Impact of HIV-1 infection and pregnancy on maternal health: comparison between perinatally and behaviorally infected young women

Abstract

BackgroundThe introduction of combination antiretroviral therapy has resulted in improved survival and quality of life for individuals infected with the human immunodeficiency virus (HIV). There is, as expected, a growing population of perinatally HIV-infected women who are, have been, or will become pregnant. We describe a large cohort of perinatally infected women, compare it with a similar age-matched behaviorally HIV-infected group, and examine factors affecting maternal and infant health.MethodsWe reviewed the records of 30 perinatally infected women who gave birth at two hospitals between January 2000 and December 2011. The comparison group comprised behaviorally infected women who delivered at these hospitals during the same period. The outcome measures were differences in CD4 counts and viral load between the cohorts, and comparisons of maternal morbidity, mortality, and mother-to-child HIV transmission.ResultsMedian CD4 counts were significantly lower in the perinatal group before, during, and after pregnancy. The median viral load was significantly higher in the perinatal group. Interval prepregnancy to post partum viral load decline was also greater in the behavioral group. Viral load decreases in the perinatal population were not sustained in the post partum period, at which time viral load trended back to prepregnancy levels. There was one mother-to-child HIV transmission in a perinatally infected woman. Over an extended 4 years of follow-up, there were four deaths in the perinatal group and none in the behavioral group.ConclusionAfter delivery, the differences between perinatally and behaviorally infected mothers accentuate, with immunologic deterioration in the former group. The perinatal population may require novel management strategies to ensure outcomes comparable with those observed in the behavioral group.

Pregnancy incidence and outcomes in women with perinatal HIV infection

“…These factors may be implicated in the association we and others report between having PHIV and failing to achieve undetectable viral load by delivery [8,13]. Though we do not report on treatment history or resistance, our finding of more raltegravir use among the PHIV group is suggestive of more complex treatment profiles or higher viral load in pregnancy in this group.…”

“…Young people with PHIV have higher risk of treatment failure and multiclass drug resistance than those with BHIV for many reasons: previous exposure to obsolete and suboptimal ART; the limited range of ART licensed for paediatric use; difficulties with adherence because of stigma, discrimination, and HIV-associated neurocognitive deficits, among others [ 35 ]. These factors may be implicated in the association we and others report between having PHIV and failing to achieve undetectable viral load by delivery [ 8 , 13 ]. Though we do not report on treatment history or resistance, our finding of more raltegravir use among the PHIV group is suggestive of more complex treatment profiles or higher viral load in pregnancy in this group.…”

“…Half of the pregnant women living with PHIV in an earlier UK case series had adherence problems [12] and US studies have shown higher HIV viral load during pregnancy but similar rates of MTCT compared with women with behaviourally acquired HIV (BHIV) [8,9,13]. Being born to a woman with PHIV was an independent risk factor for poor fetal and infant growth when compared to being born to a woman with BHIV [11,15].…”

“…Several studies in resource-rich settings have investigated pregnancy rates and outcomes in women with PHIV [ 7 – 14 ], reporting lower pregnancy incidence rates compared with HIV-negative women [ 7 , 9 ]. Half of the pregnant women living with PHIV in an earlier UK case series had adherence problems [ 12 ] and US studies have shown higher HIV viral load during pregnancy but similar rates of MTCT compared with women with behaviourally acquired HIV (BHIV) [ 8 , 9 , 13 ]. Being born to a woman with PHIV was an independent risk factor for poor fetal and infant growth when compared to being born to a woman with BHIV [ 11 , 15 ].…”

“…Being born to a woman with PHIV was an independent risk factor for poor fetal and infant growth when compared to being born to a woman with BHIV [ 11 , 15 ]. Several studies have compared women with PHIV to those with BHIV to estimate the effects of mode of HIV acquisition on pregnancy and infant outcomes [ 7 , 8 , 11 , 13 ]; however, such comparisons have been limited by key differences between groups regarding age, parity, and treatment era.…”