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Changing Patterns and Factors Associated With Mode of Delivery Among Pregnant Women With Human Immunodeficiency Virus Infection in the United States

Venkatesh, Kartik, K., MD, PhD; Morrison, Leavitt, MSc; Livingston, Elizabeth, G., MD; Stek, Alice, MD; Read, Jennifer, S., MD; Shapiro, David, E., PhD; Tuomala, Ruth, E., MD

doi: 10.1097/AOG.0000000000002566
Contents: Original Research

OBJECTIVE: To describe patterns and factors associated with mode of delivery among pregnant women with human immunodeficiency virus (HIV) infection in the United States in relation to evolving HIV-in-pregnancy guidelines.

METHODS: We conducted an analysis of two observational studies, Pediatric AIDS Clinical Trials Group and International Maternal Pediatric Adolescent AIDS Clinical Trials Network Protocol P1025, which enrolled pregnant women with HIV infection from 1998 to 2013 at more than 60 U.S. acquired immunodeficiency syndrome clinical research sites. Multivariable analyses of factors associated with an HIV-indicated cesarean delivery (ie, for prevention of mother-to-child transmission) compared with other indications were conducted and compared according to prespecified time periods of evolving HIV-in-pregnancy guidelines: 1998–1999, 2000–2008, and 2009–2013.

RESULTS: Among 6,444 pregnant women with HIV infection, 21% delivered in 1998–1999, 58% in 2000–2008, and 21% in 2009–2013; 3,025 (47%) delivered by cesarean. Cesarean delivery increased from 30% in 1998 to 48% in 2013. Of all cesarean deliveries, repeat cesarean deliveries increased from 16% in 1998 to 42% in 2013; HIV-indicated cesarean deliveries peaked at 48% in 2004 and then dropped to 12% by 2013. In multivariable analyses, an HIV diagnosis during pregnancy, initiation of antiretroviral therapy in the third trimester, a plasma viral load 500 copies/mL or greater, and delivery between 37 and 40 weeks of gestation increased the likelihood of an HIV-indicated cesarean delivery. In analyses by time period, an HIV diagnosis during pregnancy, initiation of antiretroviral therapy in the third trimester, and a plasma viral load of 500 copies/mL or greater were progressively more likely to be associated with an HIV-indicated cesarean delivery over time.

CONCLUSION: Almost 50% of pregnant women with HIV infection underwent cesarean delivery. Over time, the rate of repeat cesarean deliveries increased, whereas the rate of HIV-indicated cesarean deliveries decreased; cesarean deliveries were more likely to be performed in women at high risk of mother-to-child transmission. These findings reinforce the need for both early diagnosis and treatment of HIV infection in pregnancy and the option of vaginal delivery after cesarean among pregnant women with HIV infection.

Almost 50% of pregnant women with human immunodeficiency virus (HIV) infection in the United States undergo cesarean delivery; these are increasingly repeat cesarean deliveries and not performed for HIV transmission prevention.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina, Chapel Hill, North Carolina; the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Duke University, Durham, North Carolina; the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California; the Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, California; and the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Corresponding author: Kartik K. Venkatesh, MD, PhD, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina, 3010 Old Clinic Building, CB #7516, Chapel Hill, NC 27599-7516; email: Kartik.venkatesh@unchealth.unc.edu.

Supported by the International Maternal Pediatric Adolescent AIDS Clinical Trials Network (IMPAACT) provided by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (NIH) under Award Numbers UM1AI068632 (IMPAACT LOC), UM1AI068616 (IMPAACT SDMC), and UM1AI106716 (IMPAACT LC) with cofunding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the Infectious Diseases for Obstetrics and Gynecology Annual Meeting, August 10–12, 2017, Park City, Utah.

Each author has indicated that he or she has met the journal's requirements for authorship.

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.