Yang Lanbo, Cambou Mary Catherine, Segura Eddy R, de Melo Marineide Gonçalves, Santos Breno Riegel, Dos Santos Varella Ivana Rosângela, Nielsen-Saines Karin
Warren Alpert Medical School, Brown University, Providence, RI (Mr Yang).
Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA (Dr Cambou).
AJOG Glob Rep. 2023 Mar 11;3(2):100194. doi: 10.1016/j.xagr.2023.100194. eCollection 2023 May.
Childbirth via cesarean delivery can prevent intrapartum vertical transmission for women who are not virally suppressed at the time of delivery. Few studies have compared cesarean delivery trends between women living with HIV and women without HIV and have examined the role of cesarean delivery in the prevention of vertical transmission in the era of potent combination antiretroviral therapy.
We hypothesized that the cesarean delivery rate is high in women living with HIV compared with women without HIV and that cesarean delivery usage decreases over time among women living with HIV with advances in combined antiretroviral therapy in a country with a high national cesarean delivery rate. This study aimed (1) to evaluate cesarean delivery trends in women with and without HIV and (2) to examine its role in preventing vertical transmission among women living with HIV in a setting of free, universal combined antiretroviral therapy coverage in a retrospective cohort of nearly 56,000 deliveries at a major referral institution in a city with the highest prevalence of maternal HIV in Brazil.
Data from maternal-infant pairs from January 1, 2008, to December 31, 2018, were extracted. Cesarean delivery rates were compared using the Pearson chi-square test. Cesarean delivery predictors were evaluated by multivariate log-linear Poisson regression using a generalized estimating equations approach. HIV viral suppression was defined as a viral load of <1000 copies/ml at delivery. HIV vertical transmission was determined following national guidelines.
Over 11 years, 48,688 pregnancies occurred in 40,375 women; HIV seroprevalence was 2.7%; 18,886 cesarean deliveries (38.8%) were performed; 47.7% of women living with HIV and 38.6% of women without HIV underwent cesarean delivery (<.001). Although HIV was associated with cesarean delivery (adjusted relative risk, 1.17 [95% confidence interval, 1.05-1.29]), women living with HIV with vertical transmission achieved similar cesarean delivery rates (36.7%) as women without HIV (39.8%) in 2018. Cesarean delivery in women living with HIV with an unknown viral load at delivery (42.6%) did not increase over time. HIV vertical transmission rate was 2.2%, the highest in women living with HIV with an unknown viral load (8.4%) vs women living with HIV without vertical transmission (4.1%) and women living with HIV with vertical transmission (0.5%) (<.001).
In the HIV epicenter of Brazil, women living with HIV with vertical transmission had fewer surgical deliveries, likely because of the use of potent combination antiretroviral therapy. Nearly half of the women living with HIV with an unknown viral load did not undergo cesarean delivery, a potential missed opportunity for the prevention of HIV vertical transmission.
剖宫产可预防分娩时病毒载量未得到有效抑制的女性发生分娩期间垂直传播。很少有研究比较感染HIV的女性和未感染HIV的女性的剖宫产趋势，并且探讨在高效联合抗逆转录病毒治疗时代剖宫产在预防垂直传播中的作用。
我们假设，在一个国家剖宫产率较高的情况下，与未感染HIV的女性相比，感染HIV的女性剖宫产率较高，并且随着联合抗逆转录病毒治疗的进展，感染HIV的女性剖宫产使用率会随着时间推移而降低。本研究旨在（1）评估感染和未感染HIV的女性的剖宫产趋势，以及（2）在巴西一个产妇HIV感染率最高的城市的一家主要转诊机构进行的近56000例分娩的回顾性队列研究中，探讨剖宫产在免费、普及联合抗逆转录病毒治疗背景下预防感染HIV的女性垂直传播中的作用。
提取2008年1月1日至2018年12月31日母婴对的数据。使用Pearson卡方检验比较剖宫产率。采用广义估计方程法通过多变量对数线性泊松回归评估剖宫产预测因素。HIV病毒抑制定义为分娩时病毒载量<1000拷贝/ml。按照国家指南确定HIV垂直传播情况。
在11年期间，40375名女性发生了48688次妊娠；HIV血清阳性率为2.7%；进行了18886例剖宫产（38.8%）；47.7%感染HIV的女性和38.6%未感染HIV的女性接受了剖宫产（P<0.001）。尽管HIV与剖宫产相关（调整后相对风险，1.17[95%置信区间，1.05-1.29]），但2018年发生垂直传播的感染HIV的女性的剖宫产率（36.7%）与未感染HIV的女性（39.8%）相似。分娩时病毒载量未知的感染HIV的女性的剖宫产率（42.6%）并未随时间增加。HIV垂直传播率为2.2%，分娩时病毒载量未知的感染HIV的女性（8.4%）的垂直传播率最高，高于未发生垂直传播的感染HIV的女性（4.1%）和发生垂直传播的感染HIV的女性（0.5%）（P<0.001）。
在巴西的HIV高发地区，发生垂直传播的感染HIV的女性接受手术分娩的次数较少，可能是因为使用了高效联合抗逆转录病毒治疗。近一半病毒载量未知的感染HIV的女性未接受剖宫产，这可能是预防HIV垂直传播的一个错失的机会。
