PMTCT in a Brazilian clinic HAART is feasible in a middle income country

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PMTCT in a Brazilian clinic- HAART is feasible in
a middle income country

• Breno Riegel Santos, MD
• Hospital Nossa Senhora da Conceição/GHC
• Porto Alegre, Brazil
• IRC session at IMPAACT Leadership retreat,
  October 2007

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Guidelines for ARV therapy/prophylaxis in
pregnancy, adults/adolescents and in children,
Brazilian Ministry of Health
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Unit for Prevention of Vertical Transmission
(UPTV)

• Hospital based unit (all services free of charge
  at point of delivery- publicly funded)
• Infectologists Ob/gyns Pediatricians
• Counseling and adherence nurse
• Lab tests available at site (routine, CD4, Viral
  Load)
• Formula provided for 6 months
• ARV available at site
• C-section when VLgt1000 or unknown
• Rapid test when HIV status unk or result gt3 months

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Study objectives

• To determine the prevalence of HIV-1 infection
  among women receiving pre-natal care at Hospital
  Nossa Senhora da Conceição/GHC
• To determine HIV-1 MTCT rates among infected
  women attending pre-natal care at our institution
  and women identified as HIV-infected during the
  time of labor and delivery
• To determine the incidence of HIV-1
  seroconversion during pregnancy and assess MTCT
  risk
• To assess additional risk factors for MTCT in
  these diverse patient populations

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Methods

• Study design retrospective cohort study
  conducted from July/2004 to August/2006.
• Study population
• HIV-1 infected pregnant women followed for
  pre-natal care at the UPTV of HNSC receiving
  HAART for PMTCT
• HIV-1 infected women identified as such by rapid
  HIV-1 testing upon admission for labor and
  delivery with no prior HIV-1 testing during
  pregnancy
• HIV-1 infected women identified as such by rapid
  HIV-1 testing upon admission for labor and
  delivery with prior HIV-1 negative test results
  obtained during pre-natal care at least 90 days
  before admission (case definition for primary
  HIV-1 infection during pregnancy)
• Women referred from outside hospitals who did not
  receive prenatal care at our institution and
  received ZDV monotherapy were excluded

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Methods

• Assessment of HIV-1 infant infection
• Presence of 2 detectable HIV-1 virus load
  assessments by bDNA at different timepoints. The
  diagnosis was ruled out in the presence of 2
  negative virus loads with one obtained 5 months
  of life. No mothers breastfed and formula was
  provided according to Brazilian Ministry of
  Health guidelines
• Data analysis
• Binomial distribution with 95 CI
• Chi-square with Yates correction and Fisher test
• Kruskal Wallis test
• Analysis of variance (ANOVA)

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Results

• In 2 years, deliveries at our institution totaled
  11,241 with 318 (2.9) occuring in HIV-1 infected
  women
• The incidence of HIV-1 seroconversion was 9 in
  11,241 women or 0.8/1,000 (CI 95 0.4-1.5/1,000)
• 256 HIV women delivered at our institution
  fulfilling study entry criteria
• For 212/256 mothers (83) infants outcomes were
  determined
• Among 70 patients diagnosed at delivered, 61 had
  unknown HIV-1 seroconversion time and 9 had
  proven seroconversion during pregnancy

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Patient population and outcomes (n256)
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HIV-1 MTCT rates by patient group (n212)
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Demographic characteristics of the patient groups
Dados expressos em médiaDP (amplitude) ANOVA
(analysis of variance)
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Comparação entre medianas de carga viral conforme
categorias maternas de uso de ARV e momento da
soroconversão
Kruskall Wallis test
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MTCT risk according to mode of delivery, virus
load and maternal characteristics (ARV use and
timing of seroconversion).
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Conclusions

• Women who seroconverted during pregnancy had a
  much higer rate of HIV-1 MTCT (33) than women
  with an unknown HIV seroconversion time who did
  not receive ARV therapy (8.2). Women on HAART
  during pregnancy had an MTCT risk of 0.7
• A prior study in Thailand did not report a higher
  HIV-1 transmission rate among seroconverting
  pregnant women, however ARV therapy was not
  available for any HIV-infected women, including
  those receiving pre-natal care
• No transmissions ocurred in 122 women with
  undetectable viral load
• Among 212 women recruited over 2 years, at least
  4.2 (9 women) seroconverted during pregnancy

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Conclusions

• Demographic parameters were not very helpful in
  the identification of at risk patients
• The high prevalence of seroconversion in our
  population and the high risk of HIV-1 MTCT under
  these cirsumstances indicates that routine HIV-1
  re-screening of patients during pregnancy and at
  delivery should be implemented in our setting,
  with prompt initiation of ARV treatment upon
  identification of primary infection
• HIV-1 testing of sexual partners of women in
  prenatal care may be helpful in the
  identification of patients at risk of
  seroconversion and should be considered as a
  public health measure