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When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery?
AIDS. 2012 Jun 01; 26(9):1095-103.AIDS

Abstract

BACKGROUND

HAART dramatically reduces mother-to-child transmission of HIV allowing vaginal delivery if the viral load is low. This study provides data for the optimum timing of short-term HAART in pregnancy.

METHODS

Retrospective multicentre cohort study of pregnant women commencing HAART in London and Brighton, UK. Demographics, gestation, drug class, CD4 cell count, and viral load results were collated. Survival curves for reaching a viral load less than 50 copies/ml were stratified by initial HIV viral load. Cox's proportional hazards regression model was adjusted for demographics and immunovirological parameters.

RESULTS

Viral load was less than 50 copies/ml in 292 of 378 pregnancies (77.2%) by delivery. Pretreatment viral load was associated with the time taken, and the proportion achieving a viral load less than 50 copies/ml at (P≤0.001). When baseline viral load was less than 10 ,000 copies/ml, gestational age at HAART initiation did not affect success up to 26.3 weeks gestation. When viral load was more than 10 ,000 copies/ml, deferring HAART past 20.4 weeks reduced the probability of reaching less than 50 copies/ml by delivery (P=0.011). When baseline viral load was more than 100, 000 copies/ml the likelihood of reaching a viral load of less than 50 copies/ml was low (37%: hazard ratio 0.31), and dependent on the length of time on HAART. The hazard ratio for a nonnucleoside reverse transcriptase inhibitor regimen achieving a viral load less than 50 copies/ml compared with a protease inhibitor was 0.7 (95% confidence interval 0.52-0.94).

CONCLUSION

With a viral load more than 10, 000 copies/ml and especially with a viral load more than 100 ,000 copies/ml, the probability of achieving either less than 50 copies/ml by the time of delivery is compromised by delaying initiation of short-term highly active antiretroviral therapy beyond 20.4 weeks gestation. Current UK and other guidelines for when to commence START may therefore limit the chance of vaginal delivery.

Authors+Show Affiliations

Guy's & St Thomas' NHS Foundation Trust, London, UK.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Multicenter Study
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

22441248

Citation

Read, Phillip J., et al. "When Should HAART Be Initiated in Pregnancy to Achieve an Undetectable HIV Viral Load By Delivery?" AIDS (London, England), vol. 26, no. 9, 2012, pp. 1095-103.
Read PJ, Mandalia S, Khan P, et al. When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery? AIDS. 2012;26(9):1095-103.
Read, P. J., Mandalia, S., Khan, P., Harrisson, U., Naftalin, C., Gilleece, Y., Anderson, J., Hawkins, D. A., Taylor, G. P., & de Ruiter, A. (2012). When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery? AIDS (London, England), 26(9), 1095-103. https://doi.org/10.1097/QAD.0b013e3283536a6c
Read PJ, et al. When Should HAART Be Initiated in Pregnancy to Achieve an Undetectable HIV Viral Load By Delivery. AIDS. 2012 Jun 1;26(9):1095-103. PubMed PMID: 22441248.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery? AU - Read,Phillip J, AU - Mandalia,Sundhiya, AU - Khan,Palwasha, AU - Harrisson,Ursula, AU - Naftalin,Claire, AU - Gilleece,Yvonne, AU - Anderson,Jane, AU - Hawkins,David A, AU - Taylor,Graham P, AU - de Ruiter,Annemiek, AU - ,, PY - 2012/3/24/entrez PY - 2012/3/24/pubmed PY - 2012/9/6/medline SP - 1095 EP - 103 JF - AIDS (London, England) JO - AIDS VL - 26 IS - 9 N2 - BACKGROUND: HAART dramatically reduces mother-to-child transmission of HIV allowing vaginal delivery if the viral load is low. This study provides data for the optimum timing of short-term HAART in pregnancy. METHODS: Retrospective multicentre cohort study of pregnant women commencing HAART in London and Brighton, UK. Demographics, gestation, drug class, CD4 cell count, and viral load results were collated. Survival curves for reaching a viral load less than 50 copies/ml were stratified by initial HIV viral load. Cox's proportional hazards regression model was adjusted for demographics and immunovirological parameters. RESULTS: Viral load was less than 50 copies/ml in 292 of 378 pregnancies (77.2%) by delivery. Pretreatment viral load was associated with the time taken, and the proportion achieving a viral load less than 50 copies/ml at (P≤0.001). When baseline viral load was less than 10 ,000 copies/ml, gestational age at HAART initiation did not affect success up to 26.3 weeks gestation. When viral load was more than 10 ,000 copies/ml, deferring HAART past 20.4 weeks reduced the probability of reaching less than 50 copies/ml by delivery (P=0.011). When baseline viral load was more than 100, 000 copies/ml the likelihood of reaching a viral load of less than 50 copies/ml was low (37%: hazard ratio 0.31), and dependent on the length of time on HAART. The hazard ratio for a nonnucleoside reverse transcriptase inhibitor regimen achieving a viral load less than 50 copies/ml compared with a protease inhibitor was 0.7 (95% confidence interval 0.52-0.94). CONCLUSION: With a viral load more than 10, 000 copies/ml and especially with a viral load more than 100 ,000 copies/ml, the probability of achieving either less than 50 copies/ml by the time of delivery is compromised by delaying initiation of short-term highly active antiretroviral therapy beyond 20.4 weeks gestation. Current UK and other guidelines for when to commence START may therefore limit the chance of vaginal delivery. SN - 1473-5571 UR - https://www.unboundmedicine.com/medline/citation/22441248/When_should_HAART_be_initiated_in_pregnancy_to_achieve_an_undetectable_HIV_viral_load_by_delivery L2 - https://doi.org/10.1097/QAD.0b013e3283536a6c DB - PRIME DP - Unbound Medicine ER -