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When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery?
MedLine Citation:
PMID:  22441248     Owner:  NLM     Status:  Publisher    
Abstract/OtherAbstract:
BACKGROUND: HAART dramatically reduces HIV mother to child transmission allowing vaginal delivery if the viral load (VL) is low. This study provides data for the optimum timing of short term HAART in pregnancy. METHODS: Retrospective multicentre cohort study of pregnant women commencing HAART in London and Brighton, United Kingdom. Demographics, gestation, drug class, CD4 count, and VL results were collated. Survival curves for reaching a VL < 50 copies/ml were stratified by initial HIV VL. Cox's proportional hazards regression model adjusted for demographics and immuno-virological parameters. RESULTS: VL was <50 in 292/378 pregnancies (77.2%) by delivery. Pre-treatment VL was associated with the time taken, and the proportion achieving a VL < 50 at (p ≤ 0.001). When baseline VL was <10,000 copies/ml, gestational age at HAART initiation did not affect success up to 26.3 weeks gestation. When viral load was >10,000, deferring HAART past 20.4 weeks reduced the probability of reaching <50 copies/ml by delivery (p = 0.011). When baseline viral load was >100,000 copies/ml the likelihood of reaching a VL of <50 copies/ml was low (37%: HR 0.31), and dependent on the length of time on HAART. The Hazard Ratio for an NNRTI regimen achieving a VL < 50 compared to a PI was 0.7 (0.52-0.94 CI95%). CONCLUSIONS: With a VL >10,000 copies/ml and especially with a VL >100,000 copies/ml, the probability of achieving either <50 copies/ml by the time of delivery is compromised by delaying initiation of START beyond 20.4 weeks gestation. Current United Kingdom and other guidelines for when to commence START may therefore limit the chance of vaginal delivery.
Authors:
Phillip J Read; Sundhiya Mandalia; Palwasha Khan; Ursula Harrisson; Claire Naftalin; Yvonne Gilleece; Jane Anderson; David A Hawkins; Graham P Taylor; Annemiek D E Ruiter;
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2012-3-21
Journal Detail:
Title:  AIDS (London, England)     Volume:  -     ISSN:  1473-5571     ISO Abbreviation:  -     Publication Date:  2012 Mar 
Date Detail:
Created Date:  2012-3-23     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  8710219     Medline TA:  AIDS     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
Affiliation:
aGuy's & St Thomas' NHS Foundation Trust, London, UK bChelsea & Westminster Hospital NHS Foundation Trust, London, UK cHomerton University Hospital NHS Trust, London, UK dBrighton and Sussex University Hospitals NHS Trust, Brighton, UK eImperial College, London, UK.
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