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Time to Viral Suppression With ART for Acute HIV in Pregnancy
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20th International AIDS Conference, July 20-25, 2014, Melbourne
Mark Mascolini
Viral loads fell about 100-fold in the 3 months after antiretroviral therapy (ART) began in women who acquired HIV infection during pregnancy or in the 36 weeks after delivery [1]. But monthly viral load declined only about 2-fold, and median time from starting ART to viral suppression exceeded 140 days.
Although this study took place in Kenya, the findings underline the importance of retesting high-risk women everywhere for HIV during pregnancy and postpartum. North American Guidelines call for universal third-trimester HIV testing in areas where HIV prevalence exceeds 1 per 1000.
US and Kenyan collaborators noted that women infected with HIV during pregnancy run a high risk of mother-to-child transmission because newly infected people have high viral loads and poor immune responses. Thus identifying women infected during pregnancy and postpartum has high priority because prompt ART usually starts lowering viral loads rapidly. But because little is known about how quickly such women respond to ART virologically and immunologically, the investigators conducted this prospective study.
The analysis involved HIV-negative women seeking antenatal care in Kenya's Nyanza province who enrolled in a cohort to study peripartum HIV acquisition and continued follow-up after delivery. The investigators used serial HIV-1 RNA nucleic acid amplification tests (NAATs) to check women for acute infection at enrollment, at pregnancy weeks 28 and 32, and 6, 14, 24, and 36 weeks postpartum. Among women who became infected with HIV, the researchers measured viral loads and CD4 counts in the 2 years after infection.
From May 2011 through June 2014, the investigators detected acute HIV infection in 25 of 1304 women (1.9%). HIV incidence stood at 2.35 per 100 person-years, meaning about 2 of every 100 women got infected every year. Twelve of the 25 infections occurred during pregnancy. Women with acute HIV infection had a median age of 21 years (interquartile range [IQR] 19 to 24) and a median 8 years of education (IQR 7 to 11). Nineteen women (76%) were married, and all 25 had a current partner a median of 9 years older than the woman. Marriages had lasted for a median of 2 years and partnerships for a median of 1 year.
Twenty-four of 25 women began ART, 22 of them immediately and 2 of them 2 to 12 weeks after diagnosis. Median pretreatment CD4 count measured 572 and rose to 831 in the 6 months after HIV diagnosis.
Median viral load when treatment started stood at 5.14 log10 copies/mL (about 138,000 copies/mL), only about 0.4 log higher than levels in chronically infected mothers in historical cohorts in Kenya [2] and Botswana [3]. After 3 months of treatment, median load had dropped about 100-fold to 3.24 log (about 1750 copies). But median monthly viral load decline measured only 0.35 log (about 2.2-fold). Monthly viral load drops after ART began were greater in women infected postpartum than in those infected during pregnancy (-0.62 log versus -0.2 log), but this difference lacked statistical significance. Median time to reach a viral load below 150 copies was 146 days.
Two infants became infected with HIV, and clinicians detected one of these infant infections at the same time the mother was diagnosed.
The investigators stressed that "prompt ART for acute maternal HIV-1 is important for prevention of mother-to-child transmission." But they called for longer follow-up of such women to determine how long viral loads stayundetectable.
References
1. Drake A, Kinuthia J, Matemo D, et al. Virologic and immunologic response following antiretroviral therapy initiation among pregnant and postpartum women with acute HIV-1 infection. AIDS 2014. 20th International AIDS Conference. July 20-25, 2014. Melbourne. Abstract MOPDB0101.
2. Chung MH1, Kiarie JN, Richardson BA, et al. Highly active antiretroviral therapy versus zidovudine/nevirapine effects on early breast milk HIV type-1 RNA: a phase II randomized clinical trial. Antivir Ther. 2008;13:799-807.
3. Shapiro RL1, Ndung'u T, Lockman S, et al. Highly active antiretroviral therapy started during pregnancy or postpartum suppresses HIV-1 RNA, but not DNA, in breast milk. J Infect Dis. 2005;192:713-719.
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