HIV This Week

Mortality among HIV-positive postpartum women with high CD4 cell counts in Zimbabwe

Hargrove J, Humphrey J, for the ZVITAMBO Study Group. AIDS. 2010. 24:F11–F14 

Whereas antiretroviral treatment initiated at CD4 cell counts 351–450 cells/ml reduces mortality, compared with starting at lower CD4 levels, there is currently no evidence for the advantages of initiating treatment at CD4 cell counts greater than 450 cells/ml. Mortality hazard, as a function of CD4 cell count, was estimated among postpartum HIV-positive women in Zimbabwe, using HIV-negative women as the reference group. Mortality within 24 months postpartum was 54 times higher among women with CD4 cell counts less than 200 cells/ml, fell to 5.4 times higher for those with CD4 cell counts 400–600 cells/ml but fell little thereafter. For CD4 cell counts greater than 600 cells/ml the hazard was 6.2 (95% confidence interval 3.2–11.9).Early antiretroviral therapy initiation for all HIV-positive pregnant women may benefit individual mothers and infants, and simultaneously reduce population HIV incidence.

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Editors’ note: The striking findings in this study that enrolled 14,110 postpartum women within 96 hours of delivery to a vitamin A supplementation trial call into question the new World Health Organisation (WHO) adult treatment guidelines. The guidelines recommend that antiretroviral therapy be provided for all HIV-infected pregnant women with CD4 cell counts <350 cells/mm³, irrespective of WHO clinical staging, and for all HIV-infected pregnant women in WHO clinical stage 3 or 4, irrespective of CD4 cell count. This study found a higher risk of mortality for HIV-positive women in the 24 months following delivery across the entire CD4 cell count distribution spectrum compared to HIV-negative women. Although evidence suggests that pregnancy does not accelerate HIV disease progression beyond the passage of 9 months of time, most of the data come from industrialised settings. In contrast, these Zimbabwean findings suggest that serious consideration should be given to starting all pregnant women with HIV infection on antiretroviral treatment for life, regardless of CD4+ count.