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. 2023 Jun 1:31:100656.
doi: 10.1016/j.lanepe.2023.100656. eCollection 2023 Aug.

Viral suppression and retention in HIV care during the postpartum period among women living with HIV: a longitudinal multicenter cohort study

Paolo Paioni  1 , Karoline Aebi-Popp  2   3 , Begoña Martinez de Tejada  4 , Christoph Rudin  5 , Enos Bernasconi  6 , Dominique L Braun  7 , Roger Kouyos  7 , Noémie Wagner  8 , Pierre Alex Crisinel  9 , Sabine Güsewell  10 , Katharine E A Darling  11 , Andrea Duppenthaler  12 , Marc Baumann  13 , Christian Polli  14 , Tina Fischer  15 , Christian R Kahlert  10   16 ; Swiss HIV Cohort Study (SHCS) and the Swiss Mother and Child HIV Cohort Study (MoCHiV)
Collaborators, Affiliations

Viral suppression and retention in HIV care during the postpartum period among women living with HIV: a longitudinal multicenter cohort study

Paolo Paioni et al. Lancet Reg Health Eur. .

Abstract

Background: Low rates of postnatal retention in HIV care and viral suppression have been reported in women living with HIV (WLWH) despite viral suppression at delivery. At the same time, postpartum follow-up is of crucial importance in light of the increasing support offered in many resource-rich countries including Switzerland to WLWH choosing to breastfeed their infant, if optimal scenario criteria are met.

Methods: We longitudinally investigated retention in HIV care, viral suppression, and infant follow-up in a prospective multicentre HIV cohort study of WLWH in the optimal scenario who had a live birth between January 2000 and December 2018. Risk factors for adverse outcomes in the first year postpartum were assessed using logistic and proportional hazard models.

Findings: Overall, WLWH were retained in HIV care for at least six months after 94.2% of the deliveries (694/737). Late start of combination antiretroviral therapy (cART) during the third trimester was found to be the main risk factor for failure of retention in HIV care (crude odds ratio [OR] 3.91; 95% confidence interval [CI], 1.50-10.22; p = 0.005). Among mothers on cART until at least one year after delivery, 4.4% (26/591) experienced viral failure, with illicit drugs use being the most important risk factor (hazard ratio [HR], 13.2; 95% CI, 2.35-73.6; p = 0.003). The main risk factors for not following the recommendations regarding infant follow-up was maternal depression (OR, 3.52; 95% CI, 1.18-10.52; p = 0.024).

Interpretation: Although the results are reassuring, several modifiable risk factors for adverse postpartum outcome, such as late treatment initiation and depression, were identified. These factors should be addressed in HIV care of all WLWH, especially those opting to breastfeed in resource-rich countries.

Funding: This study has been financed within the framework of the Swiss HIV Cohort Study, supported by the Swiss National Science Foundation (grant #201369), by SHCS project 850 and by the SHCS research foundation.

Keywords: Breastfeeding; Infant follow-up; Postpartum HIV care engagement; Postpartum period; Retention in HIV care; Viral suppression.

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Conflict of interest statement

BMT received payments from Effik AG, and Pierre-Favre Pharma for her participation to advisory boards. The institution of EB received honoraria from Gilead Sciences, ViiV Healthcare, MSD, Pfizer AG, Ely Lilly, and Astra Zeneca for his participation to advisory boards, and travel grants from Gilead Sciences, ViiV Healthcare, MSD, and Pfizer AG. DLB received honoraria from Gilead Sciences, ViiV Healthcare, and Merck for his participation to advisory boards and for lectures, payments from Abbvie for lectures, and travel grants from Gilead Sciences. RK received research grants from Gilead Sciences, the Swiss National Science Foundation (SNSF) and the National Institutes of Health (NIH) unrelated to this work. CP received honoraria from Effik AG for his participation to advisory boards. The authors have no other conflicts of interest to disclose.

Figures

Fig. 1
Fig. 1
Flowchart of deliveries and patient selection ∗of which in 303 of the cases maternal pVL was not suppressed (i.e. <50 copies/ml) at the last two or three consecutive measurements before delivery, in 26 of the cases the last maternal pVL measurement was performed more than 90 days before delivery and in 64 of the cases both conditions were present. Abbreviations: pVL, plasma viral load; MoCHiV, Swiss Mother and Child HIV Cohort Study; SHCS, Swiss HIV Cohort Study.
Fig. 2
Fig. 2
Kaplan–Meier curves showing (a) the time course of viral suppression rate from the date of delivery up to the last pVL test in the postpartum period and (b) the time course of recovery from viral failure. 95% CI (shaded area) are based on simple non-parametric survival fits and do not take into account possible dependencies of multiple births from the same mother. Abbreviations: CI, confidence interval; pVL, plasma viral load.
Fig. 3
Fig. 3
Kaplan–Meier curves showing the time course of viral suppression rate from the date of delivery up to the last pVL test in the postpartum period for (a) year of delivery, (b) age at delivery, (c) time from HIV diagnosis to delivery and (d) gestational age at viral suppression. The significance of associations is given by p-values from robust score tests based on Cox regression including mother identity as cluster term. Numbers at risk are given in total (n) as well as for individual groups and times. Abbreviation: pVL, plasma viral load.
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