Abstract
The aim of this study was to describe the distribution of CD4+ T cell count (CD4) of HIV-1 infected pregnant women diagnosed during prenatal counseling and testing (VCT), in Abidjan, Côte d’Ivoire, and to assess whether HIV-related immunodeficiency influenced or not the acceptance of an antiretroviral package to prevent mother-to-child transmission. Between April and June 2002, CD4 count was systematically performed in all women diagnosed as HIV-infected (n=221) in five antenatal clinics carrying out VCT. Their median CD4 was 408 cells/mm3 and 14% were < 200 CD4. The overall uptake of the intervention (31.9%) was independent of the immune status.
Keywords: Adult, Anti-HIV Agents, administration & dosage, CD4 Lymphocyte Count, Cote d'Ivoire, Disease Transmission, Vertical, Female, HIV Infections, complications, drug therapy, immunology, prevention & control, transmission, HIV-1, Humans, Infant, Newborn, Nevirapine, administration & dosage, Patient Acceptance of Health Care, Pregnancy, Pregnancy Complications, Infectious, drug therapy, immunology, Zidovudine, administration & dosage
Introduction
Maternal CD4+ T cell count (CD4) is strongly associated with HIV disease progression and is a strong predictor of mother-to-child transmission of HIV-1 (MTCT) and its prevention (PMTCT) with antiretrovirals 1, 2. Yet, given the low uptake of PMTCT interventions in African settings, generally around 20% 1, 3, the CD4 distribution among the overall population of HIV-infected pregnant women is still unknown. Our hypothesis in Abidjan, Côte d’Ivoire, was that women less advanced in HIV disease felt no interest in receiving PMTCT interventions and self-excluded themselves during antenatal follow-up. The stigmatization towards HIV-infected patients and the inappropriate attitude of some health workers described in this population could lead to this self-exclusion 4, 5. The aim of this study was to describe the CD4 distribution in all women diagnosed antenatally as HIV-infected and to study the relation between immune status and the uptake of a PMTCT antiretroviral-based intervention.
Population and methods
Since March 2001, the Ditrame Plus ANRS 1201/1202 project has provided a comprehensive PMTCT package (perinatal antiretroviral intervention and proposition of alternatives to prolonged and predominant breastfeeding) in seven antenatal clinics in Abidjan, Côte d’Ivoire 6, 7. In April 2002, a CD4 prevalence survey was conducted within this project. After individual pre-test counseling, HIV testing was systematically proposed as before to every pregnant women attending these antenatal clinics. After having accepted HIV testing and signed an informed consent document, pregnant women were enrolled in the prevalence survey. Two venous blood samples were collected. The first sample was used for the diagnosis on-site of HIV-1 infection using rapid HIV testing (Determine™ and Genie2™). HIV test result was made available within 24 hours after blood collection. Women were considered as HIV-1 infected (HIV+) if both tests were positive. The second sample was shipped to a reference laboratory (CeDReS, Treichville University Hospital, Abidjan) to perform the CD4+ count in all HIV+ women by standard flow cytometry [FACScan Becton Dickinson]. All HIV+ pregnant women were followed until delivery to determine the proportion who received their HIV test result during an individual post-test counseling and among them, those who started the prophylactic antiretroviral regimen.
Results
Between April and June 2002, 2407 pregnant women received a prenatal counseling and 2144 (89.1%) accepted HIV testing. The women who refused to be tested were comparable to those who accepted in terms of parity and gestational age, but were older by 14 months on average (27.0 ± 5.3 vs 25.8 ± 5.6 years; p<0.001). The prevalence of HIV-1 infection was 10.5% (n=226; 95% confidence interval [9.2%-11.9%]). A total of 172/226 HIV+ women (76.1%) returned to the clinics to receive their HIV test result, a proportion comparable to the return rate of HIV-uninfected women (76.9%).
All but five HIV+ pregnant women diagnosed antenatally had a CD4 count measurement. Overall, their median CD4 count was 408 cells/mm3, Interquartile Range (IQR) [304–570] (Table 1). No difference in CD4 count was found between the 50 (22.6%) HIV+ women who did not receive their HIV test result and the 171 who received it, i.e. the 99 informed of their sero-status but who did not initiate PMTCT and the 72 informed and initiating antiretroviral prophylaxis (389 vs 420 cells/mm3 in median; p=???). Considering individual expected dates of delivery as the censoring time, 72/226 women (31.9%) received the PMTCT antiretroviral regimen. There was no difference in CD4 count between HIV+ women who started it and those 149 who did not (405 vs. 420 in median ; p= ???).
Table 1.
CD4+ T Lymphocyte count (CD4) distribution in HIV-1 infected pregnant women diagnosed in five antenatal clinics during voluntary counseling and testing in Abidjan, Côte d’Ivoire, ANRS 1201/1202 Ditrame Plus Project, April-June 2002.
| TOTAL (N=226) | Did not receive ARVs for PMTCT (n=154)
|
Received ARVs for PMTCT (n=72 ) | P * | P ** | ||
|---|---|---|---|---|---|---|
| Did not receive test result (n=54) | Received test result (n=100 ) | |||||
| CD4 measurement (n) | 221 | 50 A | 99 B | 72 C | ||
| Absolute CD4 count | ||||||
| Mean ± SD | 452.5 ± 251.7 | 433.9 ± 326.2 | 466.7 ± 223.0 | 445.8 ± 231.5 | ||
| Median [IQR] | 408 [304 – 570] | 389 [262 – 515] | 425 [313 – 616] | 405 [308 – 516] | ||
| CD4 distribution: | ||||||
| < 200/mm3 | 31 (14.0) | 10 (20.0) | 11 (11.1) | 10 (14.5) | ||
| 200 – 349/mm3 | 47 (21.3) | 12 (24.0) | 22 (22.2) | 13 (18.1) | ||
| 350 – 499/mm3 | 66 (29.9) | 12 (24.0) | 28 (28.3) | 24 (34.8) | ||
| >=500/mm3 | 77 (34.8) | 16 (32.0) | 38 (38.4) | 22 (31.9) | ||
| Percentage of CD4 | ||||||
| Mean ± SD | 26. 2 ± 10.3 | 25.1 ± 10.7 | 26.6 ± 10.5 | 26.4 ± 9.6 | ||
| Median [IQR] | 26.6 [19.5–32.0] | 25.1 [19.3–30.5] | 27.0 [20.0–32.7] | 27.3 [19.6–31.8] | ||
| < 15% | ||||||
IQR: Interquartile range, SD: Standard deviation, DP: Ditrame Plus Project, ARVs: antiretroviral prophylaxis regimen (Zidovudine + Nevirapine), PMTCT: prevention of mother to child transmission of HIV.
A vs. B+C
A+B vs. C
Discussion and conclusion
To our knowledge, this study is the first to describe the immune status of all HIV+ women diagnosed antenatally in an African setting of high HIV-1 prevalence in relation to their uptake of a PMTCT intervention. The CD4 count was similar in HIV+ women who did not return for their test result and those who were informed their sero-status. No difference was also found in HIV+ infected pregnant women who did not accept the PMTCT antiretroviral prophylaxis and those who received the PMTCT package. Thus, in our study, the low uptake of the Ditrame Plus program cannot be explained by the self-exclusion of pregnant women in relation with advanced HIV disease. We did not use any clinical criteria such as the AIDS stage to perform these comparisons as it would grossly underestimate the proportion of women with advanced HIV disease. However, in our population stigma could well be the main factor limiting the uptake of the PMTCT program. Population-specific research must be required to understand the different factors influencing the low uptake of the PMTCT interventions in sub-Saharan Africa. CD4 prevalence surveys might be helpful to adjust PMTCT antiretroviral strategies to women needs 1.
Acknowledgments
Sponsorship: This study was supported by the French National AIDS Research Agency (ANRS, Paris, France). Didier K. Ekouevi is a fellow of the French Charity Ensemble contre le Sida. Renaud Becquet is a fellow of the French Ministry of Education, Research and Technology. Laurence Bequet and François Rouet are supported by the French Ministry of Foreign Affairs. Zidovudine (Retrovir ®) is kindly provided to the Ditrame Plus programme by Glaxo Smith Kline - France.
Footnotes
Composition of the ANRS 1201/1202 Ditrame Plus Study Group : Principal Investigators: François Dabis, Valériane Leroy, Marguerite Timité-Konan, Christiane Welffens-Ekra.
Coordination in Abidjan: Laurence Bequet, Didier Koumavi Ekouévi, Besigin Towne-Gold, Ida Viho.
Clinical team: Clarisse Amani-Bosse, Ignace Ayekoe, Gédéon Bédikou, Nacoumba Coulibaly, Christine Danel, Patricia Fassinou, Appolinaire Horo, Ruffin Likikouët, Hassan Touré.
Laboratory team: Dominique Bonard, André Inwoley, Crépin Montcho, François Rouet.
Biostatistics and data management: Renaud Becquet, Laurence Dequae-Merchadou, Gérard Allou, Charlotte Sakarovitch, Dominique Touchard.
Psycho-social team: Hortense Aka-Dogo, Annabel Desgrées du Loû, Alphonse Sihé, Benjamin Zanou.
Scientific Committee: Stéphane Blanche, Jean-François Delfraissy, Philippe Lepage, Laurent Mandelbrot, Christine Rouzioux, Roger Salamon.
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