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The Body Covers: The 45th Annual Meeting of the Infectious Diseases Society of America

Postpartum ART Discontinuation is Common, Particularly Among HIV-Infected Women With Less Advanced HIV
An Interview With Turner Overton, M.D.

By Bonnie Goldman

October 6, 2007

Turner Overton, M.D.
Listen (3.4MB, 8 min.)

This is an interview that took place in the poster session at IDSA 2007, one of the year's HIV conferences. There's nothing like hearing the results of research directly from those who actually conducted the research. It is these women and men who are transforming HIV treatment and care. In this interview, the researchers introduce themselves and then summarize their study. After their summary, I'll ask a few questions.

Hi. I'm Turner Overton from Washington University in St. Louis. We have done a poster on our experience with pregnancy and HIV-infected women.1 One of our big questions is regarding HIV treatment, particularly treatment interruption. After pregnancy, women's therapy is often stopped. So we wanted to see if outcomes in women were worse in those who discontinued [HIV therapy].

Obviously, overall, our results are very in line with other studies -- we have less than 1% rates of HIV transmission to the baby. But what happens to mothers after pregnancy and discontinuation of antiretroviral therapy?

We had 226 women, 226 pregnancies. Of those, two thirds discontinued antiretroviral therapy after the pregnancy. They tended to be younger and healthier from an HIV standpoint. But regardless, when you looked at outcomes, they tended to have more outcomes. Those outcomes we were looking at were opportunistic infections and all cause mortality.

So the suggestion is that the findings from the SMART study2 apply to pregnancy, as well. If we are treating during pregnancy -- [providing] temporary ART [antiretroviral therapy] during pregnancy -- what we are actually doing is subjecting these women to an HIV treatment interruption. So in our current era, should we consider maintaining women on antiretroviral therapy? I would say that we should, if the women can be adherent with therapy.

What was the mean age of the women in your review?

The mean age was 25 years for the whole group.1 The ones who continued ART were older, although it was not statistically significant: 26 versus 25 years.

What sort of opportunistic infections [OIs] are we talking about?

PCP [Pneumocystis carinii pneumonia] was the most common OI. We also had an esophageal candidiasis, and I believe we had disseminated histo [histoplasmosis]. They were the three most common that stick out in my mind. But I don't see that we put that specifically on the poster. PCP was the most common of all the OIs.

What was the median CD4 count at the time of initiation of therapy?

It was 421 cells for the whole group. Women who continued ART actually had lower CD4 cell counts: 272 versus 476. Obviously, there was more urgency on the part of the providers to continue antiretroviral therapy. That may, to some degree, buy us our results. Regardless, there were still significant detrimental effects in those women who discontinued therapy.

What was the racial characterization of your population?

It's about 80% African American, which is representative of the epidemic, I think, in the whole United States for women. I think that St. Louis -- where we're based -- is representative of the epidemic, at large. I don't think these are unusual numbers when you look at the disparities in health outcomes overall for women.

What were some of the reasons for discontinuation of treatment?

It was highly variable. Some were concerns for adherence. Some were related to high CD4 counts. Some were provider-initiated discontinuations. Some were related to patient preference.

The one thing that you can see is that women who discontinued were less likely to be undetectable at the time of delivery. So that may have also played a role. Some of it, we were unable to gather that data for everyone, as this was a retrospective review; and so that is a limitation of our study, as well.

I see there are two deaths. What were the causes of death? I see that these were in women who remained in care.

Right. Women who remained in care. Both deaths were in women who had discontinued [HIV therapy]. One of those was to overwhelming sepsis. I believe the other one was a complication of PCP.

What are the recommendations for these women? Are these women just very vulnerable and unsupported? Do they need a particular kind of support from clinic?

I think that's a very good question. Another factor that's different is, women who discontinued ART had less social support outside of clinic. Clearly, this isn't just a racial difference. This is actually a socioeconomic difference.

So, these women do need comprehensive support. We need to truly have wraparound care services that the Ryan White clinics are here to provide. I definitely think that this indicates that we need to really get these women and keep them engaged in care.

A significant number of women actually dropped out of care altogether. We're in the process of trying to identify outcomes for those women to see if actually outcomes may be even, unfortunately, worse. What we really need to do is get these women engaged in care, where we can monitor them more closely.

All this took place at a St. Louis clinic that is Ryan White funded, and geared for the poor?

Yes. Right.

Does this clinic presently provide comprehensive support?

We do. But regardless, it's still very difficult to keep these women engaged in care. We spend a significant amount of time in our clinic identifying women -- and men, for that matter -- who are non-adherent, who develop STIs [sexually transmitted infections], or who miss more than two clinic visits. We have a retention expert whose focus is specifically on getting these people reengaged in care. I think that one of our challenges now, in the HIV epidemic, is maintaining people in care, and retaining them there.

I imagine this question wasn't asked, but are most of these women single mothers?

There is a significant number of women without partners. Seventy-three percent of women were without a partner during their pregnancy. It was significantly higher in the women who discontinued, or in 80% of those women. Clearly, not having good social support, regardless of whether you have HIV or don't, makes outcomes for you much worse. You really need to have a good social network. Anybody who has kids knows that's really critical.

In the women with opportunistic infections, how soon after they gave birth, did they have the OIs?

The OIs that occurred in the continued group happened much later.

Interestingly, the OIs that we saw in the continued group actually occurred after they had discontinued therapy, not unexpectedly. That clearly speaks again to that issue.

The time to OI was 65 months versus 40 months in the discontinued group. So they are not getting them the minute they discontinue therapy. Obviously, they had good CD4 counts. What this really probably represents is, by not continuing ART, there is less engagement in care, and there's less structure, probably, to keep them engaged in care.

It's a moving poster, if a poster can be moving. It tells the story of women who are very vulnerable and at very high risk and without any support. I don't know what we can think of doing for them, because they need so much.

Right.

But this describes their kind of predicament.

I think that the CDC [U.S. Centers for Disease Control and Prevention] and HRSA [U.S. Health Resources and Services Administration] are really taking this on. You'll see, there's more funding specifically for clinics to do research in service care delivery -- so really getting at these issues. These are the most challenging issues that we're facing here in the United States -- getting people in care and keeping them there.

And taking care of mothers who have to raise their children.

Right. Exactly.

Thank you very much.

Thank you.


Footnotes

  1. Onen NF, Nurutdinova D, Sungkanuparph S, Mondy K, Overton ET. HIV treatment interruption after pregnancy. Are we treating women SMARTly? In: Program and abstracts of the 45th Annual Meeting of the Infectious Diseases Society of America; October 4-7, 2007; San Diego, Calif. Abstract 937.
    View poster: Download PowerPoint
  2. Strategies for Management of Antiretroviral Therapy (SMART) Study Group, El-Sadr WM, Lundgren JD, et al. CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med. November 30, 2006;355(22):2283-2296.

This transcript has been lightly edited for grammar and clarity.




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