Centre for Infectious Diseases Epidemiologic Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa.
BMC Pregnancy Childbirth. 2012 Sep 11;12:94. doi: 10.1186/1471-2393-12-94.
Antiretroviral therapy (ART) initiation in eligible HIV-infected pregnant women is an important intervention to promote maternal and child health. Increasing the duration of ART received before delivery plays a major role in preventing vertical HIV transmission, but pregnant women across Africa experience significant delays in starting ART, partly due the perceived need to deliver ART counseling and patient education before ART initiation. We examined whether delaying ART to provide pre-ART counseling was associated with improved outcomes among HIV-infected women in Cape Town, South Africa.
We undertook a retrospective cohort study of 490 HIV-infected pregnant women referred to initiate treatment at an urban ART clinic. At this clinic all patients including pregnant women are screened by a clinician and then undergo three sessions of counseling and patient education prior to starting treatment, commonly introducing delays of 2-4 weeks before ART initiation. Data on viral suppression and retention in care after ART initiation were taken from routine clinic records.
A total of 382 women initiated ART before delivery (78%); ART initiation before delivery was associated with earlier gestational age at presentation to the ART service (p < 0.001). The median delay between screening and ART initiation was 21 days (IQR, 14-29 days). Overall, 84.7%, 79.6% and 75.0% of women who were pregnant at the time of ART initiation were retained in care at 4, 8 and 12 months after ART initiation, respectively. Among those retained, 91% were virally suppressed at each follow-up visit. However the delay from screening to ART initiation was not associated with retention in care and/or viral suppression throughout the first year on ART in unadjusted or adjusted analyses.
A substantial proportion of eligible pregnant women referred for ART do not begin treatment before delivery in this setting. Among women who do initiate ART, delaying initiation for patient preparation is not associated with improved maternal outcomes. Given the need to maximize the duration of ART before delivery for prevention of mother-to-child HIV transmission, there is an urgent need for new strategies to help expedite ART initiation in eligible pregnant women.
为符合条件的 HIV 感染孕妇启动抗逆转录病毒治疗（ART）是促进母婴健康的重要干预措施。增加分娩前接受 ART 的时间在预防垂直 HIV 传播方面发挥着重要作用，但非洲各地的孕妇在开始接受 ART 方面存在显著延迟，部分原因是在开始 ART 之前需要提供 ART 咨询和患者教育。我们研究了在南非开普敦，推迟提供 ART 咨询以启动 ART 是否与改善 HIV 感染孕妇的结局相关。
我们对在一家城市 ART 诊所就诊的 490 名 HIV 感染孕妇进行了回顾性队列研究。在这家诊所，所有患者（包括孕妇）都由临床医生进行筛查，然后在开始治疗前接受三次咨询和患者教育，通常会延迟 2-4 周才开始 ART。ART 启动后病毒抑制和保留在护理中的数据来自常规诊所记录。
共有 382 名孕妇在分娩前（78%）开始接受 ART；分娩前开始 ART 与更早的就诊时孕周（p<0.001）相关。从筛查到开始 ART 的中位时间为 21 天（IQR，14-29 天）。总体而言，在开始 ART 时怀孕的妇女中，分别有 84.7%、79.6%和 75.0%在 ART 启动后 4、8 和 12 个月时保留在护理中。在保留下来的患者中，91%在每次随访时病毒得到抑制。然而，在未调整和调整后的分析中，从筛查到开始 ART 的延迟与整个第一年的保留在护理中和/或病毒抑制无关。
在这种情况下，大量符合条件的孕妇在分娩前未开始接受 ART。在开始接受 ART 的女性中，为患者准备而延迟启动 ART 与改善母婴结局无关。鉴于需要最大限度地延长分娩前接受 ART 的时间以预防母婴传播 HIV，迫切需要新的策略来帮助加快符合条件的孕妇开始接受 ART。
