Longitudinal analysis of viral suppression before, during, and after pregnancy among women on antiretroviral therapy in Uganda: six-year real-world experience.
Viral suppression rates vary among different ART regimens before and after pregnancy, with adherence being a key factor for optimal outcomes.
Where it sits
this study against the rest of the navepegritide corpusSummary and findings
This study evaluated the effectiveness of antiretroviral therapy (ART) on viral suppression in 1291 pregnant and breastfeeding women. Viral suppression rates were reported for different ART regimens before, during, and after pregnancy. Statistical significance was observed in ART effectiveness before and after pregnancy, but not during.
Abstract
<h4>Introduction</h4>This study evaluated the effectiveness of antiretroviral therapy (ART) and associated factors on viral suppression before, during, and after pregnancy (maternal timeline).<h4>Methods</h4>We conducted a cohort study, retrospectively reviewing records of 1291 pregnant and breastfeeding women on ART. Descriptive statistics summarised the demographics and clinical characteristics. Chi-square, Fisher's exact, and generalised estimating equations were used to assess variations in viral suppression across the maternal timeline.<h4>Results</h4>ART regimens comprised 62.5% dolutegravir (DTG)-, 28.8% efavirenz (EFV)-, 4.5% nevirapine (NVP)-, and 4.2% protease inhibitor (PI)-based therapy. Viral suppression rates before, during, and after pregnancy were DTG- (95.0%, 94.6%, 95.7%), EFV- (94.9%, 94.2%, 93.6%), NVP- (93.1%, 94.7%, 93.5%), and PI-based (79.6%, 88.0%, 85.7%). ART regimens varied in effectiveness, with statistical significance observed before (<i>p</i> < 0.001) and after (<i>p </i>= 0.018), but not during pregnancy (<i>p</i> = 0.678). PI-based regimens showed higher risk of non-suppression in the non-adjusted model (IRR = 3.20, 95% CI: 1.63-6.30, p = 0.001). In the adjusted model, poor adherence (aIRR = 7.80, 95% CI: 2.54-23.90, <i>p</i> < 0.001), fair adherence (aIRR = 5.03, 95% CI: 1.11-22.86, <i>p</i> = 0.036), second-line ART (aIRR = 3.14, 95% CI: 1.75-5.62, <i>p</i> < 0.001), and third-line ART (aIRR = 8.48, 95% CI: 1.82-39.43, <i>p</i> = 0.006) remained significant.<h4>Conclusion</h4>ART effectiveness showed variation before and after, but not during pregnancy. EFV- and NVP-based regimens achieved suppression rates comparable to DTG across maternal timelines, with the exception of PI-based regimens. Adherence and ART drugs influence outcomes more than regimen choice alone, with good adherence essential for optimal maternal outcomes.
Background
This study addresses the effectiveness of antiretroviral therapy (ART) on viral suppression in pregnant and breastfeeding women, a critical area given the potential implications for maternal and infant health. Previous research has indicated that ART can be effective in suppressing viral loads, but variations in effectiveness across different ART regimens and stages of pregnancy have not been thoroughly explored. Understanding these dynamics is essential for optimizing treatment strategies in this population.
Methods
A cohort study design was utilized, retrospectively reviewing records of 1291 pregnant and breastfeeding women on ART. The study assessed variations in viral suppression using descriptive statistics and statistical tests including Chi-square, Fisher's exact, and generalized estimating equations. The primary outcome measure was the rate of viral suppression across the maternal timeline.
Results
The primary endpoint showed that viral suppression rates before pregnancy were 95.0% for DTG, 94.9% for EFV, 93.1% for NVP, and 79.6% for PI-based therapy. Statistical significance was observed before pregnancy with p<0.001 and after pregnancy with p=0.018, while no significance was found during pregnancy (p=0.678). In the adjusted model, poor adherence was significantly associated with non-suppression (aIRR = 7.80, 95% CI: 2.54-23.90, p<0.001).
Interpretation
The findings suggest that ART regimens have varying effectiveness, particularly before and after pregnancy, with adherence being a critical factor influencing outcomes. While the statistical significance of the results is clear, the clinical significance of the differences in suppression rates, especially among the various ART regimens, may be limited. The study's retrospective nature and potential confounding factors, such as adherence levels and ART regimen choice, may affect the reliability of the conclusions drawn.
Key findings
- Viral suppression rates before pregnancy were 95.0% for DTG, 94.9% for EFV, 93.1% for NVP, and 79.6% for PI-based therapy.
- During pregnancy, viral suppression rates were 94.6% for DTG, 94.2% for EFV, 94.7% for NVP, and 88.0% for PI-based therapy.
- After pregnancy, viral suppression rates were 95.7% for DTG, 93.6% for EFV, 93.5% for NVP, and 85.7% for PI-based therapy.
- Statistical significance was observed before pregnancy with p<0.001 and after pregnancy with p=0.018.
- In the adjusted model, poor adherence had an aIRR of 7.80 (95% CI: 2.54-23.90, p<0.001) for non-suppression.
Limitations
- Retrospective study design.
- Potential biases from record reviews.
- Findings may not be generalizable to all populations.
- Single-site study may limit external validity.