Pregnancy and HIV disease progression during the era of highly active Antiretroviral therapy

Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
The Journal of Infectious Diseases (Impact Factor: 5.78). 11/2007; 196(7):1044-52. DOI: 10.1086/520814
Source: PubMed

ABSTRACT Before the availability of highly active antiretroviral therapy (HAART), there was no clear effect of pregnancy on human immunodeficiency virus (HIV) disease progression. This has not been assessed during the HAART era.
We conducted an observational cohort study among HIV-infected women with >or=1 outpatient clinic visit between January 1997 and December 2004. HIV disease progression was defined as the occurrence of an AIDS-defining event or death.
Of 759 women who met the inclusion criteria, 139 (18%) had had >1 pregnancy, and 540 (71%) had received HAART. There was no difference in HAART duration by pregnancy status. Eleven pregnant (8%) and 149 nonpregnant (24%) women progressed to AIDS or death. After controlling for age, baseline CD4(+) lymphocyte count, baseline HIV-1 RNA level, and durable virologic suppression in a Cox proportional hazards model that included propensity score for pregnancy, pregnancy was associated with a decreased risk of disease progression (hazard ratio [HR], 0.40 [95% confidence interval {CI}, 0.20-0.79]; P=.009]). In a matched-pair analysis of 81 pregnant women matched to 81 nonpregnant women according to age, baseline CD4(+) lymphocyte count, receipt of HAART, and date of cohort entry, pregnant women had a lower risk of disease progression both before (HR, 0.10 [95% CI, 0.01-0.89]; P=.04) and after (HR, 0.44 [95% CI, 0.19-1.00]; P=.05) the pregnancy event.
Pregnancy was associated with a lower risk of HIV disease progression in this HAART-era study. This finding could be the result of the healthier immune status of women who become pregnant or could possibly be related to a beneficial interaction between pregnancy and HAART.

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    • "Similarly, in the ANRS CO8 (APROCO-COPILOTE) study in France, among women on ART, pregnancy did not affect their long-term immunological and virological response (Le Moing et al. 2008). In a study in the USA, pregnancy in the ART era was associated with a significantly lower risk of HIV clinical disease progression, and the association persisted even after controlling for factors known to affect HIV disease progression, such as age, baseline CD4 cell counts, HIV RNA viral loads and duration on ART (Tai et al. 2007). As the main risk factor for mother-to-child transmission of HIV infection is maternal viral load (Arvold et al. 2007; Garcia et al. 1999; Mofenson et al. 1999), the finding that pregnancy had no negative effect on the virological outcome of ART is important for HIV-infected mothers receiving ART in sub-Saharan Africa who may wish to have children. "
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    ABSTRACT: Objectives  Before antiretroviral therapy (ART) introduction, pregnancy was associated with a sustained drop in CD4 cell count in HIV-infected women. We examined the effects of pregnancy on immunological and virological ART outcomes. Methods  Between January 2004 and March 2009, we studied HIV-infected women receiving ART in a prospective open cohort study in rural Uganda. We used random effects regression models to compare the CD4 counts of women who became pregnant and those who did not, and among the pregnant women before and after pregnancy. CD4 count and proportions with detectable viral load (≥400 copies/ml) were compared between the two groups using the Mann-Whitney rank sum test and logistic regression respectively. Results  Of 88 women aged 20-40 years receiving ART, 23 became pregnant. At ART initiation, there were no significant differences between those who became pregnant and those who did not in clinical, immunological and virological parameters. Among women who became pregnant, CD4 cell count increased before pregnancy (average 75.9 cells/mm(3) per year), declined during pregnancy (average 106.0) but rose again in the first year after delivery (average 88.6). Among women who did not become pregnant, the average CD4 cell count rise per year for the first 3 years was 88.5. There was no significant difference in the proportions of women with detectable viral load at last clinic visit among those who became pregnant (8.7%) and those who did not (16.1%), P = 0.499. Conclusion  Pregnancy had no lasting effect on the immunological and virological outcomes of HIV-infected women on ART.
    Tropical Medicine & International Health 12/2011; 17(3):343-52. DOI:10.1111/j.1365-3156.2011.02921.x · 2.30 Impact Factor
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    • "Studies have shown the effect of pregnancy on disease progression to be minimal or nil in women infected with HIV [1] [2]. It is imperative to prevent mother-to-child transmission of HIV during pregnancy, and the effectiveness of potent antiretroviral (ARVs) in this respect is well established [3]. "
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    ABSTRACT: To assess the postpartum viral load of HIV-infected women treated with potent antiretrovirals (ARVs) during pregnancy, and look for predictors of viral load rebound. Of 112 women who took potent ARVs during pregnancy, 60 took them as prophylaxis to prevent mother-to-child transmission of HIV. The remaining 52, who had AIDS, were treated continuously with ARVs before, during, and after pregnancy. Viral load was evaluated in the weeks before, just before, and after delivery. Viral load rebound was defined as a 0.5 log(10) increase in viral RNA as measured 6 months after delivery. A viral load rebound affected women much more often in the prophylaxis than in the treatment group (84.7% vs 15.3%; P<0.001), and was associated with ARV discontinuation. The women with a viral load rebound had a higher decline in CD4 lymphocyte percentage 6 months after delivery. On multivariate analysis, variables positively or negatively associated with a viral load rebound were a decline in CD4 lymphocyte count (P=0.01), the therapeutic use of potent ARVs (P<0.001), and the number of prenatal visits (P=0.03). Discontinuing the use of potent ARVs after delivery was associated with a decrease in CD4 lymphocyte count and a viral load rebound.
    International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 11/2009; 108(2):111-4. DOI:10.1016/j.ijgo.2009.09.014 · 1.56 Impact Factor
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    ABSTRACT: In Deutschland sind ca. 56.000Menschen mit HIV infiziert, davon etwa 19% Frauen; 75% der Patienten sind zwischen 20 und 40Jahre alt. Der Kinderwunsch bei HIV-Infizierten entspricht der Normalbevölkerung. Die Möglichkeiten des Vorgehens bei einer HIV-Infektion der Frau umfassen die Selbstinsemination – und bei eingeschränkten reproduktionsmedizinischen Faktoren – sämtliche Methoden der modernen Reproduktionsmedizin inklusive In-vitro-Fertilisation (IVF) und Mikroinjektion (ICSI). Über das Restrisiko einer maternofetalen Transmission muss ausführlich aufgeklärt werden. Die Behandlung sollte nur in speziellen Kinderwunschzentren mit großer Erfahrung stattfinden. Bei HIV-Infektion des Mannes ist nach wie vor die Insemination der Goldstandard. Noch beobachtet werden müssen die Ergebnisse der Präexpositionsprophylaxe (PrEP) mit anschließend geplantem Geschlechtsverkehr, die lediglich bei Normozoospermie und Viruslast unter der Nachweisgrenze infrage kommt. Bei eingeschränkter Motilität gibt es keine Kontraindikation gegen die IVF und ICSI. Bei HIV-Konkordanz kann nach umfassender Beratung nur im Einzelfall über eine reproduktionsmedizinische Unterstützung entschieden werden. A total of 56,000 people are HIV positive in Germany, around 19% of whom are females. Seventy five per cent of patients are aged between 20 and 40 years old. The desire to have children is the same as in the normal population. Treatment options for HIV-positive women are self-insemination, in-vitro fertilisation (IVF) and microinjection (ICSI). Although the vertical transmission rate is less than 1%, patients must be prepared for the risk of materno-fetal transmission. Treatment should only be performed in centres with experience in treating these patients. If the male patient is HIV infected, homologous insemination is still the gold standard. Two other options are possible: 1. Pre-exposition prophylaxis (PrEP) with timed intercourse should be carried out only in patients with normozoospermia and an undetectable seminal viral load. 2. Patients with reduced sperm motility should be offered IVF and ICSI treatment. The treatment options for HIV-concordant couples should be considered individually.
    Gynäkologische Endokrinologie 01/2007; 6(2):123-127. DOI:10.1007/s10304-008-0249-6
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