CD4+ cell count testing more effective than HIV disease clinical staging in identifying pregnant and postpartum women eligible for antiretroviral therapy in resource-limited settings

Abstract

Objective: Identifying antiretroviral therapy (ART) eligible HIV-infected (HIV+) pregnant women and rapidly initiating treatment preserves maternal health and prevents mother-to-child transmission. However, there have been few investigations of the performance of ART eligibility criteria in pregnant and postpartum women in resource-limited settings.

Methods: Pregnant and recently postpartum HIV+ women received CD4+ cell count and World Health Organization (WHO) clinical staging at enrollment into the mother-to-child transmission Plus Initiative. We compared immunologic and clinical criteria based on 2009 WHO ART treatment guidelines (WHO stage 3/4 or CD4+ cell count ≤350 cells/mm³) in identifying ART eligible women.

Results: Among 6036 women (62% antepartum, 38% postpartum), 2915 (48%) were ART eligible. Only 23% had WHO stage 3 or 4 disease, whereas 94% met CD4+ cell count criterion. Among 5356 women with WHO stage 1 or 2 disease, 2235 (42%) had CD4+ ≤350 cells per cubic millimeter. Change of CD4+ cell count ART eligibility threshold from ≤200 to ≤350 cells per cubic millimeter increased the proportion of ART eligible women from 21% to 45%.

Conclusions: Use of CD4+ cell count criterion is superior to clinical staging in identifying pregnant and postpartum HIV+ women eligible for ART. Improving access to CD4+ testing is essential to identify and treat eligible women, optimizing maternal and child health outcomes.