Holmes Charles B, Yiannoutsos Constantin T, Elul Batya, Bukusi Elizabeth, Ssali John, Kambugu Andrew, Musick Beverly S, Cohen Craig, Williams Carolyn, Diero Lameck, Padian Nancy, Wools-Kaloustian Kara K
Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
PLoS One. 2018 Jan 17;13(1):e0190828. doi: 10.1371/journal.pone.0190828. eCollection 2018.
The World Health Organization now recommends initiating all pregnant women on life-long antiretroviral therapy (ART), yet there is limited information about the characteristics and program outcomes of pregnant women already on ART in Africa. Our hypothesis was that pregnant women comprised an increasing proportion of those starting ART, and that sub-groups of these women were at higher risk for program attrition.
We used the International Epidemiology Databases to Evaluate AIDS- East Africa (IeDEA-EA) to conduct a retrospective cohort study including HIV care and treatment programs in Kenya, Uganda, and Tanzania. The cohort consecutively included HIV-infected individuals 13 years or older starting ART 2004-2014. We examined trends over time in the proportion pregnant, their characteristics and program attrition rates compared to others initiating and already receiving ART. 156,474 HIV-infected individuals (67.0% women) started ART. The proportion of individuals starting ART who were pregnant women rose from 5.3% in 2004 to 12.2% in 2014. Mean CD4 cell counts at ART initiation, weighted for annual program size, increased from 2004 to 2014, led by non-pregnant women (annual increase 20 cells/mm3) and men (17 cells/mm3 annually), with lower rates of change in pregnant women (10 cells/mm3 per year) (p<0.0001). There was no significant difference in the cumulative incidence of program attrition at 6 months among pregnant women starting ART and non-pregnant women. However, healthy pregnant women starting ART (WHO stage 1/2) had a higher rate of attrition rate (9.6%), compared with healthy non-pregnant women (6.5%); in contrast among women with WHO stage 3/4 disease, pregnant women had lower attrition (8.4%) than non-pregnant women (14.4%). Among women who initiated ART when healthy and remained in care for six months, subsequent six-month attrition was slightly higher among pregnant women at ART start (3.5%) compared to those who were not pregnant (2.4%), (absolute difference 1.1%, 95% CI 0.7%-1.5%).
Pregnant women comprise an increasing proportion of those initiating ART in Africa, and pregnant women starting ART while healthy are at higher risk for program attrition than non-pregnant women. As ART programs further expand access to healthier pregnant women, further studies are needed to better understand the drivers of loss among this high risk group of women to optimize retention.
世界卫生组织现建议所有孕妇开始接受终身抗逆转录病毒治疗（ART），然而关于非洲已接受ART治疗的孕妇的特征和项目成果的信息有限。我们的假设是，孕妇在开始接受ART治疗的人群中所占比例不断增加，并且这些女性亚组的项目脱落风险更高。
我们使用国际流行病学数据库评估艾滋病——东非（IeDEA-EA）进行回顾性队列研究，纳入肯尼亚、乌干达和坦桑尼亚的HIV护理和治疗项目。该队列连续纳入了2004年至2014年开始接受ART治疗的13岁及以上HIV感染者。我们研究了孕妇比例、她们的特征以及与其他开始接受和已接受ART治疗者相比的项目脱落率随时间的变化趋势。156474名HIV感染者（67.0%为女性）开始接受ART治疗。开始接受ART治疗的孕妇比例从2004年的5.3%上升至2014年的12.2%。在考虑年度项目规模加权的情况下，开始接受ART治疗时的平均CD4细胞计数从2004年到2014年有所增加，以非孕妇（每年增加20个细胞/mm³）和男性（每年增加17个细胞/mm³）为首，孕妇的变化率较低（每年10个细胞/mm³）（p<0.0001）。开始接受ART治疗的孕妇与非孕妇在6个月时项目脱落的累积发生率没有显著差异。然而，开始接受ART治疗的健康孕妇（世界卫生组织1/2期）的脱落率较高（9.6%），相比之下健康非孕妇的脱落率为6.5%；相反，在世界卫生组织3/4期疾病的女性中，孕妇的脱落率（8.4%）低于非孕妇（14.4%）。在开始接受ART治疗时健康且持续接受护理6个月的女性中，开始接受ART治疗时孕妇随后6个月的脱落率（3.5%）略高于未怀孕者（2.4%），（绝对差异1.1%，95%CI 0.7%-1.5%）。
在非洲，孕妇在开始接受ART治疗的人群中所占比例不断增加，并且开始接受ART治疗时健康的孕妇比非孕妇的项目脱落风险更高。随着ART项目进一步扩大对健康孕妇的治疗覆盖，需要进一步研究以更好地了解这一高危女性群体流失的驱动因素，从而优化留存率。
