Information is lacking on outcomes in HIV-infected Brazilian women with CD4+ T-cell counts >200 cells/mm3 who initiate HAART for the prevention of mother-to-child transmission, and discontinue after delivery.
Methods
Clinical event rates after postpartum HAART discontinuation were calculated for all WHO stage 2–3 events, as well as for HIV progression warranting HAART re-initiation, defined by a WHO stage 4 event and/or CD4+ T-cell decrease to ≤200 cells/mm3. Predictors of the WHO stage 2–3 events and HIV progression outcomes were evaluated with Cox's proportional hazards models.
Results
A total of 120 women were followed for a mean of 1.5 years after delivery. Overall, 26 women had 30 events as follows: 20 developed WHO stage 2–3 events, yielding an incidence rate of 13/100 person-years (PY; 95% CI 8–20); 10 developed HIV progression requiring HAART re-initiation (incidence ratio 6/100 PY, 95% CI 3–11). Among progressors, a single woman developed a WHO stage 4 clinical event and the remainder had CD4+ T-cell decreases. Women who had baseline CD4+ T-cell counts between 200–500 cells/mm3 had a hazard ratio for WHO stage 2–3 events of 2.5 compared to women with baseline ≥500 cells/mm3 (95% CI 1.0–6.3; P=0.05). The only significant predictor of HIV progression was baseline CD4+ T-cell count (hazard ratio 0.99, 95% CI 0.98–0.99; P=0.02).
Conclusions
In this observational study, a baseline CD4+ T-cell count <500 cells/mm3 was associated with an increased risk of postpartum WHO stage 2–3 clinical events and HIV disease progression. Randomized studies are needed to further evaluate the effect of postpartum treatment discontinuation on maternal health.
References
1.
CooperE.R., CharuratM., MofensonL.Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission. J Acquir Immune Defic Syndr2002; 29: 484–494.
2.
UNAIDS Joint United Nations Programme on HIV/ AIDS Country Report: Brazil.Geneva: WHO Library Cataloguing-in-Publication Data. UNAIDS2008.
3.
[Recommendations for prophylaxis of HIV vertical transmission and antiretroviral therapy in pregnant women].Brasilia: Brazil Ministry of Health2006. Portuguese.
4.
The Strategies for Management of Antiretroviral Therapy (SMART) Study Group.CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med2006; 355: 2283–2296.
5.
World Health Organization.WHO case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children.Geneva: World Health Organization2007.
6.
BurnsD.N., NourjahP., WrightD.J.Changes in immune activation markers during pregnancy and postpartum. J Reprod Immunol1999; 42: 147–165.
7.
MikyasY., AzizN., HarawaN.Immunologic activation during pregnancy: serial measurement of lymphocyte phenotype and serum activation molecules in HIV-infected and uninfected women. J Reprod Immunol1997; 33: 157–170.
8.
WattsD.H., LambertJ., StiehmE.R.Progression of HIV disease among women following delivery. J Acquir Immune Defic Syndr2003; 33: 585–593.
9.
CaoY., KrogstadP., KorberB.T.Maternal HIV-1 viral load and vertical transmission of infection: the Ariel Project for the prevention of HIV transmission from mother to infant. Nat Med1997; 3: 549–552.
10.
BurnsD.N., LandesmanS., MinkoffH.The influence of pregnancy on human immunodeficiency virus type 1 infection: antepartum and postpartum changes in human immunodeficiency virus type 1 viral load. Am J Obstet Gynecol1998; 178: 355–359.
11.
MelvinA.J., BurchettS.K., WattsD.H.Effect of pregnancy and zidovudine therapy on viral load in HIV-1-infected women. J Acquir Immune Defic Syndr Hum Retrovirol1997; 14: 232–236.
12.
AlliegroM.B., DorrucciM., PhillipsA.N.Incidence and consequences of pregnancy in women with known duration of HIV infection. Arch Intern Med1997; 157: 2585–2590.
13.
HockeC., MorlatP., CheneG., DequaeL., DabisF.Prospective cohort study of the effect of pregnancy on the progression of human immunodeficiency virus infection. The Groupe d'Epidemiologie Clinique Du SIDA en Aquitaine. Obstet Gynecol1995; 86: 886–891.
14.
TemmermanM., ChombaE.N., Ndinya-AcholaJ., PlummerF.A., CoppensM., PiotP.Maternal human immunodeficiency virus-1 infection and pregnancy outcome. Obstet Gynecol1994; 83: 495–501.
15.
TaiJ.H., UdojiM.A., BarkanicG.Pregnancy and HIV disease progression during the era of highly active antiretroviral therapy. J Infect Dis2007; 196: 1044–1052.
16.
PalaciosR., SeniseJ., VazM., DiazR., CasteloA.Short-term antiretroviral therapy to prevent mother-to-child transmission is safe and results in a sustained increase in CD4 T-cell counts in HIV-1-infected mothers. HIV Med2009; 10: 157–162.
17.
BrownE.R., OtienoP., Mbori-NgachaD.A.Comparison of CD4 cell count, viral load, and other markers for the prediction of mortality among HIV-1-infected Kenyan pregnant women. J Infect Dis2009; 199: 1292–1300.
18.
KitahataM.M., GangeS.J., AbrahamA.G.Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med2009; 360: 1815–1826.
19.
DanelC., MohR., MingaA.CD4-guided structured antiretroviral treatment interruption strategy in HIV-infected adults in west Africa (Trivacan ANRS 1269 trial): a randomised trial. Lancet2006; 367: 1981–1989.
20.
AnanworanichJ., Gayet-AgeronA., Le BrazM.CD4-guided scheduled treatment interruptions compared with continuous therapy for patients infected with HIV-1: results of the Staccato randomised trial. Lancet2006; 368: 459–465.
21.
HargroveJ.W., HumphreyJ.H.Mortality among HIV-positive postpartum women with high CD4 cell counts in Zimbabwe. AIDS2010; 24: F11–F14.
22.
WattsD.H., LuM., ThompsonB.Treatment interruption after pregnancy: effects on disease progression and laboratory findings. Infect Dis Obstet Gynecol2009; 2009: 456717.
23.
MelekhinV.V., ShepherdB.E., JenkinsC.A.Postpartum discontinuation of antiretroviral therapy and risk of maternal AIDS-defining events, non-AIDS-defining events, and mortality among a cohort of HIV-1-infected women in the United States. AIDS Patient Care STDS2010; 24: 279–286.
