title: Reduction of maternal mortality with highly active antiretroviral therapy in a large cohort of HIV-infected pregnant women in Malawi and Mozambique.
abstract: BACKGROUND
  HIV infection is a major contributor to maternal mortality in resource-limited settings. The Drug Resource Enhancement Against AIDS and Malnutrition Programme has been promoting HAART use during pregnancy and postpartum for Prevention-of-mother-to-child-HIV transmission (PMTCT) irrespective of maternal CD4 cell counts since 2002.
  
  
  METHODS
  Records for all HIV+ pregnancies followed in Mozambique and Malawi from 6/2002 to 6/2010 were reviewed. The cohort was comprised by pregnancies where women were referred for PMTCT and started HAART during prenatal care (n = 8172, group 1) and pregnancies where women were referred on established HAART (n = 1978, group 2).
  
  
  RESULTS
  10,150 pregnancies were followed. Median (IQR) baseline values were age 26 years (IQR:23-30), CD4 count 392 cells/mm(3) (IQR:258-563), Viral Load log10 3.9 (IQR:3.2-4.4), BMI 23.4 (IQR:21.5-25.7), Hemoglobin 10.0 (IQR: 9.0-11.0). 101 maternal deaths (0.99%) occurred during pregnancy to 6 weeks postpartum: 87 (1.1%) in group 1 and 14 (0.7%) in group 2. Mortality was 1.3% in women with <than 350 CD4 cells/mm(3) and 0.7% in women with greater than 350 CD4s cells/mm(3) [OR = 1.9 (CL 1.3-2.9) p = 0.001]. Mortality was higher in patients with shorter antenatal HAART: 22/991 (2.2%) if less than 30 days and 79/9159 (0.9%) if 31 days or greater [OR = 2.6 (CL 1.6-4.2) p<0.001]. By multivariate analysis, shorter antenatal HAART (p<0.001), baseline values for CD4 cell count (p = 0.012), hemoglobin (p = 0.02), and BMI (p<0.001) were associated with mortality. Four years later, survival was 92% for women with shorter antenatal HAART and 98% for women on established therapy prior to pregnancy, p = 0.001.
  
  
  CONCLUSIONS
  Antiretrovirals for PMTCT purposes have significant impact on maternal mortality as do CD4 counts and nutritional status. In resource-limited settings, PMTCT programs should provide universal HAART to all HIV+ pregnant women given its impact in prevention of maternal death.
authors.affiliation: Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Liotta
authors.forename: Sandro
authors.initials: S
authors.lastname: Mancinelli
authors.forename: Karin
authors.initials: K
authors.lastname: Nielsen-Saines
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Gennaro
authors.forename: E
authors.initials: E
authors.lastname: Gennaro
authors.forename: Paola
authors.initials: P
authors.lastname: Scarcella
authors.forename: Nurja Abdul
authors.initials: NA
authors.lastname: Magid
authors.forename: Paola
authors.initials: P
authors.lastname: Germano
authors.forename: Haswell
authors.initials: H
authors.lastname: Jere
authors.forename: Giovanni
authors.initials: G
authors.lastname: Guidotti
authors.forename: Gianni
authors.initials: G
authors.lastname: Guidotti
authors.forename: Ersilia
authors.initials: E
authors.lastname: Buonomo
authors.forename: Fausto
authors.initials: F
authors.lastname: Ciccacci
authors.forename: Leonardo
authors.initials: L
authors.lastname: Palombi
authors.forename: Maria Cristina
authors.initials: MC
authors.lastname: Marazzi
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality / Q000635:transmission; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D053208:Kaplan-Meier Estimate; D008295:Malawi; D008428:Maternal Mortality; D009073:Mozambique; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy* / Q000401:mortality / Q000821:virology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D015996:Survival Rate; D055815:Young Adult