Options for post-partum antiretroviral treatment in HIV-positive Haitian mothers
A.L. Coria1, F. Noel2, J. Bonhomme2, V. Rouzier2, A. Marcelin2, Z. Li1, T. Tosteson1, M.-M. Deschamps2, P.F. Wright1, J.W. Pape2,3
1Dartmouth Medical School, Hanover, United States, 2Centres GHESKIO, Port-au-Prince, Haiti, 3Weill Cornell Medical College, New York, United States
Background: The Haitian Group for the Study of Kaposi´s Sarcoma and Opportunistic Infections (GHESKIO) has confirmed that HAART prophylaxis reduces mother-to-child transmission of HIV in Haiti. We are now examining the costs, risks, and benefits of continuing HAART after pregnancy, regardless of whether women meet the current treatment criteria of a CD4≤250 or AIDS-defining illness.
Methods: The electronic records of 508 Haitian women who had given birth between 1999 and 2005, with follow-up to July, 2009, were analyzed retrospectively. Endpoints were: time to HAART initiation; to death; to subsequent pregnancy; to loss to follow-up; and to CD4≤250.
Results: Thirty-seven percent of women were lost to follow-up. One hundred seventy women were prescribed long-term HAART (140 were in follow-up in July, 2009.) Sixty-seven percent of those given HAART started at CD4 counts < 200. Mortality prior to starting HAART was 0.028 deaths/person-year (95% CI: 0.018-0.038), with 31 deaths. Mortality on HAART was 0.019 deaths/person-year (95% CI: 0.009-0.029), with 15 deaths. CD4 decline was stratified by CD4 at delivery to project the mean months from birth to a CD4 of 250: CD4=350-499: 47.0 (31.4, 62.6); CD4≥500: 100.5 (80.3, 120.6). If the target for treatment was defined as CD4=350, mean projected months to treatment are: CD4=350-499: 20.9 (13.6, 28.2); CD4≥500: 70.2 (56.0, 84.3).
Conclusions: Because women with high (≥500) initial CD4 counts have a long projected time (6-8 years) to a critical CD4 count, medical and social costs of treatment may outweigh the benefits of continuing treatment in this group, if good follow-up can be assured. With lower CD4 counts, the benefits may prevail, as the time to the targeted CD4 count is much shorter, the target CD4 count is frequently missed, follow-up is difficult, and subsequent pregnancies occur. Active follow-up is key in the postpartum treatment of HIV+ women in this setting.
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