TO THE EDITOR
Katz and colleagues (1) assessed the predictors of detectable HIV viral load (VL) at delivery among treatment-naive women initiating highly active antiretroviral therapy (HAART) during pregnancy. One factor associated with lack of viral suppression at delivery was a high pretreatment VL, especially among women who initiated HAART in the third trimester (1). We compared these results—obtained in the Western hemisphere—with our experience in a resource-limited country (2) where even more treatment-naive women initiate HAART late during pregnancy, thus possibly accounting for high rates of detectable VL at delivery.
From 2009 to 2012, we enrolled 802 HIV-positive pregnant women, of whom 471 (58.7%) initiated HAART for the first time during pregnancy. Among them, 187 (39.7%) started HAART in the third trimester. Viral load at HAART initiation was measured in 251 (53.3%) of these 471 treatment-naive women and was 10 000 copies/mL or greater in as many as 160 (63.7%). Up to 35.8% of these treatment-naive women (82 of 229 [data were missing for 242 women]) had a detectable VL at delivery. In a univariate analysis, we found that a pre-treatment VL greater than 10 000 copies/mL (odds ratio, 4.3 [95% CI, 2.1 to 8.7]; P < 0.001) and HAART initiation in the third trimester of pregnancy (odds ratio, 2.4 [CI, 1.4 to 4.3]; P = 0.002) predicted a detectable VL at delivery.
Although our analysis was not adjusted for confounders, such as type of HAART and adherence to treatment, these factors are unlikely to considerably reduce the number of women with a detectable VL at delivery when high rates of late HAART initiation and high pretreatment VL are considered. In addition, these impressive rates might also account for a high proportion of infants in resource-limited countries who are exposed to high VL for at least the first 6 months of pregnancy, thus increasing the risk for HIV during pregnancy and for death among HIV-exposed, uninfected children (3). We have to intervene earlier.
Footnotes
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L15-0178.
References
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