European Research Group Recommends Offering Elective Caesarean Section Delivery to All HIV Positive Women, Even in Areas Where HAART Is Available

Very low rates of mother-to-child transmission (MTCT) of HIV are achievable with use of HAART. Researchers of the European Collaborative Study examined risk factors for MTCT in the HAART era and describe infants who were vertically infected, despite exposure to prophylactic MTCT interventions.

Of the 4525 mother-child pairs in this prospective cohort study, 1983 were enrolled during the period of January 1997 through May 2004. Factors examined included use of antiretroviral therapy during pregnancy, maternal CD4 cell count and HIV RNA level, mode of delivery, and gestational age in logistic regression analysis.

Results

Receipt of antenatal antiretroviral therapy increased from 5% at the start of the HAART era to 92% in 20012003. The overall MTCT rate in this period was 2.87%, but it was 0.99% during 20012003.

In logistic regression analysis that included 885 mother-child pairs, MTCT risk was associated with high maternal viral load (P = .003) and elective Caesarean section (P = .04).

Detection of maternal HIV RNA was significantly associated with antenatal use of antiretroviral therapy, CD4 cell count, and mode of delivery.

Among 560 women with undetectable HIV RNA levels, elective Caesarean section was associated with a 90% reduction in MTCT risk, compared with vaginal delivery or emergency Caesarean section.

Conclusions     

The authors conclude, “Our results suggest that offering an elective Caesarean section delivery to all HIV-infected women, even in areas where HAART is available, is appropriate clinical management, especially for persons with detectable viral loads. Our results also suggest that previously identified risk factors remain important.”

Discussion

The current strategy of offering an elective Caesarean section delivery to HIV-infected women in Europe appears to be appropriate. In this large cohort, approximately one-half of the women enrolled recently had detectable viral loads close to the time of delivery, and the continuing high rate of elective Caesarean section delivery indicates that these women are being recommended to undergo an elective Caesarean section delivery to prevent mother-to-child transmission of HIV.

Although, in the presence of HAART, the absolute rate of mother-to-child transmission is likely to be low (in the region of 1%2%), the findings of this study suggest that elective Caesarean section delivery would further reduce this risk to 0.5%1%. However, with these very low overall rates, a large number of elective Caesarean section deliveries would need to be performed to prevent a single vertical infection.

Finally, the authors write, “On an individual level, the decision regarding mode of delivery rests with the woman and her clinician, who should inform her of the potential risks and benefits. With adequate obstetric management, individual women may consider the benefit of a lower risk of infection in their infant to outweigh the potential disadvantages of an elective caesarean section.”

02/04/05

Reference
C Thorne and the European Collaborative Study. Mother-to-Child Transmission of HIV Infection in the Era of Highly Active Antiretroviral Therapy. Clinical Infectious Diseases 40(3): 458-465. February 1, 2005.

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