Dignitas International, Zomba, Malawi.
Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
PLoS One. 2021 Mar 12;16(3):e0248559. doi: 10.1371/journal.pone.0248559. eCollection 2021.
Long-term viral load (VL) suppression among HIV-positive, reproductive-aged women on ART is key to eliminating mother-to-child transmission (MTCT) but few data exist from sub-Saharan Africa. We report trends in post-partum VL in Malawian women on ART and factors associated with detectable VL up to 24 months post-partum.
1-6 months post-partum mothers, screened HIV-positive at outpatient clinics in Malawi, were enrolled (2014-2016) with their infants. At enrollment, 12- and 24-months post-partum socio-demographic and PMTCT indicators were collected. Venous samples were collected for determination of maternal VL (limit of detection 40 copies/ml). Results were returned to clinics for routine management.
596/1281 (46.5%) women were retained in the study to 24 months. Those retained were older (p<0.01), had higher parity (p = 0.03) and more likely to have undetectable VL at enrollment than those lost to follow-up (80.0% vs 70.2%, p<0.01). Of 590 women on ART (median 30.1 months; inter-quartile range 26.8-61.3), 442 (74.9%) with complete VL data at 3 visits were included in further analysis. Prevalence of detectable VL at 12 and 24 months was higher among women with detectable VL at enrollment than among those with undetectable VL (74 detectable VL results/66 women vs. 19/359; p<0.001). In multivariable analysis (adjusted for age, parity, education, partner disclosure, timing of ART start and self-reported adherence), detectable VL at 24 months was 9 times more likely among women with 1 prior detectable VL (aOR 9.0; 95%CI 3.5-23.0, p<0.001) and 226 times more likely for women with 2 prior detectable VLs (aOR 226.4; 95%CI 73.0-701.8, p<0.001).
Detectable virus early post-partum strongly increases risk of ongoing post-partum viremia. Due to high loss to follow-up, the true incidence of detectable VL over time is probably underestimated. These findings have implications for MTCT, as well as for the mothers, and call for intensified VL monitoring and targeted adherence support for women during pregnancy and post-partum.
在接受抗逆转录病毒疗法（ART）的艾滋病毒阳性、育龄妇女中，长期病毒载量（VL）抑制是消除母婴传播（MTCT）的关键，但撒哈拉以南非洲地区的数据很少。我们报告了马拉维妇女在接受 ART 后产后 VL 的趋势，以及与产后 24 个月内可检测到 VL 相关的因素。
2014 年至 2016 年，在马拉维的门诊诊所，对筛查出 HIV 阳性的 1-6 个月产后母亲及其婴儿进行了入组。在入组时，收集了 12 个月和 24 个月产后的社会人口统计学和 PMTCT 指标。采集静脉血样，以确定母体 VL（检测限为 40 拷贝/ml）。结果将返回给诊所进行常规管理。
596/1281（46.5%）名妇女在 24 个月时仍在研究中。与失访者相比，保留下来的妇女年龄更大（p<0.01），生育次数更多（p=0.03），在入组时 VL 更不易检测（80.0%比 70.2%，p<0.01）。590 名接受 ART 治疗的妇女（中位时间 30.1 个月；四分位间距 26.8-61.3）中，有 442 名（74.9%）在 3 次就诊时的 VL 数据完整，被纳入进一步分析。在入组时 VL 可检测的妇女中，12 个月和 24 个月时 VL 可检测的发生率高于 VL 不可检测的妇女（74 个可检测 VL 结果/66 名妇女比 19 个/359 名妇女；p<0.001）。在多变量分析（按年龄、生育次数、教育程度、伴侣告知、ART 开始时间和自我报告的依从性调整）中，24 个月时 VL 可检测的妇女，在前一次 VL 可检测的情况下，VL 可检测的可能性增加 9 倍（调整后的比值比[aOR] 9.0；95%CI 3.5-23.0，p<0.001），在前两次 VL 可检测的情况下，VL 可检测的可能性增加 226 倍（aOR 226.4；95%CI 73.0-701.8，p<0.001）。
产后早期可检测到病毒会大大增加产后持续病毒血症的风险。由于失访率高，随着时间的推移，真正的可检测到 VL 的发病率可能被低估。这些发现对母婴传播以及对母亲都有影响，需要加强对孕妇和产后妇女的 VL 监测和有针对性的依从性支持。
