Social Factors Tied to Risk for Detectable HIV in Pregnancy

Veronica Hackethal, MD

January 20, 2015

Socially disadvantaged HIV-infected women who start highly active retroviral therapy (HAART) for the first time during pregnancy may be at higher risk for detectable virus at delivery than their better-off peers‏, according to a study published in the January 20 issue of the Annals of Internal Medicine.

The study found that 13.1% of HIV-positive pregnant women had detectible viral loads at delivery. These women were more likely to be black and have low educational levels than women who did not have detectable virus. They were also more likely to have started HAART and/or prenatal care in the third trimester, have low adherence to HAART, and have higher viral loads before starting HAART.

"Optimal care for HAART-naive pregnant women with HIV should focus on initiation of HAART according to pretreatment viral load and before the third trimester," write Ingrid Katz, MD, MHS, from the Brigham and Women's Hospital at Harvard Medical School in Boston, Massachusetts, and colleagues.

"Additional interventions should focus on early prenatal care, early HIV testing, and measures to support adherence to treatment throughout pregnancy to promote both maternal and infant health," the authors emphasize.

"Social factors, including ethnicity and education, may help identify women who could benefit from focused efforts to promote early HAART initiation and adherence," they add.

Having a detectable viral load at delivery puts the mother at risk for health problems and the baby at risk for transmission of HIV, the authors note. In developed countries, HAART has become standard therapy for suppressing viral replication in HIV-positive pregnant women and has decreased maternal-to-child HIV transmission to about 1% to 2%.

The study was part of the International Maternal, Pediatric, Adolescent AIDS Clinical Trials (IMPAACT) Group Protocol 1025 study, an observational study that took place between October 2002 and December 2011 at 67 AIDS clinical research sites in the United States. The study focused on the prevention of maternal-to-child transmission.

The researchers analyzed data from 671 women who started HAART for the first time during pregnancy, of whom 88 (13.1%) had detectable viral loads at delivery. Factors associated with having a detectable viral load at delivery included black race (17.6% in the detectable-virus group vs 6.6% Hispanic and 6.6% white in the undetectable-virus group; P < .001), low educational level (at or below eleventh grade, 17.6% vs 12.1% with a high school diploma; P = .013), starting HAART in the third trimester (23.9% vs 12.3% vs 8.6% in the second and first trimesters, respectively; P = .003), and starting prenatal care during the third trimester (33.3% vs 14.3% vs 10.5% in the second and third trimesters, respectively; P = .002). Women with lower adherence to HAART were also more likely to have detectable viral loads at delivery (28.2% among women with at least one treatment interruption vs 12.2% among women with no interruptions; P = .004).

Women with high viral loads before treatment were more likely to have detectable viral loads at delivery (15.8% for ≥10,000 copies/mL vs 10.2% for ≤10,000 copies/mL; P = .065).

Several factors related to race and educational level could play roles in these results, according to Dr Shapiro and colleagues.

"It is possible that experiences of race-based discrimination or lack of trust in the medical care system may pose barriers to engagement in care, which, in turn, could be associated with unsuppressed [viral load]," they write. Variations in drug pharmacokinetics by race and differences in the type of healthcare received could also be involved, they add.

Educational level is a marker of socioeconomic status, and low levels of education have been linked to poor care, poor adherence to antiretroviral therapy, and lower HIV survival rates, they continue.

"Although the mechanisms linking lower educational attainment to detectable [viral load] at delivery remain unclear, it may reflect lower levels of health literacy or be a marker of overall poverty," they point out.

"The results of this study should prompt action. To improve health outcomes for HIV-infected pregnant women at risk of treatment failure, we need more intensive and creative interventions across the entire HIV care continuum," commented Julie Dombrowksi, MD, MPH, an assistant professor at the University of Washington School of Medicine. Dr Dombrowksi is the medical director of the Public Health–Seattle & King County STD Clinic. She also oversees the King County HIV Care and ART Promotion Program, which is focused on improving engagement in HIV care and antiretroviral use.

Although prenatal HIV care in the United States seems to be "largely successful" in terms of rare cases of maternal-to-child transmission and high rates of viral suppression at delivery, the system could be "even better," according to Dr Dombrowksi.

She emphasized, "We need a range of interventions of varying intensity for different target populations. Socially marginalized, pregnant women with uncontrolled HIV infection are a high-priority population. Extensive efforts are warranted to improve their health and the health of their children."

Four authors report receiving grants from the National Institutes of Health. One coauthor reports receiving grants from the National Institutes of Health and personal fees from Boehringer Ingelheim, Pfizer, Tibotec. The other authors have disclosed no relevant financial relationships.

Ann Intern Med. 2015;162:90-99.

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