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      Antiretroviral treatment, viral load of mothers & perinatal HIV transmission in Mumbai, India

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          Abstract

          Background & objectives:

          Mother-to-child transmission (MTCT) is the most significant route of HIV transmission in children below the age of 15 yr. In India, perinatal HIV transmission, even after treatment, accounts for 5.4 per cent of HIV cases. The present study was conducted to evaluate the efficacy of anti-retro viral therapy (ART) or prophylactic treatment (PT) to control maternal viral load in HIV positive women, and its effect on vertical HIV transmission to their infants.

          Methods:

          A total of 58 HIV positive women were enrolled at the time of delivery and their plasma samples were obtained within 24 h of delivery for estimation of viral load. Viral load analysis was completed in 38 women. Infants received single dose nevirapine within 2 h of birth and zidovudine for 6 wk. At the end of 18 month follow up, HIV positive or negative status was available in 28 infants.

          Results:

          Results revealed undetectable levels of viral load in 58.3 per cent of women with ART compared to 30.7 per cent of women with PT. No women on ART had viral load more than 10,000 copies/ml, whereas seven (26.9%, P=0.07) women receiving PT had this viral load. Median CD4 count of women on PT (483 cells/μl) was high compared to the women on ART (289 cells/ μl). At the end of 18 months follow up, only two children were HIV positive, whose mothers were on PT. One had in utero transmission; infection detected within 48 h of delivery, while the other child was infected post partum as HIV was detected at six months follow up.

          Interpretation & conclusions:

          Women who received a single dose of nevirapine during delivery had higher levels of viral load than women on ART. Combination drug therapy for pregnant women is now a standard of care in most of the western countries; use of nevirapine monotherapy at the time of delivery in our settings is not effective in controlling viral load. This highlights initiation of ART in pregnant women to control their viral load and thus to inhibit mother to child HIV transmission.

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          Most cited references27

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

          Karen Hayani, I. Hanson, William Blattner … (2002)
          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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            Perinatal transmission of human immunodeficiency virus type 1 by pregnant women with RNA virus loads <1000 copies/ml.

            Steven Shapiro, L Mofenson, Roland A. Ammann … (2001)
            In a collaboration of 7 European and United States prospective studies, 44 cases of vertical human immunodeficiency virus type 1 (HIV-1) transmission were identified among 1202 women with RNA virus loads 500 copies/mL. Perinatal HIV-1 transmission occurs in only 1% of treated women with RNA virus loads <1000 copies/mL and may be almost eliminated with antiretroviral prophylaxis accompanied by suppression of maternal viremia.
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              Factors associated with mother-to-child transmission of HIV-1 despite a maternal viral load <500 copies/ml at delivery: a case-control study nested in the French perinatal cohort (EPF-ANRS CO1).

              Josiane Warszawski, Roland Tubiana, Jerome Le Chenadec … (2010)
              The rate of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) type 1 is as low as 0.5% in non-breast-feeding mothers who delivered at term while receiving antiretroviral therapy with a plasma viral load <500 copies/mL. This situation accounted for 20% of the infected children born during the period 1997-2006 in the French Perinatal Cohort. We aimed to identify factors associated with such residual transmission risk. We performed a case-control study nested in the aforementioned subpopulation of the French Perinatal Cohort. Nineteen case patients (transmitters) and 60 control subjects (nontransmitters) were included. Case patients and control subjects did not differ by geographical origin, gestational age at HIV diagnosis, type of antiretroviral therapy received, or elective Cesarean delivery. Case patients were less often receiving treatment at the time that they conceived pregnancy than control subjects (16% vs 45%; P=.017). A lower proportion of case patients had a viral load <500 copies/mL, compared with control subjects, at 14 weeks (0% vs 38.1%; P=.02), 28 weeks (7.7% vs 62.1%; P=.005), and 32 weeks: (21.4% vs 71.1%; P=.004). The difference remained significant when we restricted analysis to the 10 of 16 intrapartum transmission cases. In a multivariate analysis at 30+/-4 weeks adjusted for viral load, CD4(+) T cell count, and time at antiretroviral therapy initiation, viral load was the only factor independently associated with MTCT of HIV (adjusted odds ratio, 23.2; 95% confidence interval, 3.5-553; P<.001). Early and sustained control of viral load is associated with a decreasing residual risk of MTCT of HIV-1. Guidelines should take into account not only CD4(+) T cell count and risk of preterm delivery, but also baseline HIV-1 load for deciding when to start antiretroviral therapy during pregnancy.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Indian J Med Res
                Journal ID (iso-abbrev): Indian J. Med. Res
                Journal ID (publisher-id): IJMR
                Title: The Indian Journal of Medical Research
                Publisher: Medknow Publications & Media Pvt Ltd (India )
                ISSN (Print): 0971-5916
                ISSN (Electronic): 0975-9174
                Publication date (Print): August 2013
                Volume: 138
                Issue: 2
                Pages: 201-208
                Affiliations
                [1] Department of Infectious Diseases Biology, National Institute for Research in Reproductive Health (ICMR), Mumbai, India
                [* ] Department of Obstetrics & Gynaecology, Seth G.S. Medical College & K.E.M. Hospital, Mumbai, India
                [** ] Department of Neonatology, Seth G.S. Medical College & K.E.M. Hospital, Mumbai, India
                [+ ] Department of Microbiology, Seth G.S. Medical College & K.E.M. Hospital, Mumbai, India
                Author notes
                Reprint requests: Dr Jayanti Mania-Pramanik, National Institute for Research in Reproductive Health (ICMR), J.M. Street, Parel, Mumbai 400 012, India e-mail: jayantimania@ 123456rediffmail.com
                Article
                Publisher ID: IJMR-138-201
                PMC ID: 3788205
                PubMed ID: 24056596
                SO-VID: cca0d1b7-1ab1-4449-aa8b-dbfb151af0fc
                Copyright © Copyright: © The Indian Journal of Medical Research
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 01 March 2012
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Medicine
                Keywords: art,mtct,perinatal hiv transmission,prophylactic treatment,viral load
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: art, mtct, perinatal hiv transmission, prophylactic treatment, viral load

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