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Pregnancy Outcomes and Postdelivery
Mortality in Perinatally HIV-Infected Women
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IDWeek 2014, October 8-12, 2014, Philadelphia
Mark Mascolini
Pregnancy outcomes did not differ substantially between HIV-positive women infected perinatally and those infected by nonperinatal transmission, according to results of an 811-woman New York City study [1]. Although mortality in the year after delivery was similar in perinatally infected women and the comparison group, the perinatal group had higher mortality in the subsequent 3 to 4 years.
With growing numbers of perinatally HIV-infected youngsters surviving to reproductive age, understanding reproductive health issues in this population gains urgency. Because New York City maintains records of pregnancy-related outcomes in women with HIV, researchers at the New York City Department of Health and Mental Hygiene and other institutions conducted this study among perinatally infected women and women infected by other routes who gave birth from 2005 through 2011.
The researchers used two data sources, the New York City HIV Registry and the Enhanced Perinatal Surveillance (EPS) database, which includes data on pregnancy outcomes and perinatal HIV transmission for about two thirds of HIV-positive women who give birth in the city. They used univariate analysis to compare pregnancy outcomes in the two groups of women, and they conducted a survival analysis after delivery in the two groups.
The investigators identified 123 deliveries by 95 US-born perinatally infected mothers and 870 deliveries by 716 US-born nonperinatal mothers. Comparing deliveries in perinatally infected women and the comparison group, the researchers determined that median age was significantly lower in the perinatal group (21 versus 30, P < 0.0001). One third of deliveries in the perinatal group occurred when women were younger than 20. Race did not differ substantially between the two groups, with about two thirds black and one third Hispanic.
All women in the perinatal group knew they had HIV before pregnancy, compared with 81% in the comparison group (P < 0.0001). A somewhat higher proportion of deliveries in the perinatal group involved prenatal care (97% versus 85%, P = 0.08), and a significantly higher proportion of perinatally infected women used antiretroviral therapy (ART) before pregnancy (98% versus 85% of deliveries, P = 0.0002). The perinatal group also used intrapartum ART more than the comparison group (95% versus 88% of deliveries, P = 0.0595). Almost all infants in both groups received ART.
A lower proportion of perinatally infected women had a substance-use history (10% versus 39%, P < 0.0001) and a lower proportion had been incarcerated (2% versus 11%, P = 0.0022). Few women in either group were homeless, and about one quarter in each group had sexually transmitted diseases.
A lower proportion of women with perinatal HIV infection had an undetectable viral load at delivery (54% versus 59% of deliveries, P = 0.0029), and median CD4 count at delivery was much lower in the perinatal group (266 versus 433, P < 0.0001). A lower proportion of the perinatal group delivered vaginally (24% versus 40% of deliveries), and a higher proportion delivered by elective C-section (67% versus 50%, P = 0.0020).
Two infants of perinatally infected women and 1 infant in the comparison group acquired HIV infection, a nonsignificant difference (2% versus 1%, P = 0.4859). Three infants in the perinatal group and 10 in the comparison group died (2% versus 1%, P = 0.2389).
Four years after delivery, 10 perinatally infected women and 33 of the other women had died, a significant difference (11% versus 5%, P = 0.0156). Mortality was similar in the perinatal group and the nonperinatal group in the first year after delivery (2% versus 1%) but not in the subsequent 3 to 4 years (8% versus 4%).
The researchers concluded that, despite higher awareness of their HIV status and greater ART use by perinatally infected women, at delivery they were more likely to have a viral load above 1000 copies and a CD4 count below 200, and they were more likely to have elective C-section. The investigators surmised that the higher postdelivery death rate in perinatally infected women may reflect their more advanced HIV disease. They called for further research "to better understand predictors of long-term mortality among perinatal mothers and the contribution of pregnancy/childbirth as a life event."
Reference
1. Abraham B, Gill B, Braunstein S, et al. Pregnancy-related outcomes and mortality in the years following pregnancy among women perinatally infected with HIV--New York City, 2005-2011. IDWeek 2014. October 8-12, 2014, Philadelphia. Abstract 1615.
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