The impact of revised PMTCT guidelines: a view from a public sector ARV clinic in Cape Town, South Africa.

BACKGROUND: In April 2010, revised Prevention of Mother-to-Child Transmission guidelines were implemented in South Africa, advising fast-tracked lifelong highly active antiretroviral therapy (HAART) initiation at a higher CD4 count (≤350 cells per microliter). This study describes the impact of these changes on the management of pregnant women who initiated HAART at Tygerberg Hospital, Cape Town. METHODS: We conducted a retrospective review of all women who initiated HAART in pregnancy at the Tygerberg Hospital between January 2008 and December 2010. Year cohorts were compared. RESULTS: Two hundred and fifty HIV-infected women were included in the study and stratified by HAART initiation year: 2008:N = 82, 2009:N = 71, 2010:N = 97. There were no differences between the groups in age or parity. Median booking CD4 count was 155 cells per microliter [interquartile range (IQR) 107-187], 157 cells per microliter (IQR 104-206) and 208 cells per microliter (IQR 138-270), respectively (P < 0.001). Median gestation at HAART initiation was 31 weeks (IQR 27-35), 30 weeks (IQR 26-34), and 25 weeks (IQR 21-31; P < 0.001). HIV transmission rates were 3/65 (4.6%), 4/57 (7.0%), and 0/90 (0.0%; P = 0.021). Women <8 weeks on HAART before delivery were more likely to transmit than women ≥8 weeks [odds ratio 9.69; 95% confidence interval 1.66 to 56.58; P = 0.017]. Ninety-four (37.6%) women were lost to follow-up, 18.4% within 28 days of delivery. CONCLUSIONS: The positive impact of the new Prevention of Mother-to-Child Transmission program is evident. A longer duration of HAART before delivery was associated with less transmission. However, the lost to follow-up rates remain concerning. Further research is needed to better understand the reasons for nonadherence and mechanisms to improve support for these women.

Progression and persistence of low-grade cervical squamous intraepithelial lesions in women living with human immunodeficiency virus.

OBJECTIVE: This study aimed to investigate the progression and persistence of low-grade squamous intraepithelial lesions (SILs) in human immunodeficiency virus (HIV)-infected women. METHODS: Study participants for this retrospective cohort study were 1,720 women who had LSIL as their first abnormal Pap smear. A comparison of the survival of LSIL without progression to high-grade SIL as progression-free time and the survival of SIL without clearance of the lesion as persistence of SIL was done for women of HIV-positive, HIV-negative, or unknown status using the Kaplan-Meier method. Multivariable Cox proportional hazards regression model was applied to identify independent risk factors for disease progression or persistence. RESULTS: We found progression of LSIL not different between HIV groups but that persistence occurred more in HIV-positive women (63.8% vs 35.0%, p < .001). For the HIV group, antiretroviral therapy that was started before the first LSIL was associated with decreased risk for progression compared with no antiretroviral therapy (hazard ratio = 0.66, 95% CI = 0.54-0.81, p < .001). Antiretroviral therapy also improved clearance when corrected for excision treatment and age (hazard ratio = 1.71, 95% CI = 1.29-2.27, p < .001). Excision of LSIL reduced the risk of progression. In HIV-negative women, progression was reduced from 54.7% to 0.0% (p < .001), and from 46.9% to 6.4% in HIV-positive women (p < .001). Excision also reduced persistence in HIV-negative women from 39.5% to 7.1% (p = .001), but for HIV-positive women, the effect was smaller (from 66.3% to 45.5%, p < .001). CONCLUSIONS: Antiretroviral treatment reduced the risk for progression and persistence of LSIL in HIV-infected women.