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Letters to the Editor

Indian Pediatrics 2001; 38: 683-684  

Strategy for Preventing Vertical Transmission of HIV


We read with interest the recent article on this subject(1). In the backdrop of the information already available from sub-Saharan Africa, Thailand and Europe, the conclusions of the authors are not surprising. However, there are several limitations that are relevant to the interpretation of the results of the study in question.

Firstly, the two groups (intervention versus non-intervention) are non-comparable, because this was a non-blinded and non-randomized intervention trial. There is an obvious bias in patient selection, because the women in the intervention group belonged to a higher socio-economic class, who could afford therapy; and also had a more desirable health seeking behavior, having come for antenatal visits from before 32 weeks gestation. This in itself could confound the results because severity of underlying HIV disease, nutritional status, vitamin deficiency status, co-infections with other sexually trans-mitted disease, etc. could all be related to economic class and health seeking behavior, and these factors could independently influ-ence the outcome. This is further com-pounded by the fact that in the non-interven-tion group, the dropout rate is enormous and is far higher than in the intervention group.

Secondly, we have no information whether there was any cross-contamination between the two groups. Despite being in the non-intervention group, it is possible that many patients in this group would have also undergone Caesarean sections beyond 38 weeks for reasons other than HIV, thus getting an inadvertent benefit. Since the mothers were counseled about the pros and cons of breastfeeding and the final decision was left to them, it is quite likely that there would be some mothers in the intervention group who opted to breastfeed and vice versa in the non-intervention group. It is not clear from the article what were the numbers in each of these sub-groups and how they were tackled in analysis. Since the authors are testing a package of interventions, rather than individual interventions, it is desirable that there should be homogeneity within each group.

Thirdly, the authors say that the ELISA and Western blot tests can be falsely positive till 15 to 18 months of age. In that case why did they test at 15 to 18 months by ELISA to confirm "infection status" and use this parameter as their key outcome. They should have either chosen a time period that was clearly beyond the grey zone, e.g., 21 to 24 months, or they should have chosen a test that unequivocally demonstrate presence of virus, such as PCR or p24 antigen. The test at 15 to 18 months continues to leave one in doubt whether these were genuine infections or passive transfer of antibodies.

Fourthly, only the cost of zidovudine treatment of the mothers has been mentioned. The cost of treating the babies for 6 weeks (roughly Rs 100 to Rs 150), the cost of feeding formula milk for many months, and the cost related to increased infections in the formula fed babies are qually relevant. Only then can the cost-benefit ratio of the package of interventions be ascertained.

     Saurabh Dutta, 
Anil Narang,
Neonatology Unit, Department of Pediatrics,
Postgraduate Institute of Medical Education and Research,

Chandigarh 160 012, India


1. Merchant RH, Damania K, Gilada IS, Bhagwat RV, Karkare JS, Oswal JS, et al. Strategy for preventing vertical transmission of HIV: Bombay experience. Indian Pedia-trics 2001; 38: 132-138.


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