The impact of revised PMTCT guidelines: A view from a public sector ARV clinic in Cape Town, South Africa
Journal of Acquired Immune Deficiency Syndromes
Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa; Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa; Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
Background: In April 2010, revised Prevention of Mother-to-Child Transmission guidelines were implemented in South Africa, advising fast-tracked lifelong highly active antiretroviral therapy (HAART) initiation at a higher CD4 count (#350 cells per microliter). This study describes the impact of these changes on the management of pregnant women who initiated HAART at Tygerberg Hospital, Cape Town. Methods: We conducted a retrospective review of all women who initiated HAART in pregnancy at the Tygerberg Hospital between January 2008 and December 2010. Year cohorts were compared. Results: Two hundred and fifty HIV-infected women were included in the study and stratified by HAART initiation year: 2008:N = 82, 2009: N = 71, 2010:N = 97. There were no differences between the groups in age or parity. Median booking CD4 count was 155 cells per microliter [interquartile range (IQR) 107-187], 157 cells per microliter (IQR 104- 206) and 208 cells per microliter (IQR 138-270), respectively (P , 0.001). Median gestation at HAART initiation was 31 weeks (IQR 27-35), 30 weeks (IQR 26-34), and 25 weeks (IQR 21-31; P , 0.001). HIV transmission rates were 3/65 (4.6%), 4/57 (7.0%), and 0/ 90 (0.0%; P = 0.021). Women ,8 weeks on HAART before delivery were more likely to transmit than women $8 weeks [odds ratio 9.69; 95% confidence interval 1.66 to 56.58; P = 0.017]. Ninety-four (37.6%) women were lost to follow-up, 18.4% within 28 days of delivery. Conclusions: The positive impact of the new Prevention of Mother-to-Child Transmission program is evident. A longer duration of HAART before delivery was associated with less transmission. However, the lost to follow-up rates remain concerning. Further research is needed to better understand the reasons for nonadherence and mechanisms to improve support for these women. Copyright © 2013 by Lippincott Williams & Wilkins.
adult; article; CD4 lymphocyte count; female; follow up; highly active antiretroviral therapy; human; Human immunodeficiency virus; major clinical study; organization and management; practice guideline; pregnancy; pregnant woman; priority journal; retrospective study; South Africa; disease transmission; Human immunodeficiency virus infection; outpatient department; patient compliance; practice guideline; pregnancy complication; vertical transmission; anti human immunodeficiency virus agent; Adult; Ambulatory Care Facilities; Anti-HIV Agents; Antiretroviral Therapy, Highly Active; CD4 Lymphocyte Count; Female; Guidelines as Topic; HIV Infections; Humans; Infectious Disease Transmission, Vertical; Lost to Follow-Up; Patient Compliance; Pregnancy; Pregnancy Complications, Infectious; Retrospective Studies; South Africa