Detectable Viral Load in Late Pregnancy among Women in the Rwanda Option B+ PMTCT Program: Enrollment Results from the Kabeho Study

Abstract

There are limited viral load (VL) data available from programs implementing “Option B+,” lifelong antiretroviral treatment (ART) to all HIV-positive pregnant and postpartum women, in resource-limited settings. Extent of viral suppression from a prevention of mother-to-child transmission of HIV program in Rwanda was assessed among women enrolled in the Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) Study. ARV drug resistance testing was conducted on women with VL>2000 copies/ml. In April 2013-January 2014, 608 pregnant or early postpartum HIV-positive women were enrolled in 14 facilities. Factors associated with detectable enrollment VL (>20 copies/ml) were examined using generalized estimating equations. The most common antiretroviral regimen (56.7%, 344/607) was tenofovir/lamivudine/efavirenz. Median ART duration was 13.5 months (IQR 3.0–48.8); 76.1% of women were on ART at first antenatal visit. Half of women (315/603) had undetectable RNA-PCR VL and 84.6% (510) had <1,000 copies/ml. Detectable VL increased among those on ART > 36 months compared to those on ART 4–36 months (72/191, 37.7% versus 56/187, 29.9%), though the difference was not significant. The odds of having detectable enrollment VL decreased significantly as duration on ART at enrollment increased (AOR = 0.99, 95% CI: 0.9857, 0.9998, p = 0.043). There was a higher likelihood of detectable VL for women with lower gravidity (AOR = 0.90, 95% CI: 0.84, 0.97, p = 0.0039), no education (AOR = 2.25, (95% CI: 1.37, 3.70, p = 0.0004), nondisclosure to partner (AOR = 1.97, 95% CI: 1.21, 3.21, p = 0.0063) and side effects (AOR = 2.63, 95% CI: 1.72, 4.03, p<0.0001). ARV drug resistance mutations were detected in all of the eleven women on ART > 36 months with genotyping available. Most women were receiving ART at first antenatal visit, with relatively high viral suppression rates. Shorter ART duration was associated with higher VL, with a concerning increasing trend for higher viremia and drug resistance among women on ART for >3 years.

Viraemia before, during and after pregnancy in HIV‐infected women on antiretroviral therapy in rural KwaZulu‐Natal, South Africa, 2010–2015

“…Longer ART duration should reduce viraemia risk as viral reservoirs decline over time . In this study, longer ART duration independently increased the risk of viraemia, consistent with the higher viraemia trend around delivery among Rwandan women on ART for >3 years . However, when ART duration was combined with viraemia risk through the pregnancy period, longer ART duration in pregnancy and post‐partum reduced viraemia risk in our study, confirming diminishing VL over time and consistent with a small study in Benin where ART was started in pregnancy .…”

Low detectable postpartum viral load is associated with HIV transmission in Malawi's prevention of mother‐to‐child transmission programme

“…Our VL suppression estimate indicates that the Malawi PMTCT programme is close to reaching the final UNAIDS goal of 90% among HIV‐infected pregnant and breastfeeding women on ART. Similar estimates are documented in the postpartum period in three Option B+ study cohorts: 81.2% among Zimbabwean women at four to twelve weeks , 84% among Malawian women at six months postpartum and 84% among Rwandan women in late pregnancy/early postpartum . Among women who achieve VL suppression, the Malawi PMTCT programme shows remarkable reductions in MTCT.…”

“…Regionally, countries face similar challenges in estimating VL suppression in the Option B+ population and there is a lack of consensus on best practices of VL monitoring for women initiating ART during pregnancy or breastfeeding [6]. Extrapolating from study settings, VL suppression estimates are 84.6% among women enrolled in Option B+ during late pregnancy/early postpartum in Rwanda and 89.6% in Uganda among women starting ART in pregnancy and retained in care at five years [7,8].…”

HIV viral suppression among pregnant and breastfeeding women in routine care in the Kinshasa province: a baseline evaluation of participants in CQI‐PMTCT study

“…The usual clinic and socio‐demographic characteristics known to be associated with retention in care and adherence were also associated with higher viral suppression in our population. At the individual level, being married or cohabiting, not walking to the clinic, disclosure of HIV status were all positively associated with viral suppression . Nonetheless, our finding in that disclosure of HIV status to anyone might negatively affect viral suppression in breastfeeding women warrants further investigations.…”