Maternal Outcomes after Haart for the Prevention of Mother-To-Child Transmission in HIV-Infected Women in Brazil

Abstract

Background Information is lacking on outcomes in HIV-infected Brazilian women with CD4+ 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 2–3 events as well as for HIV progression warranting HAART re-initiation, defined by a WHO 4 event and/or CD4+ decline to ≤ 200 cells/mm3. Predictors of the WHO 2–3 events and HIV progression outcomes were evaluated with Cox`s proportional hazards models. Results One hundred and twenty women were followed for a mean of 1.5 years after delivery. Twenty-six women had 30 events as follows: 20 developed WHO stage 2–3 events, yielding an incidence rate of 13/100 PY (95% CI 8–20 per 100 PY); 10 developed HIV progression requiring HAART re-initiation (IR: 6/100 PY; 95% CI: 3–11 per 100 PY). Among progressors, a single woman developed a WHO 4 clinical event and the remainder had CD4+ declines. Women who had baseline CD4+ cell counts between 200–500 cells/mm3 had a hazard ratio for WHO 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+ cell count (HR=0.99, CI: 0.98–0.99; p=0.02). Conclusions In this observational study, a baseline CD4+ cell count below 500 cells/mm3 was associated with an increased risk of postpartum WHO 2–3 clinical events and HIV disease progression. Randomized studies are needed to further evaluate the impact of postpartum treatment discontinuation on maternal health.

Maternal Antiretroviral Therapy for the Prevention of Mother-To-Child Transmission of HIV in Malawi: Maternal and Infant Outcomes Two Years after Delivery

“…Our findings on the immunological and virological data at 24 months extends data obtained in a previous study at 1 year [29], showing the declining trend in the CD4+ count and the expected rebound of viral load in women discontinuing ART. Interestingly, in our study hemoglobin levels at Month 24 remained lower in women discontinuing drugs at 6 months compared to women who did not stop the drugs, who indeed continued to benefit from drug administration.…”

HIV Disease Progression in the First Year After Delivery Among African Women Followed in the HPTN 046 Clinical Trial

“…11 These data are also consistent with a study from Brazil, which showed that among women discontinuing ARV agents after delivery, the group with levels between 250–500 cells/uL had a risk of progression to stage II or III events that was 2.5 times higher than women with CD4+ counts above 500 cells/uL. 12 The importance of CD4+ lymphocyte results for predicting progression were also shown in a study from Kenya demonstrating that CD4 counts and percentage during pregnancy were most predictive of mortality over the first two years postpartum, compared to total lymphocyte count, hemoglobin, HIV RNA level, or body mass index. 8 …”

Early Infant Feeding Patterns and HIV-free Survival

“…[35][36][37] Of concern here would be the possibility that the transmission risk after interruption of preventive treatment may be increased due to a viral rebound in breast milk [38][39][40] and the infant might be at greater risk of receiving drugresistant viruses. Unreported breastfeeding continuation has been recognized in other studies and linked with concerns of societal criticism and worries about impact on infant health.…”