Postpartum HIV Treatment Discontinuation and Maternal Outcomes

Though the use of highly active antiretroviral therapy (HAART) during pregnancy has significantly contributed to decreased rates of mother to child transmission of HIV, the question of whether HAART should be routinely continued in HIV-infected mothers after delivery has not been definitively answered to date. Currently, practice is based on the stage of HIV infection, the bias of the medical team managing the mother’s care, and the individual’s desire and ability to adhere to therapy. Despite emerging evidence suggesting that HAART usage in individuals with high CD4 counts (>500) who lack any traditional indications for HAART initiation have decreased risks of death compared to those patients with lower CD4 counts, that continuous antiretroviral therapy is safer than intermittent antiretroviral therapy, and the demonstration of drug resistant HIV mutants in patients with scheduled treatment interruptions, few studies have evaluated long-term clinical outcomes after pregnancy in HIV-infected women. This paper retrospectively assessed antenatal and delivery outcomes in a group of 172 HIV-infected women treated with antiretrovirals during pregnancy between 1997 and 2005 at Washington University in St. Louis . The authors also sought to identify factors associated with postpartum discontinuation of antiretrovirals and tracked long-term maternal clinical outcomes including new opportunistic maternal infections and maternal death.
Eighty percent of these women were African-American, and 45% of the women had newly diagnosed HIV infections. Eight-five percent of the women received HAART. The median number of days during which HAART was administered antepartum was 133. The median CD4 count was 502 at delivery with a viral load less than <1000 copies/mL in 83% of patients. Eight-six percent of women received intravenous AZT during labor and 85% of liveborn neonates received antiretroviral prophylaxis after delivery. Ninety-eight percent of pregnancies resulted in live births, 63 percent of births were vaginal, and 27 percent were preterm births. The maternal to child transmission rate of HIV infection was 0.6%.
By the third month after delivery, 71% of mothers had discontinued antiretroviral therapy. Characteristics of women in the groups which continued therapy and discontinued therapy were very similar in many respects (e.g. age, previous history of opportunistic infections, treatment regimen used, gestation at initiation of antiretroviral initiation, previous antiretroviral experience, etc). Factors associated with discontinuation of antiretrovirals included absence of a partner, no indication for opportunistic infection prophylaxis or preconception antiretrovirals, and shorter duration of antiretroviral administration during pregnancy. Though those who discontinued therapy had a higher “lowest value” CD4 count, pre-therapy CD4 count, and lower HIV pre-therapy RNA levels, these women who discontinued therapy postpartum were more likely to have detectable HIV RNA levels at delivery (55% <400 copies/mL vs. 90% <400 copies/mL), suggesting perhaps either more resistant maternal disease or poorer adherence to the regimen. Ninety-two percent of women remained in the clinic for follow-up, with median duration of follow-up 32.5 months postpartum. Follow-up duration did not vary based on whether women discontinued antiretroviral therapy postpartum or remained on therapy. New opportunistic infections occurred in 2 women (4%) in the continued group with median time to first new opportunistic infection of 81.0 months, versus 10 women (9%) in the discontinued group with median time to first new infection of 32.0 months in the discontinued group. Both deaths which occurred were in women in the discontinued group. Given the small number of women in the study, the differences between incidence of postpartum opportunistic infections, deaths, and time to first new infection were not statistically significant. Of the entire study cohort, only 11 women consistently remained on therapy from pregnancy through follow-up.
This article represents a worthwhile contribution to the existing literature and emphasizes the need for further studies looking at postpartum antiretroviral therapy discontinuation in HIV positive patients. While sleep deprivation, care-giving responsibilities, lack of integrated services, and anxiety over health of the newborn are all powerful potential deterrents to continuation of maternal antiretroviral therapy, this study suggests that there may be benefits beyond the well-documented decrease in vertical transmission to maternal antiretroviral therapy, and that postpartum continuation of HIV therapy may plausibly be associated with improved long-term maternal outcomes. The small size of the number of women followed and the retrospective nature of the study are recognizable study limitations, but overall, the decision to discontinue antiretrovirals postpartum is a weighty decision which may place women doing so at increased risk of poor long-term outcomes compared to women who choose to continue antiretroviral therapy.
--Summarized by Barrett Robinson, MD, MPH
Barrett Robinson is a Maternal-Fetal Medicine Fellow at Northwestern Memorial Hospital, where he participates in the ongoing care of one of Illinois’ largest clinics exclusively servicing HIV-positive pregnant patients.


Citation:
Onen NF, Nurutdinova D, Sungkanuparph S, Gase D, Mondy K, Overton ET. Effect of postpartum HIV treatment discontinuation on long-term maternal outcome. J Int Assoc Physicians AIDS Care (Chic Ill). 2008 Sep-Oct;7(5):245-51.
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Abstract