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

BMC Pregnancy and Childbirth

Elaine Abrams²  Linda-Gail Bekker¹  Rose Zulliger⁴  Landon Myer³ 

[1]Desmond Tutu HIV Centre, Institute of Infectious Diseases & Molecular Medicine, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa

[2]ICAP, Mailman School of Public Health & College of Physicians & Surgeons, Columbia University, 722 West 168th Street, New York, New York, 10032, USA

[3]Centre for Infectious Diseases Epidemiologic Research, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa

[4]Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, Maryland, 21205, USA

关键词: South Africa;    HIV/AIDS;    Prevention of mother-to-child transmission (PMTCT);    Patient preparation;    Pregnancy;    Antiretroviral therapy;   

Others  :  1152339
DOI  :  10.1186/1471-2393-12-94

 received in 2012-06-12, accepted in 2012-09-06,  发布年份 2012

【 摘 要 】

Background

Antiretroviral 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.

Methods

We 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.

Results

A 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.

Conclusions

A 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.

【 授权许可】

   
2012 Myer et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

【 参考文献 】

• [1]UNAIDS: Global report: UNAIDS report on the global AIDS epidemic, 2010. UNAIDS: UNAIDS/10.11E JC1958E, Geneva; 2010.
• [2]South African National Department of Health: The 2010 National Antenatal Sentinel HIV & Syphilis Prevalence Survey in South Africa. Directorate: Epidemiology & Surveillance, National Department of Health, Pretoria; 2011.
• [3]Kuhn L, Aldrovandi GM, Sinkala M, Kankasa C, Mwiya M, Thea DM: Potential impact of new WHO criteria for antiretroviral treatment for prevention of mother-to-child HIV transmission. AIDS 2010, 24:1374-1377.
• [4]Abrams EJ, Myer L, Rosenfield A, El-Sadr WM: Prevention of mother-to-child transmission services as a gateway to family-based human immunodeficiency virus care and treatment in resource-limited settings: rationale and international experiences. Am J Obstet Gynecol 2007, 197:S101-S106.
• [5]European Collaborative Study: Time to Undetectable Viral Load after Highly Active Antiretroviral Therapy Initiation among HIV-Infected Pregnant Women. Clin Infect Dis 2007, 44:1647-1656.
• [6]Townsend CL, Cortina-Borja M, Peckham CS, de Ruiter A, Lyall H, Tookey PA: Low rates of mother-to-child transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000–2006. AIDS 2008, 22:973-981.
• [7]Fitzgerald FC, Bekker L-G, Kaplan R, Myer L, Lawn SD, Wood R: Mother-to-child transmission of HIV in a community-based antiretroviral clinic in South Africa. S Afr Med J 2010, 100:827-831.
• [8]Hoffman RM, Black V, Technau K, Van Der Merwe KJ, Currier J, Coovadia A, Chersich M: Effects of Highly Active Antiretroviral Therapy Duration and Regimen on Risk for Mother-to-Child Transmission of HIV in Johannesburg, South Africa. J Acquir Immune Defic Syndr 2010, 54:35-41.
• [9]Chibwesha CJ, Giganti MJ, Putta N, Chintu N, Mulindwa J, Dorton BJ, Chi BH, Stringer JS, Stringer EM: Optimal Time on HAART for Prevention of Mother-to-Child Transmission of HIV. J Acquir Immune Defic Syndr 2011, 58:224-228.
• [10]Myer L: Initiating antiretroviral therapy in pregnancy: the importance of timing. J Acquir Immune Defic Syndr 2011, 58:125-126.
• [11]Ferguson L, Grant AD, Watson-Jones D, Kahawita T, Ong’ech JO, Ross DA: Linking women who test HIV-positive in pregnancy-related services to long-term HIV care and treatment services: a systematic review. Trop Med Int Health 2012, 17:564-580.
• [12]Stinson K, Boulle A, Coetzee D, Abrams EJ, Myer L: Initiation of highly active antiretroviral therapy among pregnant women in Cape Town, South Africa. Trop Med Int Health 2010, 15:825-832.
• [13]Carter RJ, Dugan K, El-Sadr WM, Myer L, Otieno J, Pungpapong N, Toro PL, Abrams EJ: CD4+ cell count testing more effective than HIV disease clinical staging in identifying pregnant and postpartum women eligible for antiretroviral therapy in resource-limited settings. J Acquir Immune Defic Syndr 2010, 55:404-410.
• [14]Myer L, Zulliger R, Pienaar D: Diversity of patient preparation activities before initiation of antiretroviral therapy in Cape Town, South Africa. Tropical Medicine & International Healthin press
• [15]Kwaan L, Kindra G, Mdutyana L, Coutsoudis A: Prevention is better than cure – the art of avoiding non-adherence to antiretroviral treatment. Southern African Journal of HIV Medicine 2010, 11:8-11.
• [16]Gebrekristos HT, Mlisana KP, Karim QA: Patients’ readiness to start highly active antiretroviral treatment for HIV. BMJ 2005, 331:772-775.
• [17]Coetzee D, Boulle A, Hildebrand K, Asselman V, Van Cutsem G, Goemaere E: Promoting adherence to antiretroviral therapy: the experience from a primary care setting in Khayelitsha, South Africa. AIDS 2004, 18(Suppl 3):S27-S31.
• [18]Siedner MJ, Lankowskei A, Haberer J, Kembabazi A, Emenyonu N, Tsai AC, Muzoora C, Geng E, Martin JN, Bangsberg DR: Rethinking the “Pre” in Pre-Therapy Counseling: No Benefit of Additional Visits Prior to Therapy on Adherence or Viremia in Ugandans Initiating ARVs. PLoS One 2012, 7:e39894.
• [19]Bekker LG, Orrell C, Reader L, Matoti K, Cohen K, Martell R, Abdullah F, Wood R: Antiretroviral therapy in a community clinic–early lessons from a pilot project. S Afr Med J 2003, 93:458-462.
• [20]Bekker LG, Myer L, Orrell C, Lawn S, Wood R: Rapid scale-up of a community-based HIV treatment service: programme performance over 3 consecutive years in Guguletu, South Africa. S Afr Med J 2006, 96:315-320.
• [21]Read PJ, Mandalia S, Khan P, Harrisson U, Naftalin C, Gilleece Y, Anderson J, Hawkins DA, Taylor GP, de Ruiter A: When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery? AIDS 2012, 26:1095-103.
• [22]Stinson K, Myer L: Barriers to initiating antiretroviral therapy during pregnancy: a qualitative study of women attending services in Cape Town, South Africa. African Journal of AIDS Research 2012, 11:65-73.
• [23]Grimes RM, Grimes DE: Readiness: the state of the science (or the lack thereof). Curr HIV/AIDS Rep 2010, 7:245-252.
• [24]Lawn SD, Myer L, Orrell C, Bekker LG, Wood R: Early mortality among adults accessing a community-based antiretroviral service in South Africa: implications for programme design. AIDS 2005, 19:2141-2148.
• [25]Abdool Karim SS, Naidoo K, Grobler A, Padayatchi N, Baxter C, Gray A, Gengiah T, Nair G, Bamber S, Singh A, et al.: Timing of initiation of antiretroviral drugs during tuberculosis therapy. N Engl J Med 2010, 362:697-706.
• [26]Violari A, Cotton MF, Gibb DM, Babiker AG, Steyn J, Madhi SA, Jean-Philippe P, McIntyre JA: Early antiretroviral therapy and mortality among HIV-infected infants. N Engl J Med 2008, 359:2233-2244.
• [27]Makadzange AT, Ndhlovu CE, Takarinda K, Reid M, Kurangwa M, Gona P, Hakim JG: Early versus delayed initiation of antiretroviral therapy for concurrent HIV infection and cryptococcal meningitis in sub-saharan Africa. Clin Infect Dis 2010, 50:1532-1538.
• [28]Zolfo M, Anja , Schouten E, Lynen L: Time for “Test and Treat” in Prevention of Mother-to-Child Transmission Programs in Low- and Middle-Income Countries. J Acquir Immune Defic Syndr 2010, 55:287-289.
• [29]Schouten EJ, Jahn A, Midiani D, Makombe SD, Mnthambala A, Chirwa Z, Harries AD, van Oosterhout JJ, Meguid T, Ben-Smith A, et al.: Prevention of mother-to-child transmission of HIV and the health-related Millennium Development Goals: time for a public health approach. Lancet 2011, 378:282-284.
• [30]Greenland S, Neutra R: Control of confounding in the assessment of medical technology. Int J Epidemiol 1980, 9:361-367.
• [31]Kitahata MM, Gange SJ, Abraham AG, Merriman B, Saag MS, Justice AC, Hogg RS, Deeks SG, Eron JJ, Brooks JT, et al.: Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med 2009, 360:1815-1826.
• [32]Bosco JL, Silliman RA, Thwin SS, Geiger AM, Buist DS, Prout MN, Yood MU, Haque R, Wei F, Lash TL: A most stubborn bias: no adjustment method fully resolves confounding by indication in observational studies. J Clin Epidemiol 2010, 63:64-74.
• [33]Coutsoudis A, England K, Rollins N, Coovadia H, Newell M-L, Bland R: Women’ s morbidity and mortality in the first 2 years after delivery according to HIV status. AIDS 2010, 24:2859-2866.
• [34]Myer L, Zulliger R, Black S, Pienaar D, Bekker LG: Pilot programme for the rapid initiation of antiretroviral therapy in pregnancy in Cape Town, South Africa. AIDS Care 2012, 24:986-992.