fights back.
J Clin Invest 2001;107:267–9.
 Mechanisms of Mother-to-Child Transmission of HIV-1 735

103. St Louis M, Kamenga M, Brown C, et al. Risk of perinatal HIV-1 transmission ac-
cording to maternal immunologic, virologic, and placental factors. J Am Med
Assoc 1993;269:2853–9.
104. Wabwire-Mangen F, Gray R, Mmiro F, et al. Placental membrane inflammation
and risks of maternal to child transmission of HIV-1 in Uganda. J Acquir Immune
Defic Syndr 1992;22:379–85.
105. Taha TE, Brown ER, Hoffman IF, et al. A phase III clinical trial of antibiotics to
reduce chorioamnionitis-related perinatal HIV-1 transmission. AIDS 2006;20:
1313–21.
106. Taha TE, Gray RH. Genital tract infections and perinatal transmission of HIV. Ann
N Y Acad Sci 2000;918:84–98.
107. Chen KT, Segu M, Lumey LH, et al. Genital herpes simplex virus infection and
perinatal transmission of HIV. Obstet Gynecol 2005;106:1341–8.
108. Drake AL, John-Stewart GC, Wald A, et al. Herpes simplex virus type 2 and risk
of intrapartum HIV transmission. Obstet Gynecol 2007;109:403–9.
109. Semba RD, Miotti P, Chiphangwi J, et al. Maternal vitamin A deficiency and
mother-to-child transmission of HIV-1. Lancet 1994;343:1593–7.
110. Kumwenda N, Miotti P, Taha T, et al. Antenatal vitamin A supplementation
increases birthweight and decreases anemia, but does not prevent HIV trans-
mission or decrease mortality in infants born to HIV-infected women in Malawi.
Clin Infect Dis 2002;35:618–24.
111. Coutsoudis A, Pillay K, Spooner E, et al. Randomized trial testing the effect of
vitamin A supplementation on pregnancy outcomes and early mother-to-child
transmission in Durban, South Africa. AIDS 1999;13:1517–24.
112. Fawzi W, Msamanga G, Hunter D, et al. Randomized trial of vitamin supple-
ments in relation to transmission of HIV-1 through breastfeeding and early child
mortality. AIDS 2002;16:1935–44.
113. Humphrey JH, Iliff PJ, Marinda ET, et al. Effects of a single large dose of vitamin
A, given during the postpartum period to HIV-positive women and their infants,
on child HIV infection, HIV-free survival, and mortality. J Infect Dis 2006;193:
860–71.
114. Baeten J, Mostad S, Hughes M, et al. Selenium deficiency is associated with
shedding of HIV-1 infected cells in the female genital tract. J Acquir Immune
Defic Syndr 2001;26:360–4.
115. Kupka R, Garland M, Msamanga G, et al. Selenium status, pregnancy
outcomes, and mother-to-child transmission of HIV-1. J Acquir Immune Defic
Syndr 2005;29:201–10.
116. Mehta S, Hunter DJ, Mugusi FM, et al. Perinatal outcomes, including mother-to-
child transmission of HIV, and child mortality and their association with maternal
vitamin D status in Tanzania. J Infect Dis 2009;200:1022–30.
117. Lunney KM, Iliff P, Mutasa K, et al. Associations between breast milk viral load,
mastitis, exclusive breast-feeding, and postnatal transmission of HIV. Clin Infect
Dis 2010;50:762–9.
118. Kuhn L, Steketee RW, Weedon J, et al. Distinct risk factors for intrauterine and
intrapartum HIV transmission and consequences for disease progression in in-
fected children. Perinatal AIDS Collaborative Transmission Study. J Infect Dis
1999;179:52–8.
119. Landesman SH, Kalish SA, Burns DN, et al. Obstetrical factors and the transmis-
sion of HIV-1 from mother to child. N Engl J Med 1996;334:1617–23.
120. Pitt J, Schluchter M, Jenson H, et al. Maternal and perinatal factors related to
maternal–infant transmission of HIV-1 in the P2C2 HIV Study. The role of EBV
736 Kourtis & Bulterys

shedding Pediatric Pulmonary and Cardiovascular Complications of Vertically

Transmitted HIV-1 infection (P2C2 HIV) Study Group. J Acquir Immune Defic
Syndr Hum Retrovirol 1998;19:462–70.
121. Simonds RJ, Steketee R, Nesheim S, et al. Impact of zidovudine use on risk and
risk factors for perinatal transmission of HIV Perinatal AIDS Collaborative Trans-
mission Studies. AIDS 1998;12:301–8.
122. International Perinatal HIV Group. Duration of ruptured membranes and vertical
transmission of HIV-1: a meta-analysis from fifteen prospective cohort studies.
AIDS 2001;15:357–68.
123. Mandelbrot L, Mayaux M, Bongain A, et al. Obstetric factors and mother-to-child
transmission of HIV-1: the French perinatal cohorts. Am J Obstet Gynecol 1996;
175:661–7.
124. Kuhn L, Abrams E, Matheson P, et al. Timing of maternal–infant HIV transmis-
sion: association between intrapartum factors and early polymerase chain reac-
tion results. AIDS 1997;11:429–35.
125. The International Perinatal HIV Group. The mode of delivery and the risk of
vertical transmission of HIV-1. N Engl J Med 1999;340:977–87.
126. European Collaborative Study. Risk factors for mother-to-child transmission of
HIV-1. Lancet 1992;339:1007–12.
127. Van Dyke RB, Korber BT, Popek E, et al. The Ariel project. A prospective cohort
study of maternal–child transmission of HIV-1 in the era of maternal antiretroviral
therapy. J Infect Dis 1999;179:319–28.
128. Mandelbrot L, LeChenadec J, Berrebi A, et al. Perinatal HIV-1 transmission:
interaction between zidovudine prophylaxis and mode of delivery in the French
Perinatal Cohort. JAMA 1998;280:55–60.
129. Kind C, Rudin C, Siegrist CA, et al. Prevention of vertical HIV transmission: addi-
tive protective effect of elective cesarean section and zidovudine prophylaxis.
AIDS 1998;12:205–10.
130. D’Agaro P, Burgnich P, Comar M, et al. HHV-6 is frequently detected in dried
cord blood spots from babies born to HIV-positive mothers. Curr HIV Res
2008;6:441–6.
131. Pembrey L, Newell ML, Tovo PA, et al. The management of HCV-infected preg-
nant women and their children. J Hepatol 2005;43:515–25.
132. Thio C, Locarnini S. Treatment of HIV/HBV coinfection: clinical and virologic
issues. AIDS Rev 2007;9:40–53.
133. Kovaks A, Schluchter M, Easley K, et al. Cytomegalovirus infection and HIV-1
disease progression in infants born to HIV-1 infected women. Pediatric Pulmo-
nary and Cardiovascular Complications of Vertically Transmitted HIV Infection
Study Group. N Engl J Med 1999;341:77–84.
134. Kositanont U, Wasi C, Wanprapar N, et al. Primary infection of human herpes-
virus 6 in children with vertical infection of HIV-1. J Infect Dis 1999;180:50–5.
135. Taha TE, Canner JK, Dallabetta GA, et al. Childhood malaria parasitaemia and
HIV infection in Malawi. Trans R Soc Trop Med Hyg 1994;88:164–5.
136. Steketee RW, Wirima JJ, Bloland PB, et al. Impairment of a pregnant woman’s
acquired ability to limit Plasmodium falciparum by infection with human immuno-
deficiency virus type 1. Am J Trop Med Hyg 1996;55:42–9.
137. Msamanga GI, Taha TE, Young AM, et al. Placental malaria and mother-to-child
transmission of human immunodeficiency virus-1. Am J Trop Med Hyg 2009;80:
508–15.
138. Greenberg AE, Nsa W, Ryder RW, et al. Plasmodium falciparum malaria and peri-
natally acquired HIV-1 infection in Kinshasa, Zaire. N Engl J Med 1991;325:105–9.
 Mechanisms of Mother-to-Child Transmission of HIV-1 737

139. Hoffman IF, Jere C, Taylor T, et al. The effect of Plasmodium falciparum malaria
on HIV-1 RNA blood plasma concentration. AIDS 1999;13:487–94.
140. Ayouba A, Badaut C, Kfutwah A, et al. Specific stimulation of HIV-1 replication in
human placental trophoblasts by an antigen of Plasmodium falciparum. AIDS
2008;30:785–7.
141. Brahmbhatt H, Kigozi G, Wabwire-Mangen F, et al. The effects of placental ma-
laria on mother-to-child HIV transmission in Rakai, Uganda. AIDS 2003;17:
2539–41.
142. Brahmbhatt H, Sullivan D, Kigozi G, et al. Association of HIV and malaria with
mother-to-child transmission birth outcomes and child mortality. AIDS 2008;
47:472–6, 145.
143. Inion I, Mwanyumba F, Gaillard P, et al. Placental malaria and perinatal transmis-
sion of human immunodeficiency virus type 1. J Infect Dis 2003;188:1675–8.
144. Mwapasa V, Rogerson SJ, Molyneux ME, et al. The effect of Plasmodium falci-
parum malaria on peripheral and placental HIV-1 RNA concentrations in preg-
nant Malawian women. AIDS 2004;18:1051–9.
145. Ayisi JG, van Eijk AM, Newman RD, et al. Maternal malaria and perinatal HIV
transmission, western Kenya. Emerg Infect Dis 2004;10:643–52.
146. Gupta A, Gupte N, Patil S, et al. Maternal TB is associated with increased risk of HIV
mother-to-child transmission. Presented at the 17th Conference for Retroviruses
and Opportunistic Infections 2010. San Francisco (CA), February 16–19, 2010.
147. Public Health Service Task Force. Recommendations for use of antiretroviral
drugs in pregnant HIV-infected women for maternal health and interventions
to reduce perinatal HIV transmission in the United States. Available at: http://
aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf. Accessed May 2, 2010.
148. Bulterys M, Fowler MG. Prevention of HIV infection in children. Pediatr Clin North
Am 2000;47:241–60.

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