Initiating antiretroviral therapy (ART) in pregnant women who are HIV positive on the same day as their first antenatal visit does not worsen or improve outcomes compared with delaying ART initiation, according to a prospective cohort study published in the Journal of the International AIDS Society.
Same-day initiation of ART in HIV-positive pregnant women is common across Africa. However, there are concerns that this practice disallows patient counseling and education prior to choosing treatment, resulting in subsequent nonadherence.
Investigators recruited 628 pregnant patients who were HIV positive from a primary care clinic in Cape Town, South Africa, during their first visit between March 2013 and June 2014. All patients selected for the study before July 2013 were eligible for ART at the time of the visit — that is, CD4 cell counts were ≤350 cells/µL — and ART was not initiated until 1 to 2 weeks later. Patients selected for the study after July 2013 were administered ART on the day of their clinic visit, regardless of CD4 cell count.
ART was comprised of tenofovir, emtricitabine, and efavirenz, administered once daily. Viral load testing was conducted regularly, with viral suppression defined as <50 copies/mL. Participants were monitored until 12 months postpartum.
The levels of viral suppression at delivery and 12 months postpartum were similar, regardless of whether ART was initiated at the first clinic visit or 12 months postpartum (74% vs 82% and 74% vs 71% respectively). Women with a CD4 count >350 cell/μL were twice as likely to have a suppressed viral load at delivery compared with those with a CD4 count ≤350 cell/μL (P =.054).
Neither timing of ART initiation nor level of engagement in clinical care throughout the study had significant effects on time to viral rebound following initial suppression. There were no differences in engagement in clinical care through the end of follow-up between delayed vs same-day ART initiators.
“[T]hese findings do not support the hypotheses that delaying ART initiation in pregnancy contributes to worsened or improved maternal outcomes,” the authors wrote. “While these results are reassuring for ART programs implementing immediate ART initiation during pregnancy, further research is required to examine long-term engagement in care, particularly postpartum.”
Langwenya N, Phillips TK, Brittain K, Zerbe A, Abrams EJ, Myer L. Same-day antiretroviral therapy (ART) initiation in pregnancy is not associated with viral suppression or engagement in care: a cohort study. J Int AIDS Soc. 2018;21(6):e25133.