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examine here the potential role of HAART in HIV prevention and the resulting eff ect this would have on the cost-eff ectiveness of the treatment. We also discuss a theoretical HAART-driven strategy to control the continued expansion of the HIV/AIDS pandemic.

The Lancet Editors ( July 11, p104) recently commented on successes in Cuba in elimination of mother-to-child transmission of HIV infection as a public health threat; however, this Editorial neglected to address the important point that this was a dual effort to validate the elimination of mother-to-child transmission of both HIV infection and syphilis. WHO certifi ed that Cuba had eliminated mother-to-child transmission not only of HIV, but also of syphilis. We were not surprised that The Lancet would omit one of the most neglected, but still common, sexually transmitted infections. Syphilis affects more pregnancies worldwide than does HIV infection. Maternal syphilis infections cause hundreds of thousands of adverse outcomes of pregnancy, including fetal loss or stillbirth, prematurity or low birthweight, neonatal death, and syphilis infection in the infant. In women with HIV, syphilis infection during pregnancy is associated with more than a 2·7 times increased risk of mother-to-child HIV transmission. The similarities in screening recommendations for HIV infection and syphilis (ie, testing at first antenatal visit) provide an important opportunity to strengthen eff orts to eliminate congenital syphilis together with prevention of mother-to-child transmission of HIV—both highpriority initiatives that can help countries to reach common goals of improved maternal health and decreased mortality of children aged younger than 5 years. Rapid, dual point-of-care tests have been created that can detect antibodies to both HIV and Treponema pallidum, the organism that causes syphilis. Emergence of dual rapid tests for HIV infection and syphilis can result in earlier detection, reduced loss to follow-up, expanded case fi nding outside clinical settings, and enhanced global control of syphilis and HIV. Results of studies have shown that dual tests are accurate and reproducible in both fi eld and laboratory settings. However, compared with no syphilis testing, even moderate performance is associated with enhanced detection and treatment of infections. With those fi ndings, donors and national health programmes should feel confident that further investments in the implementation of dual testing would produce expected benefits through increased uptake of testing and streamlined procurement and implementation that can lead to improved maternal and newborn health outcomes. Cuba can be the fi rst of many to eliminate motherto-child transmission of syphilis and HIV infection, and dual rapid tests can make programme integration an achievable reality.

Fawzi and colleagues found that multivitamin supplementation during pregnancy had beneficial effects on pregnancy outcomes and maternal T cell counts in HIV-1-infected women in Tanzania but there was no such effect for vitamin A supplementation alone. Several features of the studys design raise questions about the lack of effect of vitamin A however. The sample size was insufficient to identify vitamin A benefits on outcomes with low frequencies the comparability of the two intervention groups during pregnancy was not described and possible differences in compliance rates between women receiving a multivitamin versus vitamin A were not reported. Moreover details about maternal characteristics at the beginning and end of pregnancy were not reported; some characteristics (e.g. maternal weight gain) could affect pregnancy outcome and be improved by multivitamin supplementation thereby reducing the power to detect a difference in the vitamin A comparison. Other trials have demonstrated a benefit of vitamin A supplementation on maternal and infant morbidity.