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      Most women living with HIV can deliver vaginally—National data from Finland 1993–2013

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          Abstract

          Introduction

          Vaginal delivery has been recommended for more than ten years for women living with HIV (WLWH) with good virological control. However, in Europe most WLWH still deliver by cesarean section (CS). Our aim was to assess the rate of vaginal delivery and the indications for CS in WLWH over 20 years in a setting of low overall CS rate.

          Materials and methods

          This was a retrospective study of all WLWH delivering in Finland 1993–2013. We identified the women by combining national health registers and extracted data from patient files.

          Results

          The study comprised 212 women with 290 deliveries. Over 35% of the women delivered several children during the study years. During 2000–2013, with consistent viral load monitoring, 80.0% showed HIV viral loads <50 copies/mL in the last measurement preceding the delivery. Altogether 74.5% of all WLWH delivered vaginally and the rate of both elective CS and emergency CS was 12.8% each. For most CSs (63.5%) the indication was obstetrical, for 28.4% it was avoiding HIV transmission and for 0.7% it was mother’s request. In hospitals with less than ten HIV-related deliveries during the study period, the rate of elective CS was higher than in more experienced hospitals (22.7% versus 10.6% [ p = 0.024]). No perinatal HIV transmissions occurred.

          Conclusions

          Most WLWH can achieve good virological control and deliver vaginally. This will help them to maintain their future child bearing potential and reduce CS-related morbidity.

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          Most cited references18

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          Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission.

          The Women and Infants Transmission Study is a prospective natural history study that has been enrolling HIV-1-infected pregnant women and their infants since 1989. To evaluate the impact of different antiretroviral regimens on perinatal HIV-1 transmission at the population level. Prospective cohort study. Plasma HIV-1 RNA levels were serially measured in 1542 HIV-1-infected women with singleton live births between January 1990 and June 2000. HIV-1 status of the infant. HIV-1 transmission was 20.0% (95% confidence interval [CI], 16.1%-23.9%) for 396 women who not receiving prenatal antiretroviral therapy; 10.4% (95% CI, 8.2%-12.6%) for 710 receiving zidovudine monotherapy; 3.8% (95% CI, 1.1%-6.5%) for 186 receiving dual antiretroviral therapy with no or one highly active drug (Multi-ART); and 1.2% (95% CI, 0-2.5%) for 250 receiving highly active antiretroviral therapy (HAART). Transmission also varied by maternal delivery HIV RNA level: 1.0% for 30,000 copies/mL (p =.0001 for trend). The odds of transmission increased 2.4-fold (95% CI, 1.7-3.5) for every log10 increase in delivery viral load. In multivariate analyses adjusting for maternal viral load, duration of therapy, and other factors, the odds ratio for transmission for women receiving Multi-ART and HAART compared with those receiving ZDV monotherapy was 0.30 (95% CI, 0.09-1.02) and 0.27 (95% CI, 0.08-0.94), respectively. Levels of HIV-1 RNA at delivery and prenatal antiretroviral therapy were independently associated with transmission. The protective effect of therapy increased with the complexity and duration of the regimen. HAART was associated with the lowest rates of transmission.
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            The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1--a meta-analysis of 15 prospective cohort studies. The International Perinatal HIV Group.

            To evaluate the relation between elective cesarean section and vertical transmission of human immunodeficiency virus type 1 (HIV-1), we performed a meta-analysis using data on individual patients from 15 prospective cohort studies. North American and European studies of at least 100 mother-child pairs were included in the meta-analysis. Uniform definitions of modes of delivery were used. Elective cesarean sections were defined as those performed before onset of labor and rupture of membranes. Multivariate logistic-regression analysis was used to adjust for other factors known to be associated with vertical transmission. The primary analysis included data on 8533 mother-child pairs. After adjustment for receipt of antiretroviral therapy, maternal stage of disease, and infant birth weight, the likelihood of vertical transmission of HIV-1 was decreased by approximately 50 percent with elective cesarean section, as compared with other modes of delivery (adjusted odds ratio, 0.43; 95 percent confidence interval, 0.33 to 0.56). The results were similar when the study population was limited to those with rupture of membranes shortly before delivery. The likelihood of transmission was reduced by approximately 87 percent with both elective cesarean section and receipt of antiretroviral therapy during the prenatal, intrapartum, and neonatal periods, as compared with other modes of delivery and the absence of therapy (adjusted odds ratio, 0.13; 95 percent confidence interval, 0.09 to 0.19). Among mother-child pairs receiving antiretroviral therapy during the prenatal, intrapartum, and neonatal periods, rates of vertical transmission were 2.0 percent among the 196 mothers who underwent elective cesarean section and 7.3 percent among the 1255 mothers with other modes of delivery. The results of this meta-analysis suggest that elective cesarean section reduces the risk of transmission of HIV-1 from mother to child independently of the effects of treatment with zidovudine.
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              Elective caesarean-section versus vaginal delivery in prevention of vertical HIV-1 transmission: a randomised clinical trial.

              (1999)
              Results from observational studies suggest that caesarean-section delivery may reduce the risk of mother-to-child transmission of HIV-1 infection in comparison with vaginal delivery. We carried out a randomised clinical trial to address this issue and to assess the extent of postdelivery complications. Eligible women were between 34 and 36 weeks of pregnancy, with a confirmed diagnosis of HIV-1 infection, and without an indication for caesarean-section delivery or a contraindication to this mode of delivery. Women were randomly assigned elective caesarean-section delivery at 38 weeks of pregnancy or vaginal delivery. An infant was classified as uninfected if he or she became negative for antibody to HIV-1 by age 18 months or was negative for virus by PCR or culture on at least two occasions, with no clinical, immunological, or viral evidence of infection. From 1993, to March, 1998, 436 women were randomised. We present the results of an analysis updated to November, 1998, with data on the infection status of 370 infants. Three (1.8%) of 170 infants born to women assigned caesarean-section delivery were infected, compared with 21 (10.5%) of 200 born to women assigned vaginal delivery (p<0.001). Seven (3.4%) of 203 infants of women who actually gave birth by caesarean section were infected compared with 15 (10.2%) of 167 born vaginally (p=0.009). There were few postpartum complications and no serious adverse events in either group. Our findings provide evidence that elective caesarean-section delivery significantly lowers the risk of mother-to-child transmission of HIV-1 infection without a significantly increased risk of complications for the mother.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: Project administrationRole: Writing – original draft
                Role: Data curationRole: InvestigationRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: Project administrationRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                22 March 2018
                2018
                : 13
                : 3
                : e0194370
                Affiliations
                [1 ] Department of Infectious diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
                [2 ] Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
                [3 ] National Institute of Health and Welfare, Oulu and Faculty of Medicine, University of Oulu, Oulu, Finland
                Massachusetts General Hospital, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                ¶ Membership of the FINHIVPREG Study Team is provided in the Acknowledgments.

                Author information
                http://orcid.org/0000-0002-0281-8485
                Article
                PONE-D-17-40305
                10.1371/journal.pone.0194370
                5864005
                29566017
                a90114ae-b340-4c33-9eae-8e86bbb55228
                © 2018 Aho et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 14 November 2017
                : 1 March 2018
                Page count
                Figures: 1, Tables: 2, Pages: 9
                Funding
                Funded by: Finnsh Medical Foundation
                Award Recipient :
                Funded by: Infektiotautien tutkimusyhdistys
                Award Recipient :
                IA has received non-restricted grants from the Finnish Medical Association and Infektiotautien tutkimusyhdistys. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Biology and Life Sciences
                Organisms
                Viruses
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Biology and Life Sciences
                Organisms
                Viruses
                Immunodeficiency Viruses
                HIV
                Biology and life sciences
                Organisms
                Viruses
                RNA viruses
                Retroviruses
                Lentivirus
                HIV
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Retroviruses
                Lentivirus
                HIV
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Viral Pathogens
                Retroviruses
                Lentivirus
                HIV
                Biology and Life Sciences
                Organisms
                Viruses
                Viral Pathogens
                Retroviruses
                Lentivirus
                HIV
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Birth
                Labor and Delivery
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Birth
                Labor and Delivery
                Biology and Life Sciences
                Microbiology
                Virology
                Viral Transmission and Infection
                Viral Load
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Pregnancy
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Pregnancy
                People and places
                Geographical locations
                Europe
                European Union
                Finland
                Medicine and Health Sciences
                Health Care
                Health Care Facilities
                Hospitals
                Medicine and health sciences
                Diagnostic medicine
                HIV diagnosis and management
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Obstetric Procedures
                Cesarean Section
                Custom metadata
                Due to patient privacy restrictions data cannot be made publicly available. The authors of this study hold data with the permission of the Ethics committee of the Helsinki University Hospital and the National Institute of Health and Welfare. Access to data can be requested by an application to the Ethics committee of the Helsinki University Hospital. Detailed information can be obtained from the secretariat of the Ethics committee ( eettiset.toimikunnat@ 123456hus.fi tel. +358947172118). After the permission from the Ethics committee an application to the National Institute of Health and Welfare is needed to get access to the data. Information on the process at the National Institute of Health and Welfare can be obtained from the Director of Information Services, Pekka Kahri (tel. +358295246146; pekka.kahri@ 123456thl.fi ).

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