Systemic delays in the initiation of antiretroviral therapy during pregnancy do not improve outcomes of HIV-positive mothers: a cohort study

Landon Myer,Rose Zulliger,Elaine Abrams,Linda-Gail Bekker

doi:10.1186/1471-2393-12-94

Abstract

BackgroundAntiretroviral therapy (ART) initiation in eligible HIV-infected pregnant women is an important intervention to promote maternal and child health. Increasing the duration of ART received before delivery plays a major role in preventing vertical HIV transmission, but pregnant women across Africa experience significant delays in starting ART, partly due the perceived need to deliver ART counseling and patient education before ART initiation. We examined whether delaying ART to provide pre-ART counseling was associated with improved outcomes among HIV-infected women in Cape Town, South Africa.MethodsWe undertook a retrospective cohort study of 490 HIV-infected pregnant women referred to initiate treatment at an urban ART clinic. At this clinic all patients including pregnant women are screened by a clinician and then undergo three sessions of counseling and patient education prior to starting treatment, commonly introducing delays of 2–4 weeks before ART initiation. Data on viral suppression and retention in care after ART initiation were taken from routine clinic records.ResultsA total of 382 women initiated ART before delivery (78%); ART initiation before delivery was associated with earlier gestational age at presentation to the ART service (p < 0.001). The median delay between screening and ART initiation was 21 days (IQR, 14–29 days). Overall, 84.7%, 79.6% and 75.0% of women who were pregnant at the time of ART initiation were retained in care at 4, 8 and 12 months after ART initiation, respectively. Among those retained, 91% were virally suppressed at each follow-up visit. However the delay from screening to ART initiation was not associated with retention in care and/or viral suppression throughout the first year on ART in unadjusted or adjusted analyses.ConclusionsA substantial proportion of eligible pregnant women referred for ART do not begin treatment before delivery in this setting. Among women who do initiate ART, delaying initiation for patient preparation is not associated with improved maternal outcomes. Given the need to maximize the duration of ART before delivery for prevention of mother-to-child HIV transmission, there is an urgent need for new strategies to help expedite ART initiation in eligible pregnant women.

Highlights

Antiretroviral therapy (ART) initiation in eligible HIV-infected pregnant women is an important intervention to promote maternal and child health
We examined the association between delays to ART initiation and women’s subsequent retention in care and viral suppression during the first 12 months after ART initiation using log-linked regression models with robust standard errors
In the model building process, we examined a range of potential variables of interest, including calendar year and baseline demographic, clinical and laboratory measures; variables were retained in the analysis if they were the a priori exposures of interest, if they were independently associated with the outcome of interest, or if their inclusion changed other associations in the model appreciably

Summary

Introduction

Antiretroviral therapy (ART) initiation in eligible HIV-infected pregnant women is an important intervention to promote maternal and child health. Because most perinatal HIV transmission takes place in women with advanced HIV disease who are eligible for lifelong antiretroviral therapy (ART) [3], ART initiation in pregnancy is a critical intervention both for PMTCT and for the long-term health of mothers [4]. In this context, increasing the time on ART before delivery contributes to reductions in viraemia and decreases the risk of HIV transmission in utero, during labour and delivery, and postpartum when breastfeeding [5,6]. The systems for adult ART initiation are focused on the needs of the general adult population of non-pregnant women and men, as pregnant women comprise only a small fraction of new patients. [4,13] In the general population of nonpregnant adults, systemic delays in ART initiation are routinely used to allow time for patient education and psychosocial preparation before treatment [14], based on the idea that patient preparation before initiation may improve retention in care and treatment adherence over time [15,16,17], evidence for this is lacking [18]

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