High Risk of Postpartum Viremia in Women With Perinatal HIV Infection

By Scott Baltic

January 23, 2020

NEW YORK (Reuters Health) - The risk of postpartum viremia is high among women with perinatal HIV infection, and younger age at conception, pre-conception viremia and pre-conception immune suppression are all associated with rebound and persistent postpartum viremia, researchers have found.

The findings "could help identify women most likely to benefit from targeted post-partum adherence interventions," write Dr. Kunjal Patel of Harvard T.H. Chan School of Public Health, in Boston, and colleagues in The Lancet HIV. They defined viremia as 400 or more copies per mL.

In a secondary analysis of the Pediatric HIV/AIDS Cohort Study, the researchers evaluated 234 women with perinatal HIV infection, along with 39 women who were perinatally exposed to HIV but were uninfected. Race and ethnicity were similar in the two groups (67% African-American and 29% Hispanic).

After adjustment for age, pregnancy rates were lower in the perinatally infected group. Unintended pregnancies were common in both groups.

Of 172 total pregnancies recorded among 99 women with perinatal HIV infection, data on 147 (104 live births and 43 spontaneous or elective abortions) made them eligible for viral load trajectory analyses.

These showed mean viral loads increasing in the one-year pre-conception period through the beginning of pregnancy. Viral loads then typically suppressed by the end of pregnancy before diverging by pregnancy outcome in the year after pregnancy.

The trend of persistently elevated average postpartum viral loads was limited to live births. The study was unable to answer whether this finding reflects "contextual factors associated with having a newborn baby that present challenges to ART (anti-retroviral therapy) adherence or the health burden of pregnancies carried to term," the authors write.

The team found identified three distinct groups of viral-load trajectories after the 104 live births, classified as reflecting sustained suppression (30%), rebound viremia (53%) and persistent viremia (17%).

Dr. Patel said her hypothesis "is that the increase in viral loads during the year prior to conception of a likely unintended pregnancy is due to poor adherence."

"The decrease in viral loads during pregnancy is likely due to the increased engagement in care due to the pregnancy and increased commitment to adhere and decrease viral loads to prevent perinatal transmission of HIV to the baby," she told Reuters Health by email.

The post-pregnancy divergence of viral loads by pregnancy outcome, the authors note, might result from such challenges to ART adherence as having a busy schedule with a newborn baby or medication side effects.

In an accompanying editorial, Dr. Rachel K. Scott of Georgetown University School of Medicine, in Washington, D.C., notes that, "After pregnancy, an alarming proportion of HIV-positive women discontinue ART and disengage from care."

"Understanding determinants and predictors of adherence and retention in care, especially post-partum, in this understudied population is vitally important to maternal and child health and to the broader public," she adds.

Dr. Anandi Sheth of Emory University School of Medicine's Division of Infectious Diseases, told Reuters Health by email that, "The important take-home point here is that viral loads were suppressed during pregnancy, but in women who had live births . . . viral loads increased after delivery, and remained increased through 1 year after delivery."

The reasons, she suggested, could include "financial, social, physical, and emotional stressors that frequently occur after the birth of a child," as well as changes in medical insurance and transitions of care between obstetric and HIV care providers, which occur frequently during that period.

Because this paper included data only from women who had two or more viral load measurements in the first year after delivery, Dr. Sheth said, "its findings may underestimate the problem of falling off the HIV care continuum during the postpartum period." She noted that women who are lost to follow-up after delivery are at the highest risk for stopping antiretroviral therapy.

Dr. Sheth, who was not involved with this study, participated in a previous study on long-term engagement in HIV care among postpartum women with perinatal HIV infection.

The study was funded by the National Institutes of Health.

SOURCE: https://bit.ly/2t02E1k and https://bit.ly/2RApRiZ The Lancet HIV, online December 20, 2019.