Abstract:
Background: In the Mitra plus study of prevention of mother-to-child transmission of HIV-1, which included 501
women in Dar es Salaam, Tanzania, triple antiretroviral therapy (ART) was given from late pregnancy throughout
breastfeeding up to 6 months postnatally. Here we report findings in a sub-cohort of women with ≤200 CD4cells/μL at
enrolment who were continued on ART for life and followed up during 24 months after delivery to determine virologic
and immunologic responses, drug resistance and mortality.
Methods: Blood samples for viral load and CD4 counts testing were collected at enrolment and at 3, 6, 12 and 24 months
postpartum. HIV drug resistance testing was performed at 12 months. Data analysis included descriptive statistics and
multivariate analysis using Generalized Estimated Equations of 73 women with at least two postpartum assessments.
The mortality analysis included 84 women who had delivered.
Results: The proportion of women with a viral load ≥400 copies/mL was 97% (71/73) at enrolment, 16% (11/67), 22%
(15/69), 61% (36/59) and 86% (48/56) at 3, 6, 12 and 24 months postpartum, respectively. The proportion of women with
immunologic failure was 12% (8/69), 25% (15/60) and 41% (24/58) at 6, 12 and 24 months, respectively. At 12 months,
drug resistance was demonstrated in 34% (20/59), including 12 with dual-class resistance. Self-report on drug adherence
was 95% (64/68), 85% (56/66), 74% (39/53) and 65% (30/46) at 3, 6, 12 and 24 months, respectively. The mortality rate
was 5.9% (95% CI 2.5-13.7%) at 24 months. The probability of virologic and immunologic failure was significantly higher
among women who reported non-perfect adherence to ART at month 24 postpartum.
Conclusions: Following an initial decline of viral load, virologic failure was common at 12 and 24 months postpartum
among women initiated on ART for life during pregnancy because of low CD4 cell counts. A high proportion of viremic
mothers also had resistance mutations. However, at 24 months follow-up, the mortality rate was still fairly low. Continuous
adherence counseling and affordable means of monitoring of the virologic response are crucial for successful implementation
of the WHO Option B+ guidelines to start all HIV-infected pregnant women on ART for life.
