Immunologic status and virologic outcomes in repeat pregnancies to HIV-positive women not on antiretroviral therapy at conception

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.

Presentation for care and antenatal management of HIV in the UK, 2009−2014

“…Women with a prior HIV diagnosis, many of whom will have been diagnosed during a previous pregnancy , should be receiving ongoing HIV care, which might be expected to facilitate early ART initiation in subsequent pregnancies. However, we have previously demonstrated that retention in HIV care after delivery may be suboptimal, with two‐fifths of women presenting with a second pregnancy not being on treatment despite an immunological indication . Women not on ART at conception booked later than those conceiving on treatment, which is of concern as timely booking and prompt referral to HIV services are needed, especially for those with low CD4 counts.…”

Rate, correlates and outcomes of repeat pregnancy in HIV‐infected women

“…The observed lower rate of preterm delivery in subsequent pregnancies, in the presence of a higher rate of antiretroviral therapy coverage at conception, does not exclude per se an association between antiretroviral therapy and preterm delivery, but highlights the importance of the timing of the start of antiretroviral therapy, consistent with the hypothesis of a higher risk of preterm delivery with antiretroviral therapy started in pregnancy compared with treatment started before pregnancy . Clinical HIV progression to AIDS, during or between pregnancies, was almost absent (0.3%), and immunological decline (to < 350 cells/mL) between two sequential pregnancies was also infrequent (14.7%), and even lower than in other studies (25.9% in a recent UK/Ireland study) . A new finding of our study was that voluntary pregnancy termination was significantly more common in the second pregnancy.…”

Postnatal retention in HIV care: insight from the Swiss HIV Cohort Study over a 15‐year observational period

“…We found that 17% of women in our cohort had a subsequent pregnancy. A recent study from the UK showed that HIV-infected women not on ART at conception of their second pregnancy were nearly five times more likely to have a detectable VL at delivery, the pre-eminent risk factor for MTCT [23]. This implies that lack of continuity between antenatal and general HIV care and long periods of LTFU after childbirth can cause delays in women re-accessing HIV care and starting ART during their subsequent pregnancy.…”

“…This shows that women with LTFU after delivery are at an increased risk with respect to their own health as they miss regular monitoring to ensure that treatment is started in a timely manner once it is indicated by reaching the CD4 threshold or because of HIV-associated diseases even at high CD4 counts. The UK and Ireland National Study of HIV in Pregnancy and Childhood showed that nearly 40% of women had an immunological indication for ART at the start of their second pregnancy, of whom nearly half had reported CD4 counts ≥ 350 cells/μL at their first pregnancy [23]. A Brazilian study revealed that a baseline CD4 cell count of 200-500 cells/μL was a significant predictor of progressing to clinical WHO stage 2 and 3 for women who stopped ART after delivery [24].…”

“…Gestational age was reported to the nearest completed week based on ultrasound or last menstrual period. The first trimester was defined as 1-12 weeks, the second trimester as [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] weeks, and the third trimester as 28 weeks of gestation onwards. The period of interest was the period after delivery and the main outcome was the time interval between clinical visits in the year after delivery.…”