Black Vivian, Black Andrew D, Rees Helen V, Guidozzi Franco, Scorgie Fiona, Chersich Matthew F
Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
PLoS One. 2016 Dec 29;11(12):e0168199. doi: 10.1371/journal.pone.0168199. eCollection 2016.
To assess the impact of expanded access to antiretroviral treatment (ART) on maternal mortality in Johannesburg, South Africa between 2003 and 2012.
Audit of patient files, birth registers and death certificates at a tertiary level referral hospital. Cause of death was assigned independently, by two reviewers. We compared causes of deaths and the maternal mortality ratios (MMR, deaths/100,000 live births) over three periods corresponding to changes in government policy on ART provision: period one, 2003-2004 (pre-ART); period two, 2005-2009 (ART eligibility with CD4 count <200cells/μL or WHO stage 4 disease); and period three, 2010-2012 (eligibility with CD4 count <350 cells/μL).
There were 232 deaths and 80,376 deliveries in the three periods. The proportion of pregnant women tested for HIV rose from 43.4% in 2003 to 94.6% in 2012. MMR was 301, 327 and 232 in the three periods, (p = 0.10). The third period MMR was lower than the first and second combined (p = 0.03). Among HIV-positive women, the MMR fell from 836 in the first time period to 431 in the third (p = 0.008) but among HIV negative women it remained unchanged over the three periods, averaging 148. Even in the third period, however, the MMR among HIV-infected women was 3-fold higher than in other women. Mortality from direct obstetric causes such as hemorrhage did not decline over time, but deaths from tuberculosis and HIV-associated malignancy did. In 38.3% of deaths, women had not attended antenatal care.
Higher coverage of HIV testing and ART has substantially reduced MMR in this hospital setting. Though the gap in MMR between women with and without HIV narrowed, a third of deaths still remain attributable to HIV. Lowering overall MMR will require further strengthening of HIV services, increased antenatal care coverage, and improved care for obstetric emergencies at all levels of care.
评估2003年至2012年期间，扩大抗逆转录病毒治疗（ART）的可及性对南非约翰内斯堡孕产妇死亡率的影响。
对一家三级转诊医院的患者档案、出生登记册和死亡证明进行审计。由两名审核人员独立确定死因。我们比较了与政府ART提供政策变化相对应的三个时期的死亡原因和孕产妇死亡率（MMR，每10万例活产死亡数）：第一时期，2003 - 2004年（ART治疗前）；第二时期，2005 - 2009年（CD4细胞计数<200个/μL或世界卫生组织4期疾病时符合ART治疗条件）；第三时期，2010 - 2012年（CD4细胞计数<350个/μL时符合治疗条件）。
三个时期共有232例死亡和80376例分娩。接受HIV检测的孕妇比例从2003年的43.4%上升到2012年的94.6%。三个时期的MMR分别为301、327和232（p = 0.10）。第三时期的MMR低于第一和第二时期之和（p = 0.03）。在HIV阳性女性中，MMR从第一时期的836降至第三时期的431（p = 0.008），但在HIV阴性女性中，三个时期保持不变，平均为148。然而即使在第三时期，HIV感染女性的MMR仍比其他女性高3倍。诸如出血等直接产科原因导致的死亡率并未随时间下降，但结核病和HIV相关恶性肿瘤导致的死亡有所下降。在38.3%的死亡病例中，女性未接受产前护理。
在该医院环境中，更高的HIV检测覆盖率和ART治疗显著降低了MMR。尽管有HIV和无HIV女性之间的MMR差距缩小，但仍有三分之一的死亡可归因于HIV。降低总体MMR将需要进一步加强HIV服务、提高产前护理覆盖率，并改善各级医疗机构对产科急症的护理。
