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Missed Opportunities Among HIV-Positive Women to Control Viral Replication During Pregnancy and to Have a Vaginal Delivery

Aebi-Popp, Karoline MD, MSc*,†; Mulcahy, Fiona MD; Glass, Tracy R. PhD‡,§; Rudin, Christoph MD; Martinez de Tejada, Begona MD; Bertisch, Barbara MD#; Fehr, Jan MD**; Grawe, Claudia MD††; Scheibner, Kathrin MD‡‡; Rickenbach, Martin MD§§; Hoesli, Irene MD*; Thorne, Claire PhD‖‖; for the European Collaborative Study in EuroCoord and the Swiss Mother & Child HIV Cohort Study

JAIDS Journal of Acquired Immune Deficiency Syndromes: 1 September 2013 - Volume 64 - Issue 1 - p 58–65
doi: 10.1097/QAI.0b013e3182a334e3
Clinical Science

Introduction: Most national guidelines for the prevention of mother-to-child transmission of HIV in Europe updated between 2001 and 2010 recommend vaginal deliveries for women with undetectable or very low viral load (VL). Our aim was to explore the impact of these new guidelines on the rates of vaginal deliveries among HIV-positive women in Europe.

Methods: In a pooled analysis of data on HIV-positive pregnant women enrolled in the Swiss Mother & Child HIV Cohort Study and the European Collaborative Study 2000 to 2010, deliveries were classified as occurring pre- or postpublication of national guidelines recommending vaginal delivery.

Results: Overall, 2663 women with 3013 deliveries were included from 10 countries; 28% women were diagnosed with HIV during pregnancy. Combination antiretroviral therapy was used in most pregnancies (2020, 73%), starting during the first or second trimester in 78% and during the third trimester in 22%; in 25% pregnancies, the woman conceived on combination antiretroviral therapy. Overall, in 86% pregnancies, a VL < 400 copies per milliliter was achieved before delivery. The proportion of vaginal deliveries increased from 17% (414/2377) before the change in guidelines to 52% (313/600) after; elective Caesarean section rates decreased from 65% to 27%. The proportion of women with undetectable VL having a Caesarean section was 55% after implementation of new guidelines. We observed a decrease of late preterm deliveries from 16% (377/2354) before to 7% (42/599) after the change in guidelines (P < 0.001).

Conclusion: There are still missed opportunities for women with HIV to fully suppress their VL and to deliver vaginally in Europe.

*Department of Obstetrics and Gynecology, University Women’s Hospital Basel, Basel, Switzerland;

Division of Infectious Diseases, St. James’s Hospital Dublin, Dublin, Ireland;

Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland;

§Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel, Basel, Switzerland;

Department of Nephrology, University Children’s Hospital Basel, Basel, Switzerland;

Department of Obstetrics and Gynecology, University Women’s Hospital Geneva, Geneva, Switzerland;

#Division of Infectious Diseases, Cantonal Hospital, St. Gallen, Switzerland;

**Division of Infectious Diseases University Hospital Zuerich, Zuerich, Switzerland;

††Department of Obstetrics and Gynecology, University Women’s Hospital Zuerich, Zuerich, Switzerland;

‡‡Department of Obstetrics and Gynecology, University Women’s Hospital Bern, Switzerland;

§§Data Centre of the Swiss HIV Cohort Study, Institute for Social and Preventive Medicine, University Lausanne, Switzerland; and

‖‖MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, University College London, London, United Kingdom.

Correspondence to: Karoline Aebi-Popp, MD, MSc, Department of Obstetrics and Gynecology, University Women’s Hospital Basel, Spitalstrasse 21, Basel CH-4031, Switzerland (e-mail: mail@aebi-popp.com).

This study has been financed in the framework of the Swiss HIV Cohort Study (SHCS), supported by the Swiss National Science Foundation (SNF) Grant 33CS30_134277. K.A.-P. was supported by a fellowship research grant of the University Basel, Switzerland, and a grant by the European AIDS society (EACS) while working at St. James’s Hospital in Dublin, Ireland. The European Collaborative Study receives funding from the European Union Seventh Framework Programme (FP7/2007–2013) under EuroCoord grant agreement number 260694 (www.eurocoord.net). Some of this work was undertaken at GOSH/UCL Institute of Child Health, which received a proportion of funding from the UK Department of Health’s NIHR Biomedical Research Centres funding scheme. The Centre for Paediatric Epidemiology and Biostatistics also benefits from funding support from the Medical Research Council in its capacity as the MRC Centre of Epidemiology for Child Health.

I.H. and C.T. contributed equally. K.A.P., C.T., C.R., F.M., T.G., and I.H., contributed to study conception, study design, study performance, and article writing. T.R.G. was responsible for undertaking the statistical analyses. B.M.T., B.B., J.F., C.G., K.S., and M.R. contributed to study conception and article review. The Swiss Mother and Child HIV Cohort Study and the European Collaborative Study group contributed to data collection and article review.

Presented at the 11th International Congress on Drug Therapy in HIV Infection, November 11–15, 2012, Glasgow, United Kingdom.

Received March 14, 2013

Accepted June 24, 2013

© 2013 by Lippincott Williams & Wilkins