Reduction of maternal mortality with highly active antiretroviral therapy in a large cohort of HIV-infected pregnant women in Malawi and Mozambique

PLoS One. 2013 Aug 19;8(8):e71653. doi: 10.1371/journal.pone.0071653. eCollection 2013.

Abstract

Background: HIV infection is a major contributor to maternal mortality in resource-limited settings. The Drug Resource Enhancement Against AIDS and Malnutrition Programme has been promoting HAART use during pregnancy and postpartum for Prevention-of-mother-to-child-HIV transmission (PMTCT) irrespective of maternal CD4 cell counts since 2002.

Methods: Records for all HIV+ pregnancies followed in Mozambique and Malawi from 6/2002 to 6/2010 were reviewed. The cohort was comprised by pregnancies where women were referred for PMTCT and started HAART during prenatal care (n = 8172, group 1) and pregnancies where women were referred on established HAART (n = 1978, group 2).

Results: 10,150 pregnancies were followed. Median (IQR) baseline values were age 26 years (IQR:23-30), CD4 count 392 cells/mm(3) (IQR:258-563), Viral Load log10 3.9 (IQR:3.2-4.4), BMI 23.4 (IQR:21.5-25.7), Hemoglobin 10.0 (IQR: 9.0-11.0). 101 maternal deaths (0.99%) occurred during pregnancy to 6 weeks postpartum: 87 (1.1%) in group 1 and 14 (0.7%) in group 2. Mortality was 1.3% in women with <than 350 CD4 cells/mm(3) and 0.7% in women with greater than 350 CD4s cells/mm(3) [OR = 1.9 (CL 1.3-2.9) p = 0.001]. Mortality was higher in patients with shorter antenatal HAART: 22/991 (2.2%) if less than 30 days and 79/9159 (0.9%) if 31 days or greater [OR = 2.6 (CL 1.6-4.2) p<0.001]. By multivariate analysis, shorter antenatal HAART (p<0.001), baseline values for CD4 cell count (p = 0.012), hemoglobin (p = 0.02), and BMI (p<0.001) were associated with mortality. Four years later, survival was 92% for women with shorter antenatal HAART and 98% for women on established therapy prior to pregnancy, p = 0.001.

Conclusions: Antiretrovirals for PMTCT purposes have significant impact on maternal mortality as do CD4 counts and nutritional status. In resource-limited settings, PMTCT programs should provide universal HAART to all HIV+ pregnant women given its impact in prevention of maternal death.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Antiretroviral Therapy, Highly Active*
  • CD4 Lymphocyte Count
  • Female
  • Follow-Up Studies
  • HIV Infections / drug therapy*
  • HIV Infections / mortality
  • HIV Infections / transmission
  • Humans
  • Infectious Disease Transmission, Vertical / prevention & control*
  • Kaplan-Meier Estimate
  • Malawi
  • Maternal Mortality
  • Mozambique
  • Multivariate Analysis
  • Outcome Assessment, Health Care / statistics & numerical data
  • Pregnancy
  • Pregnancy Complications, Infectious / drug therapy*
  • Pregnancy Complications, Infectious / mortality
  • Pregnancy Complications, Infectious / virology
  • Proportional Hazards Models
  • Retrospective Studies
  • Survival Rate
  • Young Adult

Grants and funding

The DREAM (Drug Resource Enhancement Against AIDS and Malnutrition) Program, of the Sant’Egidio Community, a faith-based NGO in Rome, Italy is sponsored by multiple organizations including the World Bank Treatment Acceleration Program, several Italian private banks, several governmental cooperations including the German Agency for Technical Cooperation, the Agence Francaise de De’veloppement, the Catalan Agency for Development Cooperation, the Belgium Development Cooperation, and the United States President Emergency Plan for AIDS Relief among others. DREAM Program–Project Malawi was funded in Malawi by Intesa Sanpaolo, Italy and the CARIPLO Foundation, Italy. The present analysis was not funded by a specific award. Funders do not have any role in study design, data collection and analysis, decision to publish or preparation of the manuscript.