aDivision of Infectious Disease, Massachusetts General Hospital, Center for Global Health bDivision of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts cSimon Fraser University, Faculty of Health Sciences, Burnaby, Canada dDepartment of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, California eUniversity of British Columbia, School of Population and Public Health, Vancouver, Canada fMbarara University of Science and Technology, Mbarara, Uganda gDepartment of Medicine, Massachusetts General Hospital, Center for Global Health, Boston, Massachusetts hUniversity of California at San Francisco, Department of Medicine, San Francisco, California, USA.
AIDS. 2013 Oct;27 Suppl 1(0 1):S105-12. doi: 10.1097/QAD.0000000000000040.
To assess the impact of pregnancy on mortality among HIV-infected Ugandan women initiating ART.
Prospective cohort study.
HIV-infected women initiating ART in the Uganda AIDS Rural Treatment Outcomes study were assessed quarterly for self-reported pregnancy. The association between pregnancy and postpartum ('pregnancy-related') follow-up periods and mortality was assessed with Cox proportional hazards models adjusted for age, CD4 cell count, plasma HIV-1 RNA levels, and ART duration.
Three hundred and fifty-four women with median age 33 years (IQR: 27-37) and CD4 142 cells/μl (IQR: 82-213) were followed for a median of 4.0 years (IQR: 2.5-4.8) after ART initiation, with 3 and 7% loss-to-follow-up at years 1 and 5. One hundred and nine women experienced pregnancy. Five deaths occurred during pregnancy-related follow-up and 16 during nonpregnancy-related follow-up, for crude mortality rates during the first year after ART initiation of 12.57/100 PYs and 3.53/100 PYs (rate ratio 3.56, 95% CI: 0.97-11.07). In adjusted models, the impact of pregnancy-related follow-up on mortality was highest at ART initiation (aHR: 21.48, 95% CI: 3.73-123.51), decreasing to 13.44 (95% CI 3.28-55.11) after 4 months, 8.28 (95% CI 2.38-28.88) after 8 months, 5.18 (95% CI: 1.36-19.71) after 1 year, and 1.25 (95% CI: 0.10-15.58) after 2 years on ART. Four of five maternal deaths occurred postpartum.
Pregnancy and the postpartum period were associated with increased mortality in HIV-infected women initiating ART, particularly during early ART. Contraception proximate to ART initiation, earlier ART initiation, and careful monitoring during the postpartum period may reduce maternal mortality in this setting.
评估怀孕对开始抗逆转录病毒治疗的乌干达 HIV 感染女性死亡率的影响。
前瞻性队列研究。
在乌干达艾滋病农村治疗结果研究中，对开始抗逆转录病毒治疗的 HIV 感染女性每季度进行自我报告妊娠评估。使用 Cox 比例风险模型评估怀孕和产后（“与妊娠相关”）随访期与死亡率之间的关系，模型调整了年龄、CD4 细胞计数、血浆 HIV-1 RNA 水平和抗逆转录病毒治疗持续时间。
354 名中位年龄 33 岁（IQR：27-37）和 CD4 细胞 142 个/μl（IQR：82-213）的女性在开始抗逆转录病毒治疗后中位随访 4.0 年（IQR：2.5-4.8），第 1 年和第 5 年的失访率分别为 3%和 7%。109 名女性经历了妊娠。在与妊娠相关的随访期间发生了 5 例死亡，在非妊娠相关的随访期间发生了 16 例死亡，因此，在开始抗逆转录病毒治疗后的第一年死亡率为 12.57/100 人年和 3.53/100 人年（比率为 3.56，95%CI：0.97-11.07）。在调整后的模型中，与妊娠相关的随访对死亡率的影响在抗逆转录病毒治疗开始时最高（调整后 HR：21.48，95%CI：3.73-123.51），4 个月后降至 13.44（95%CI 3.28-55.11），8 个月后降至 8.28（95%CI 2.38-28.88），1 年后降至 5.18（95%CI：1.36-19.71），2 年后降至 1.25（95%CI：0.10-15.58）。五例产妇死亡中有四例发生在产后。
在开始抗逆转录病毒治疗的 HIV 感染女性中，怀孕和产后与死亡率增加相关，尤其是在抗逆转录病毒治疗早期。在开始抗逆转录病毒治疗前及时使用避孕措施、尽早开始抗逆转录病毒治疗以及在产后期间进行仔细监测，可能会降低该人群的产妇死亡率。
