Postpartum plasma CD4 change in HIV-positive women: implications for timing of HAART initiation

Ai Koyanagi, Andrea J Ruff, Lawrence H Moulton, Robert Ntozini, Kuda Mutasa, Peter Iliff, Jean H Humphrey, ZVITAMBO Study Group, Henry Chidawanyika, John Hargrove, Agnes I Mahomva, Florence Majo, Lucie C Malaba, Michael T Mbizvo, Faith Mzengeza, Kusum J Nathoo, Mary Ndhlovu, Ellen Piwoz, Lidia Propper, Phillipa Rambanepasi, Naume Tavengwa, Brian J Ward, Lynn S Zijenah, Clare D Zunguza, Partson Zvandasara, Ai Koyanagi, Andrea J Ruff, Lawrence H Moulton, Robert Ntozini, Kuda Mutasa, Peter Iliff, Jean H Humphrey, ZVITAMBO Study Group, Henry Chidawanyika, John Hargrove, Agnes I Mahomva, Florence Majo, Lucie C Malaba, Michael T Mbizvo, Faith Mzengeza, Kusum J Nathoo, Mary Ndhlovu, Ellen Piwoz, Lidia Propper, Phillipa Rambanepasi, Naume Tavengwa, Brian J Ward, Lynn S Zijenah, Clare D Zunguza, Partson Zvandasara

Abstract

CD4 counts increase during the postpartum period and may not correctly identify HAART-eligible HIV-positive women. HAART eligibility when defined by two CD4 cutoffs (<200 and <350 cells/microl) measured at two time points (within 96 h of delivery and 6 weeks) in postpartum HIV-positive women was compared. Among HIV-positive women who had CD4 at delivery and 6 weeks (n = 423), time to Stage 3 or 4 opportunistic infection or death was compared using Cox regression between three groups of women: (1) CD4 <200 cells/microl at delivery and 6 weeks, (2) CD4 <200 cells/microl at delivery but >or=200 cells/microl at 6 weeks, and (3) CD4 >or=200 cells/microl at delivery and at 6 weeks. The analysis was repeated using the CD4 <350 cells/microl cut-off. CD4 counts increased by a median (IQR) of 70 (1-178) cells/microl between delivery and 6 weeks and decreased thereafter to approximately delivery levels at 12 months. Only 60% and 61% who had CD4 <200 cells/microl and CD4 <350 cells/microl, respectively, at delivery also had those levels at 6 weeks. Among those with CD4 <350 cells/microl at both delivery and 6 weeks, the risk of death or Stage 3 or 4 disease was 5.27 (95% CI 1.85-14.96) times higher than those with CD4 <350 at delivery but >or=350 cells/microl at 6 weeks. The use of CD4 counts immediately postpartum to define HAART eligibility may lead to substantial misclassification.

Figures

FIG. 1.
FIG. 1.
Median and interquartile ranges of CD4 cell counts at delivery, 6 weeks, and 3, 6, 9, and 12 months postpartum. Only those who had information on CD4 counts at delivery, 6 weeks, and 12 months are included.
FIG. 2.
FIG. 2.
Scatter plot of plasma CD4 counts at delivery, 6 weeks, and 12 months. The diagonal line corresponds to y = x. The dashed line is a reference line for CD4 350 cells/μl. It is restricted to the 226 women who had CD4 count at delivery, 6 weeks, and 12 months.
FIG. 2.
FIG. 2.
Scatter plot of plasma CD4 counts at delivery, 6 weeks, and 12 months. The diagonal line corresponds to y = x. The dashed line is a reference line for CD4 350 cells/μl. It is restricted to the 226 women who had CD4 count at delivery, 6 weeks, and 12 months.
FIG. 2.
FIG. 2.
Scatter plot of plasma CD4 counts at delivery, 6 weeks, and 12 months. The diagonal line corresponds to y = x. The dashed line is a reference line for CD4 350 cells/μl. It is restricted to the 226 women who had CD4 count at delivery, 6 weeks, and 12 months.
FIG. 3.
FIG. 3.
Kaplan–Meier survival curves of time to first Stage 3 or 4 opportunistic infection or death after 42 days postpartum by CD4 count at delivery and at 6 weeks. The 423 women who had CD4 count available at delivery and 6 weeks are included. §Opportunistic infections. Refer to the text for definitions.

Source: PubMed

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