title: Mortality during the first 24 months after delivery in relation to CD4 T-lymphocyte levels and viral load in a cohort of breast-feeding HIV-1-infected women in Dar es Salaam, Tanzania.
abstract: The objective of this study was to analyze the mortality during the first 24 months after delivery in relation to CD4 T-lymphocyte levels and viral load at enrollment (36 weeks of gestation) in a cohort of HIV-1-seropositive breast-feeding women at the Dar es Salaam site of the multicenter Petra trial (a mother-to-child HIV-1 transmission intervention trial using antiretroviral therapy). Antiretroviral treatment was not available in this setting apart from the short treatment given within the trial around delivery to prevent mother-to-child transmission of HIV. T-lymphocyte subsets were determined by flow cytometry. Plasma HIV-1 RNA was quantified by the Amplicor HIV-1 RNA Monitor v 1.5 assay. Mortality after delivery was analyzed using the life-table technique and Cox regression. The analysis included 266 mothers. The CD4 cell counts at enrollment were <200 cells/mm in 14.5% of the mothers. The viral load at enrollment was >100,000 RNA copies/mL in 33.6% of the mothers. The mortality 24 months after delivery was 6.7% (95% CI = 3.1-10.1%). The mortality 24 months after delivery was 29.9% (95% CI = 13.1-46.9%) for mothers with <200 CD4 cells/mm at enrollment, 3.3% (95% CI = 0-6.6%) for mothers with 200-499 CD4 cells/mm, 2.9% (95% CI = 0-7.1%) for mothers with >500 CD4 cells/mm (P = 0.0000), 15.0% (95% CI = 6.6-23.4%) for mothers with viral load >100,000 copies/mL at enrollment, and 2.8% (95% CI = 0-5.6%) for mothers with viral load <100,000 copies/mL (P = 0.0000). In the multivariate analysis CD4 cell counts and viral load were both independent risk factors for mortality (P < 0.001 and P = 0.004, respectively). In conclusion, the mortality was high among women with severe immunosuppression or high viral load at enrollment, but not in the rest of the women. CD4 lymphocyte count in late pregnancy was a better predictor of death within 2 years than was viral load. The results support the World Health Organization recommendation to initiate antiretroviral treatment in resource-limited settings in HIV-1-infected adults with CD4 cell counts <200/mm and show that this is appropriate also among perinatal women.
authors.affiliation: Department of Obstetrics and Gynecology, Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania.
authors.forename: Charles
authors.initials: C
authors.lastname: Kilewo
authors.forename: Katarina
authors.initials: K
authors.lastname: Karlsson
authors.forename: Andrew
authors.initials: A
authors.lastname: Swai
authors.forename: Augustine
authors.initials: A
authors.lastname: Massawe
authors.forename: Eligius
authors.initials: E
authors.lastname: Lyamuya
authors.forename: Fred
authors.initials: F
authors.lastname: Mhalu
authors.forename: Gunnel
authors.initials: G
authors.lastname: Biberfeld
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000276:immunology / Q000401:mortality*; D001942:Breast Feeding; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D036861:Delivery, Obstetric; D005260:Female; D015483:HIV Antibodies / Q000097:blood; D015658:HIV Infections / Q000276:immunology / Q000401:mortality*; D015497:HIV-1 / Q000235:genetics / Q000302:isolation & purification; D006801:Humans; D010352:Patient Dropouts; D011247:Pregnancy; D013636:Tanzania / Q000453:epidemiology; D013997:Time Factors; D019562:Viral Load
chemical_list: D015483:HIV Antibodies