Abstract
BackgroundHIV infection is a major contributor to maternal mortality in resource-limited settings. The Drug Resource Enhancement Against AIDS and Malnutrition Programme has been promoting HAART use during pregnancy and postpartum for Prevention-of-mother-to-child-HIV transmission (PMTCT) irrespective of maternal CD4 cell counts since 2002.MethodsRecords for all HIV+ pregnancies followed in Mozambique and Malawi from 6/2002 to 6/2010 were reviewed. The cohort was comprised by pregnancies where women were referred for PMTCT and started HAART during prenatal care (n = 8172, group 1) and pregnancies where women were referred on established HAART (n = 1978, group 2).Results10,150 pregnancies were followed. Median (IQR) baseline values were age 26 years (IQR:23–30), CD4 count 392 cells/mm3 (IQR:258–563), Viral Load log10 3.9 (IQR:3.2–4.4), BMI 23.4 (IQR:21.5–25.7), Hemoglobin 10.0 (IQR: 9.0–11.0). 101 maternal deaths (0.99%) occurred during pregnancy to 6 weeks postpartum: 87 (1.1%) in group 1 and 14 (0.7%) in group 2. Mortality was 1.3% in women with <than 350 CD4 cells/mm3 and 0.7% in women with greater than 350 CD4s cells/mm3 [OR = 1.9 (CL 1.3–2.9) p = 0.001]. Mortality was higher in patients with shorter antenatal HAART: 22/991 (2.2%) if less than 30 days and 79/9159 (0.9%) if 31 days or greater [OR = 2.6 (CL 1.6–4.2) p<0.001]. By multivariate analysis, shorter antenatal HAART (p<0.001), baseline values for CD4 cell count (p = 0.012), hemoglobin (p = 0.02), and BMI (p<0.001) were associated with mortality. Four years later, survival was 92% for women with shorter antenatal HAART and 98% for women on established therapy prior to pregnancy, p = 0.001.ConclusionsAntiretrovirals for PMTCT purposes have significant impact on maternal mortality as do CD4 counts and nutritional status. In resource-limited settings, PMTCT programs should provide universal HAART to all HIV+ pregnant women given its impact in prevention of maternal death.
Highlights
Maternal death classically encompasses the period of pregnancy until 42 days after the termination of gestation, and is attributable to causes related or aggravated by pregnancy or its management
In 2010, for example, 287,000 maternal deaths were reported globally, of which 56% occurred in Sub-Saharan Africa, where the average Maternal Mortality Rate (MMR) was 500 deaths per 100,000 live births with 10% of deaths occurring as a direct consequence of HIV infection [1]
We previously reported a significant association between extended antenatal Highly Active Antiretroviral Therapy (HAART) and reduced maternal mortality and improved pregnancy outcomes in a cohort of 3000 HIV-infected pregnant women followed in the program [3]
Summary
Maternal death classically encompasses the period of pregnancy until 42 days after the termination of gestation, and is attributable to causes related or aggravated by pregnancy or its management. Pregnancy related-deaths, are defined as maternal deaths occurring during the same time period irrespective of cause. Late maternal deaths encompass the period between 42 days post pregnancy up to one year within termination of gestation and include deaths from direct or indirect obstetric causes. Pregnancy is a condition which tends to worsen HIV infection and its co-morbidities Due to these differences in categorization and timing of maternal mortality, it is difficult for surveillance programs to gauge the impact of HIV on maternal mortality and the impact of pregnancy on HIV-related deaths. HIV-infection is a major contributor to maternal mortality in resource-limited settings. The Drug Resource Enhancement Against AIDS and Malnutrition Programme has been promoting HAART use during pregnancy and postpartum for Prevention-of-mother-to-child-HIV transmission (PMTCT) irrespective of maternal CD4 cell counts since 2002
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