Safety and Efficacy of Initiating Highly Active Antiretroviral Therapy in an Integrated Antenatal and HIV Clinic in Johannesburg, South Africa

Abstract

Objective To describe the safety and efficacy of highly active antiretroviral therapy (HAART) in pregnant women treated in an integrated antenatal antiretroviral programme (ANC ARV). Methods A retrospective analysis was performed on patients attending the ANC ARV from August 2004 through February 2007. Results Data was collected on 689 treatment-na誰ve pregnant women initiated on HAART. The mean age was 29.2 years. The mean baseline CD4+ count was 154 cells/uL and mean baseline HIV viral load was 101,561 copies/ml. Tuberculosis was the most prevalent presenting opportunistic infection (7.7%). Stavudine, lamivudine, and nevirapine were initiated in 82% of women with the most frequent adverse drug reaction being nevirapine-associated skin rash (3.5%). Mean gestational age at HAART initiation was 27 weeks. Among women with follow-up data, 80% gained 50 or more CD4 cells/uL, and 80.5% achieved viral suppression to <1000 copies/ml. Of 302 mother/infant pairs who completed postnatal follow-up, the HIV transmission rate was 5%. In women who received more than seven weeks of HAART during pregnancy, transmission was 0.3%. Conclusions Within the ANC ARV programme, initiating pregnant women on HAART was feasible, safe, and effective. Advanced gestational age at treatment initiation and loss to follow-up emerge as important challenges in this population.

Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis

“…The remaining 35 full text articles were assessed for eligibility: 29 were excluded because the study's intervention did not meet the definition used in this review; 2 more studies 27,28 were excluded because they lacked a comparator arm (Fig. 1).…”

“…44,45 Indeed, in an integrated South African ANC clinic, fewer than 1% of the women who had been on ART for at least 7 weeks during pregnancy transmitted HIV to their infants. 28 Therefore, optimizing service delivery by minimizing the number of clinic visits and the number of weeks that transpire before initiating ART could reduce losses to care and the risk of vertical HIV transmission. Although the process for delivering ART to eligible pregnant women varies, it generally involves: (i) attendance at an ANC clinic; (ii) provider-initiated HIV testing and counselling; (iii) referral to an HIV clinic; (iv) enrolment in care at the HIV clinic; (v) assessment of eligibility for ART (based on CD4+ Tlymphocyte count and/or WHO clinical stage); (vi) initiation of ART if eligible, and (vii) maintaining high adherence to ART and life-long retention in HIV treatment and care (Fig.…”

“…Furthermore, results from randomized controlled trials were not available; all findings were generated by prospective and retrospective cohort studies, which tend to be more vulnerable to unmeasured selection bias, measurement bias and confounding than cluster-randomized trials. We excluded studies without a comparator arm, 27,28 but descriptive studies can also provide important lessons on feasibility and best practices. Finally, the decision to provide ART in ANC clinics must be made by both MCH and HIV programmes.…”

Hcv coinfection, an important risk factor for hepatotoxicity in pregnant women starting antiretroviral therapy

“…In developing countries nevirapine (NVP) is the most frequently used drug to prevent vertical transmission. 1 During the last decade studies from different regions in the world reported conflicting results on the risk on mainly NVP-related liver toxicity in pregnant women. 1e10 One of the possible risk factors of hepatotoxicity is a CD4 þ cell count >250 cells/ml.…”

Safety of Antiretrovirals in Pregnancy

“…[2][3][4] Research and programmes from resource-limited settings have largely focused on short-course regimens of antiretrovirals in pregnancy, with the objective of reducing MTCT, but data are gradually emerging from cohorts of women from these settings receiving HAART. [5][6][7] That a woman should receive HAART if it is indicated for her own health is not controversial. Benefits to a woman's health clearly outweigh the known or theoretical risks associated with antiretroviral use, and her health and survival are paramount.…”