抗逆转录病毒初治和经治的 HIV 感染孕妇在高效抗逆转录病毒治疗下达到病毒载量抑制的时间：对妊娠晚期就诊孕妇的影响。

Time to viral load suppression in antiretroviral-naive and -experienced HIV-infected pregnant women on highly active antiretroviral therapy: implications for pregnant women presenting late in gestation.

机构信息

Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA; Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA.

出版信息

BJOG. 2013 Nov;120(12):1534-47. doi: 10.1111/1471-0528.12226. Epub 2013 Aug 7.

DOI:10.1111/1471-0528.12226

PMID:23924192

Abstract

OBJECTIVE

To compare time to achieve viral load <400 copies/ml and <1000 copies/ml in HIV-infected antiretroviral (ARV) -naive versus ARV-experienced pregnant women on highly active antiretroviral therapy (HAART).

DESIGN

Retrospective cohort study.

SETTING

Three university medical centers, USA.

POPULATION

HIV-infected pregnant women initiated or restarted on HAART during pregnancy.

METHODS

We calculated time to viral load <400 copies/ml and <1000 copies/ml in HIV-infected pregnant women on HAART who reported at least 50% adherence, stratifying based on previous ARV exposure history.

MAIN OUTCOME MEASURES

Time to HIV viral load <400 copies/ml and <1000 copies/ml.

RESULTS

We evaluated 138 HIV-infected pregnant women, comprising 76 ARV-naive and 62 ARV-experienced. Ninety-three percent of ARV-naive women achieved a viral load < 400 copies/ml during pregnancy compared with 92% of ARV-experienced women (P = 0.82). The median number of days to achieve a viral load < 400 copies/ml in the ARV-naive cohort was 25.0 (range 3.5-133; interquartile range 16-34) days compared with 27.0 (range 8-162.5; interquartile range 18.5-54.3) days in the ARV-experienced cohort (P = 0.02). In a multiple predictor analysis, women with higher adherence (adjusted relative hazard [aRH] per 10% increase in adherence 1.29, 95% confidence interval [CI] 1.08-1.54, P = 0.01) and receiving a non-nucleotide reverse transcriptase inhibitor (NNRTI) -based regimen (aRH 2.48, 95% CI 1.33-4.63, P = 0.01) were more likely to achieve viral load <400 copies/ml earlier. Increased baseline HIV log10 viral load was associated with a later time of achieving viral load <400 copies/ml (aRH 0.60, 95% CI 0.39-0.92, P = 0.02). In a corresponding model of time to achieve viral load <1000 copies/ml, adherence (aRH per 10% increase in adherence 1.79, 95% CI 1.34-2.39, P < 0.001), receipt of NNRTI (aRH 2.95, 95% CI 1.23-7.06, P = 0.02), and CD4 cell count (aRH per 50 count increase in CD4 1.12, 95% CI 1.03-1.22, P = 0.01) were associated with an earlier time to achieve viral load below this threshold. Increasing baseline HIV log10 viral load was associated with a longer time of achieving viral load <1000 copies/ml (aRH 0.54, 95% CI 0.34-0.86, P = 0.01). In multiple predictor models, previous ARV exposure was not significantly associated with time to achieve viral load below thresholds of <400 copies/ml and <1000 copies/ml.

CONCLUSIONS

Pregnant women with ≥50% adherence, whether ARV-naive or ARV-experienced, on average achieve a viral load <400 copies/ml within a median of 26 days and a viral load of <1000 copies/ml within a median of 14 days of HAART initiation. Increased adherence, receipt of NNRTI-based regimen and lower baseline HIV log10 viral load were all statistically significant predictors of earlier time to achieve viral load <400 copies/ml and <1000 copies/ml. Increased CD4 count was statistically significant as a predictor of earlier time to achieve viral load <1000 copies/ml.

摘要

目的

比较初治与经治 HIV 感染的、接受高效抗逆转录病毒治疗（HAART）的孕妇实现病毒载量<400 拷贝/ml 和<1000 拷贝/ml 的时间。

设计

回顾性队列研究。

地点

美国三所大学医学中心。

人群

在怀孕期间开始或重新开始 HAART 的 HIV 感染孕妇。

方法

我们计算了报告至少 50%依从性的初治与经治 HIV 感染孕妇实现病毒载量<400 拷贝/ml 和<1000 拷贝/ml 的时间，按照既往抗逆转录病毒暴露史进行分层。

主要观察指标

HIV 病毒载量<400 拷贝/ml 和<1000 拷贝/ml 的时间。

结果

我们评估了 138 例 HIV 感染孕妇，包括 76 例初治和 62 例经治。93%的初治孕妇在怀孕期间实现了病毒载量<400 拷贝/ml，而 92%的经治孕妇实现了这一目标（P=0.82）。在初治队列中，实现病毒载量<400 拷贝/ml 的中位数天数为 25.0（范围 3.5-133；四分位间距 16-34）天，而在经治队列中为 27.0（范围 8-162.5；四分位间距 18.5-54.3）天（P=0.02）。在多因素预测分析中，依从性更高（每增加 10%的依从性，调整后的相对危险度[aRH]为 1.29，95%置信区间[CI]为 1.08-1.54，P=0.01）和接受非核苷酸逆转录酶抑制剂（NNRTI）为基础的方案（aRH 为 2.48，95%CI 为 1.33-4.63，P=0.01）的女性更早地实现了病毒载量<400 拷贝/ml。较高的基线 HIV log10 病毒载量与实现病毒载量<400 拷贝/ml 的时间较晚相关（aRH 为 0.60，95%CI 为 0.39-0.92，P=0.02）。在实现病毒载量<1000 拷贝/ml 的相应模型中，依从性（每增加 10%的依从性，aRH 为 1.79，95%CI 为 1.34-2.39，P<0.001）、接受 NNRTI（aRH 为 2.95，95%CI 为 1.23-7.06，P=0.02）和 CD4 细胞计数（每增加 50 个 CD4 计数，aRH 为 1.12，95%CI 为 1.03-1.22，P=0.01）与更早地实现病毒载量<1000 拷贝/ml 相关。较高的基线 HIV log10 病毒载量与实现病毒载量<1000 拷贝/ml 的时间较长相关（aRH 为 0.54，95%CI 为 0.34-0.86，P=0.01）。在多因素预测模型中，既往抗逆转录病毒暴露与实现病毒载量<400 拷贝/ml 和<1000 拷贝/ml 的时间无显著相关性。

结论

在 HAART 开始后，无论是否有既往抗逆转录病毒治疗暴露，平均依从性≥50%的孕妇在开始 HAART 后中位数 26 天内实现病毒载量<400 拷贝/ml，中位数 14 天内实现病毒载量<1000 拷贝/ml。更高的依从性、接受 NNRTI 为基础的方案和更低的基线 HIV log10 病毒载量均是更早实现病毒载量<400 拷贝/ml 和<1000 拷贝/ml 的统计学显著预测因素。更高的 CD4 计数是更早实现病毒载量<1000 拷贝/ml 的统计学显著预测因素。