Triple antiretroviral therapy improves pregnancy outcomes

Besides preventing mother-to-child transmission of HIV-1, triple antiretroviral therapy (ART) during pregnancy improves pregnancy outcomes, according to new findings.

"All HIV infected women should receive triple antiretrovirals in pregnancy," Dr Karin Nielsen-Saines from David Geffen UCLA School of Medicine, Los Angeles, US 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 foetal demise and prematurity."

Nielsen-Saines and colleagues reviewed all mother-infant pairs enrolled in a public health programme in Mozambique and Malawi to prevent mother-to-child transmission. Their results are published in the journal AIDS.

Mortality higher with no treatment

Among 3,148 live births from 3,273 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%.

The maternal mortality rate 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 than in women who had at least 90 days of triple ART before giving birth. Maternal deaths were reduced by 70% with more than 30 days of triple ART before delivery.

Improves child survival

Foetal demise rates declined from 26.5% in women with no treatment to 5% 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.

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

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

Early treatment better

"In the Dream programme, which is the public health programme 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," Nielsen-Saines said.

"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 foetal organogenesis," Dr. Nielsen-Saines said. "Most specialists would agree, however, that the third (trimester) of pregnancy is a period in which definitely triple antiretrovirals exert their greatest benefit for preventing mother-to-child transmission." - (Will Boggs MD/Reuters Health, July 2011)

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