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      Immunologic status and virologic outcomes in repeat pregnancies to HIV-positive women not on antiretroviral therapy at conception: a case for lifelong antiretroviral therapy?

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          Abstract

          During their second pregnancy with diagnosed HIV ( n = 1177), two-fifths of women in the UK/Ireland not on antiretroviral therapy (ART) at conception had an immunological indication for treatment (CD4 + <350 cells/μl), of whom nearly half had CD4 + at least 350 cells/μl in their previous pregnancy. Those initiating ART during pregnancy had a 4.3-fold increased odds of detectable viral load at delivery compared with those conceiving on treatment, suggesting that continuation of ART after pregnancy may be beneficial for many women.

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          CD4+ count-guided interruption of antiretroviral treatment.

          B. Gazzard, Richard A. Phillips, G Fätkenheuer … (2006)
          Despite declines in morbidity and mortality with the use of combination antiretroviral therapy, its effectiveness is limited by adverse events, problems with adherence, and resistance of the human immunodeficiency virus (HIV). We randomly assigned persons infected with HIV who had a CD4+ cell count of more than 350 per cubic millimeter to the continuous use of antiretroviral therapy (the viral suppression group) or the episodic use of antiretroviral therapy (the drug conservation group). Episodic use involved the deferral of therapy until the CD4+ count decreased to less than 250 per cubic millimeter and then the use of therapy until the CD4+ count increased to more than 350 per cubic millimeter. The primary end point was the development of an opportunistic disease or death from any cause. An important secondary end point was major cardiovascular, renal, or hepatic disease. A total of 5472 participants (2720 assigned to drug conservation and 2752 to viral suppression) were followed for an average of 16 months before the protocol was modified for the drug conservation group. At baseline, the median and nadir CD4+ counts were 597 per cubic millimeter and 250 per cubic millimeter, respectively, and 71.7% of participants had plasma HIV RNA levels of 400 copies or less per milliliter. Opportunistic disease or death from any cause occurred in 120 participants (3.3 events per 100 person-years) in the drug conservation group and 47 participants (1.3 per 100 person-years) in the viral suppression group (hazard ratio for the drug conservation group vs. the viral suppression group, 2.6; 95% confidence interval [CI], 1.9 to 3.7; P<0.001). Hazard ratios for death from any cause and for major cardiovascular, renal, and hepatic disease were 1.8 (95% CI, 1.2 to 2.9; P=0.007) and 1.7 (95% CI, 1.1 to 2.5; P=0.009), respectively. Adjustment for the latest CD4+ count and HIV RNA level (as time-updated covariates) reduced the hazard ratio for the primary end point from 2.6 to 1.5 (95% CI, 1.0 to 2.1). Episodic antiretroviral therapy guided by the CD4+ count, as used in our study, significantly increased the risk of opportunistic disease or death from any cause, as compared with continuous antiretroviral therapy, largely as a consequence of lowering the CD4+ cell count and increasing the viral load. Episodic antiretroviral therapy does not reduce the risk of adverse events that have been associated with antiretroviral therapy. (ClinicalTrials.gov number, NCT00027352 [ClinicalTrials.gov].). Copyright 2006 Massachusetts Medical Society.
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            Mother-to-child transmission of HIV infection in the era of highly active antiretroviral therapy.

            (2005)
            Very low rates of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) are achievable with use of highly active antiretroviral therapy (HAART). We examine risk factors for MTCT in the HAART era and describe infants who were vertically infected, despite exposure to prophylactic MTCT interventions. Of the 4525 mother-child pairs in this prospective cohort study, 1983 were enrolled during the period of January 1997 through May 2004. Factors examined included use of antiretroviral therapy during pregnancy, maternal CD4 cell count and HIV RNA level, mode of delivery, and gestational age in logistic regression analysis. Receipt of antenatal antiretroviral therapy increased from 5% at the start of the HAART era to 92% in 2001-2003. The overall MTCT rate in this period was 2.87% (95% confidence interval [CI], 2.11%-3.81%), but it was 0.99% (95% CI, 0.32%-2.30%) during 2001-2003. In logistic regression analysis that included 885 mother-child pairs, MTCT risk was associated with high maternal viral load (adjusted odds ratio [AOR], 12.1; P=.003) and elective Caesarean section (AOR, 0.33; P=.04). Detection of maternal HIV RNA was significantly associated with antenatal use of antiretroviral therapy, CD4 cell count, and mode of delivery. Among 560 women with undetectable HIV RNA levels, elective Caesarean section was associated with a 90% reduction in MTCT risk (odds ratio, 0.10; 95% CI, 0.03-0.33), compared with vaginal delivery or emergency Caesarean section. Our results suggest that offering an elective Caesarean section delivery to all HIV-infected women, even in areas where HAART is available, is appropriate clinical management, especially for persons with detectable viral loads. Our results also suggest that previously identified risk factors remain important.
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              British HIV Association Guidelines for the treatment of HIV-1-infected adults with antiretroviral therapy 2008.

              Barry Peters, Brian Gazzard, Ian Williams … (2008)
              Article 0 comments Cited 84 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): AIDS
                Journal ID (iso-abbrev): AIDS
                Journal ID (publisher-id): AIDS
                Title: AIDS (London, England)
                Publisher: Lippincott Williams & Wilkins
                ISSN (Print): 0269-9370
                ISSN (Electronic): 1473-5571
                Publication date (Print): 1 June 2014
                Publication date (Electronic): 14 May 2014
                Volume: 28
                Issue: 9
                Pages: 1369-1372
                Affiliations
                [a ]Population, Policy and Practice Programme, UCL Institute of Child Health, University College London, UK
                [b ]School of Health Sciences, City University London, UK.
                Author notes
                Correspondence to Clare E. French, BSc, MSc, Population, Policy and Practice Programme, UCL Institute of Child Health, 30 Guilford St, London WC1N 1EH, UK. E-mail: clare.french.09@ 123456ucl.ac.uk
                Article
                DOI: 10.1097/QAD.0000000000000282
                PMC ID: 4032213
                PubMed ID: 24685820
                SO-VID: aea386fd-152e-4088-842f-dccab67a4b92
                Copyright © © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivitives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

                History
                Date received : 6 February 2014
                Date revision received : 10 March 2014
                Date accepted : 11 March 2014
                Categories
                Subject: Research Letter
                Custom metadata
                OPEN-ACCESS TRUE

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