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Triple antiretroviral therapy improves pregnancy outcomes

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Besides preventing HIV-1 mother-to-child transmission (PMTCT), triple antiretroviral therapy during pregnancy improves pregnancy outcomes, according to findings published in the June 6th online AIDS.

“All HIV infected women should receive triple antiretrovirals in pregnancy,” Dr. Karin Nielsen-Saines from David Geffen UCLA School of Medicine, Los Angeles, California told Reuters Health. “Besides greatly reducing HIV transmission to the infant, they have a dramatic impact on reduction of maternal mortality and in our study they were protective against fetal demise and prematurity.”

Dr. Nielsen-Saines and colleagues reviewed all mother-infant pairs enrolled in a public health PMTCT program in Mozambique and Malawi.

Among 3148 live births resulting from 3273 pregnant women, infant 12 month HIV-free survival was 92.5%, infant mortality was 6.7%, and the cumulative HIV-transmission rate at 12 months of age was 2%.

Maternal mortality was 1.2%, the abortion/stillbirth rate was 5.2%, and premature deliveries occurred in 19.1% of pregnancies.

Maternal mortality was 10 times higher in women with no treatment before delivery, compared with women having 90 or more days of triple antiretroviral therapy (ART) before giving birth, and maternal mortality was reduced by 70% among those receiving more than 30 days of triple ART before delivery.

Fetal demise rates declined from 26.5% in women with no treatment to 5.0% in women with more than 90 days of antenatal ART (p<0.001), and the decrease was 25-fold after adjustment for days of patient observation.

Maternal triple ART was also associated with significant reductions in the rate of prematurity, regardless of CD4 category. [p. 5, col. 1, para. 2]

Rates of low birth weight (present in 11.5% of infants) did not differ significantly from those for the general population of Malawi and Mozambique.

Toxicity associated with ART use was low, considering the high background morbidity, the researchers note, and there were no toxicity-related deaths. Just over 5% had severe adverse reactions, and 11.2% of women required changes to alternate ART due to toxicities (mostly peripheral neuropathy).

“In the Dream program, which is the public health program in sub-Saharan Africa described in the paper, triple antiretrovirals are initiated routinely at 14 weeks for recently identified patients who have CD4 cell counts less than 350 or have symptomatic HIV disease, (WHO stages 3 or 4), and at 25 weeks of pregnancy for patients who have higher CD4 cell counts and no clinical symptomatology,” Dr. Nielsen-Saines explained. “Ideally, in settings where there are no cost constraints, as in North America or western Europe, antiretrovirals are initiated as early as 12 to 14 weeks of pregnancy unless patients require them immediately for their own health.”

“The rationale is to spare antiretrovirals during the period of fetal organogenesis,” Dr. Nielsen-Saines said. “Most specialists would agree, however, that the third semester of pregnancy is a period in which definitely triple antiretrovirals exert their greatest benefit for PMTCT purposes.”

AIDS.