title: Mortality and virologic outcomes after access to antiretroviral therapy among a cohort of HIV-infected women who received single-dose nevirapine in Lusaka, Zambia.
abstract: OBJECTIVE
  Single-dose nevirapine (SDNVP) for prevention of mother-to-child HIV transmission selects mutations conferring resistance to nonnucleoside reverse transcriptase inhibitor (NNRTI)-based therapy. We investigated mortality and virologic and clinical outcomes after introduction of antiretroviral treatment (ART) among a cohort of women given SDNVP.
  
  
  METHODS
  When ART programs were introduced in 2004 in Lusaka, Zambia, we were completing a trial of infant feeding, which involved following HIV-infected women who received SDNVP between 2001 and 2005. Women still in follow-up or who could be contacted were evaluated for eligibility for ART (CD4 count <200 or <350 and World Health Organization stage >or=3) and started on NNRTI-based therapy if eligible. We compared mortality in the cohort of women before and after ART access, and examined, among women initiating ART, whether virologic response was better allowing a longer time to elapse between SDNVP and treatment initiation.
  
  
  RESULTS
  In the cohort of 872 women, mortality more than halved after ART became available (relative hazard = 0.46, 95% confidence interval: 0.23 to 0.91, P = 0.03). Of 161 SDNVP-exposed women followed on NNRTI-based ART, 70.8% suppressed (viral load <400 copies/mL). Only 3 of 8 SDNVP-exposed women (37.5%) <6 months of starting therapy suppressed compared with 13 of 22 (59.1%) who started 6-12 months, 44 of 61 (72.1%) 12-24 months, and 54 of 70 (77.1%) >24 months after exposure (chi2 trend P = 0.01).
  
  
  CONCLUSIONS
  Most SDNVP-exposed women respond well to NNRTI-based therapy, but there was an attenuation of therapy efficacy that persisted to 12 months after exposure. Women should be screened for ART eligibility during pregnancy and started on effective regimens before delivery.
authors.affiliation: Gertrude H. Sergievsky Center, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY 10032-3702, USA. lk24@columbia.edu
authors.forename: Louise
authors.initials: L
authors.lastname: Kuhn
authors.forename: Katherine
authors.initials: K
authors.lastname: Semrau
authors.forename: Shobana
authors.initials: S
authors.lastname: Ramachandran
authors.forename: Moses
authors.initials: M
authors.lastname: Sinkala
authors.forename: Nancy
authors.initials: N
authors.lastname: Scott
authors.forename: Prisca
authors.initials: P
authors.lastname: Kasonde
authors.forename: Mwiya
authors.initials: M
authors.lastname: Mwiya
authors.forename: Chipepo
authors.initials: C
authors.lastname: Kankasa
authors.forename: Don
authors.initials: D
authors.lastname: Decker
authors.forename: Donald M
authors.initials: DM
authors.lastname: Thea
authors.forename: Grace M
authors.initials: GM
authors.lastname: Aldrovandi
mesh_terms: D019380:Anti-HIV Agents / Q000008:administration & dosage*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality* / Q000821:virology; D006801:Humans; D019829:Nevirapine / Q000008:administration & dosage*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy* / Q000401:mortality* / Q000821:virology; D016016:Proportional Hazards Models; D016896:Treatment Outcome; D019562:Viral Load; D015024:Zambia / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents; D019829:Nevirapine