title: Mode of delivery and postpartum HIV-1 disease progression and mortality in a Kenyan cohort.
abstract: BACKGROUND
  There are limited data on the impact of cesarean section delivery on HIV-1 infected women in Sub-Saharan Africa. The purpose of this study was to assess the effect of mode of delivery on HIV-1 disease progression and postpartum mortality in a Kenyan cohort.
  
  
  METHODS
  A prospective cohort study was conducted in Nairobi, Kenya from 2000-2005. We determined changes in CD4+ counts, HIV-1 RNA levels and mortality during the first year postpartum between HIV-1 infected women who underwent vaginal delivery (VD), non-scheduled cesarean section (NSCS) and scheduled cesarean section (SCS) and received short-course zidovudine. Loess curves and multivariate linear mixed effects models were used to compare longitudinal changes in maternal HIV-1 RNA and CD4+ counts by mode of delivery. Kaplan Meier curves, the log rank test, and Cox proportional hazards regression were used to assess difference in mortality.
  
  
  RESULTS
  Of 501 women, 405 delivered by VD, 74 delivered by NSCS and 22 by SCS. Baseline characteristics were similar between the VD and NSCS groups. Baseline antenatal CD4+ counts were lowest and HIV-1 RNA levels highest in the NSCS group but HIV-1 RNA levels were similar between groups at delivery. The rate of decline in CD4+ cells and rate of increase in HIV-1 RNA did not differ between groups. After adjusting for confounders, women who underwent NSCS had a 3.39-fold (95% CI 1.11, 10.35, P = 0.03) higher risk of mortality in the first year postpartum compared to women with VD.
  
  
  CONCLUSIONS
  Non-scheduled cesarean section was an independent risk factor for postpartum mortality in HIV-1 positive Kenyan women. The cause of death was predominantly due to HIV-1 related infections, and not direct maternal deaths, however, this was not mirrored by differential changes in HIV-1 progression markers between the groups.
authors.affiliation: Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA. junger@uw.edu.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Unger
authors.forename: Barbra A
authors.initials: BA
authors.lastname: Richardson
authors.forename: Phelgona A
authors.initials: PA
authors.lastname: Otieno
authors.forename: Carey
authors.initials: C
authors.lastname: Farquhar
authors.forename: Dalton
authors.initials: D
authors.lastname: Wamalwa
authors.forename: Grace C
authors.initials: GC
authors.lastname: John-Stewart
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D002423:Cause of Death; D002585:Cesarean Section; D018450:Disease Progression; D004630:Emergencies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000276:immunology* / Q000401:mortality*; D015497:HIV-1 / Q000235:genetics / Q000276:immunology*; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D008428:Maternal Mortality; D036801:Parturition; D049590:Postpartum Period; D011446:Prospective Studies; D012367:RNA, Viral / Q000097:blood; D055815:Young Adult; D015215:Zidovudine / Q000627:therapeutic use
chemical_list: D019380:Anti-HIV Agents; D012367:RNA, Viral; D015215:Zidovudine
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