Abstract
BackgroundWe evaluated maternal CD4+ cell count (CD4+) decline after PMTCT prophylaxis in a multi-country HIV care program.MethodsAnalysis was restricted to antiretroviral therapy (ART)-naive, HIV-infected pregnant women with CD4+ ≥250 cells/mm3 at enrollment. Single-dose nevirapine (sd-NVP) or short-course antiretroviral prophylaxis (sc-ARVp) with zidovudine (AZT) or AZT + lamivudine (3TC) was initiated in 11 programs while 2 programs offered triple-drug antiretroviral prophylaxis (tARVp) (AZT+3TC+ NVP or nelfinavir). All regimens were stopped at delivery. CD4+ decline was defined as proportion of women who declined to CD4+ <350 cells/mm3 or <200 cells/mm3 at 24 months. Weibull regression was used for multivariable analysis.FindingsA total of 1,393 women with enrollment CD4+ ≥250 cells/mm3 initiated tARVp (172; 12%) or sc-ARVp (532; 38%) during pregnancy or received intrapartum sd-NVP (689; 50%). At enrollment, maternal median age was 27 years (interquartile range (IQR) 23–30), median CD4+ was 469 cells/mm3 (IQR: 363–613). At 24 months post-delivery, the cumulative probability of CD4+ decline to <200 cells/mm3 was 12% (95% CI: 10–14). Among a subgroup of 903 women with CD4+ ≥400 cells at enrollment, the 24 month cumulative probability of decline to CD4+ <350 cells/mm3 was 28%; (95% CI: 25–32). Lower antepartum CD4+ was associated with higher probability of CD4+ decline to <350 cells/mm3: 46% (CD4+400–499 cells/mm3) vs. 19% (CD4+ ≥500 cells/mm3). After adjusting for age, enrollment CD4+ and WHO stage, women who received tARVp or sd-NVP were twice as likely to experience CD4+ decline to <350 cells/mm3 within 24 months than women receiving sc-ARVp (adjusted hazard ratio: 2.2; 95% CI: 1.5–3.2, p<0.0001).ConclusionDecline in CD4+ cell count to ART eligibility thresholds by 24 months postpartum was common among women receiving PMTCT prophylaxis during pregnancy and/or delivery.
Highlights
In resource-limited countries HIV-infected pregnant women not yet eligible for antiretroviral treatment (ART) typically receive short-course antiretroviral (ARV) prophylaxis [1] for the prevention of mother-to-child transmission
Decline in CD4+ cell count to ART eligibility thresholds by 24 months postpartum was common among women receiving PMTCT prophylaxis during pregnancy and/or delivery
Two options of similar efficacy are offered for women with a CD4+ cell count (CD4+) .350 cells/mm3, the current immunologic eligibility threshold for initiating ART [2]: Option A, zidovudine (AZT) during pregnancy plus single-dose nevirapine at delivery and daily NVP prophylaxis to the infant during breast feeding or Option B, triple ARV prophylaxis starting at 14 weeks of gestation until cessation of all breastfeeding [2]
Summary
In resource-limited countries HIV-infected pregnant women not yet eligible for antiretroviral treatment (ART) typically receive short-course antiretroviral (ARV) prophylaxis [1] for the prevention of mother-to-child transmission. In non-pregnant HIV-infected adults, structured interruption of treatment significantly increases the risk of opportunistic disease or death in patients eligible for ART [5,6], raising the possibility that tARVp may lead to suboptimal long-term outcomes compared to other forms of prophylaxis. The objective of this analysis was to describe CD4+ decline after discontinuation of ARV prophylaxis post-delivery among HIVinfected women not eligible for ART in a large, multi-country cohort of HIV-infected pregnant women and to compare whether this decline varied by PMTCT regimen. We evaluated maternal CD4+ cell count (CD4+) decline after PMTCT prophylaxis in a multi-country HIV care program
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