Pregnant … pause? Is there a difference in the long‐term outcome of women starting ART for the first time in pregnancy?

Purpose of the study The guidelines on the initial choice of antiretroviral therapy (ART) in women starting ART for the first time in pregnancy have changed considerably over the past 13 years [1,2]. We sought to determine whether these different ART strategies have influenced subsequent clinical, immunological or virological outcomes in our population. Women in our cohort received either zidovudine (AZT) monotherapy, short course antiretroviral therapy (SCART) or continued ART post‐partum. AZT monotherapy in pregnancy was common a decade ago, but its use declined amidst concerns about efficacy and the potential development of resistance with monotherapy. SCART more effectively suppresses viral load (VL) but avoids unnecessary treatment post‐partum in those considered at low risk of disease progression. This is used less now the benefits of starting ART at better‐conserved CD4 counts and the risks of treatment interruption are known. Method 30 women who commenced ART during a pregnancy which resulted in a live birth between 1999 and 2004 were identified from a departmental database. Women already on ART or who had previously received AZT monotherapy or SCART were excluded, as were women with less than 2 years follow up post‐partum. Outcomes included time to starting ART, CD4 count and VL on starting ART and at last follow up. Summary of results 12 women received AZT monotherapy, 7 SCART and 11 continued ART post‐partum. In total there were 269 years of patient follow up (mean 9, range 2–13).(mean) AZT monotherapy SCART Continued ARTBaseline CD4 409 359 190 Baseline VL 1,950 6,799 59,566 Time to starting ART 5.2 years* 4.6 years**CD4 on starting ART 254 178CD4 <350 on starting ART 3/12 3/7CD4 at last follow up 519 451 543* 1 still not on ART at last follow up; **2 not on ART at last follow up.None of the women who received AZT monotherapy or SCART experienced clinical disease progression during their time off therapy, which was considerable (mean 4–5 years). All achieved virological suppression and good CD4 recovery on commencing ART. None of the available genotypes in these patients showed resistance mutations. Of the women who continued ART, more than half modified their regimen and a significant number experienced transient VL rebounds. Conclusions The clinical choices made a decade ago do not appear to have been detrimental to the longer‐term treatment responses in this group of women. However, the effects of treatment interruption remain unclear and we suggest a cautious approach.