Background
Small studies reported poor post-partum outcomes among young women living with perinatal
HIV infection who are now ageing into adulthood and becoming pregnant. For targeted
clinical intervention, we sought to identify women in this population at risk of poor
post-partum virological control.
Methods
We abstracted data on pregnancy history for women living with perinatal HIV infection
in the Pediatric HIV/AIDS Cohort Study-AMP Up protocol, a prospective study of young
adults living with perinatal HIV from 14 sites in the USA. Linear models with generalised
estimating equations described trends in HIV viral load through 1 year post-pregnancy
by pregnancy outcome. We used group-based trajectory modelling to identify viral load
trajectory groups in the first post-partum year after livebirths. We then compared
sociodemographic and clinical factors across identified groups. We defined viraemia
as 400 copies per mL or more.
Findings
Between April 15, 2014, and Oct 1, 2017, we enrolled 323 women, of whom 234 had perinatal
HIV infection, and reported age at sexual debut and history of heterosexual vaginal
intercourse. Of the 172 pregnancies recorded in these women, 147 (85%, 104 livebirths
and 43 spontaneous or elective abortions) were eligible for post-pregnancy viral load
trajectory analyses (ie, had at least two viral loads in the year after end of pregnancy).
Viral load increased by 0·7 log
10 copies per mL (95% CI 0·5 to 1·0) in the first 12 weeks post partum after 104 livebirths,
and subsequently stabilised from 13 weeks to 1 year post partum (slope −0·01 log
10 copies per mL, 95% CI −0·3 to 0·3). By comparison, the average viral load trajectory
after 43 spontaneous or elective abortions remained at less than 400 copies per mL.
We identified three distinct groups of viral load trajectories after 104 livebirths,
classified as reflecting sustained suppression (31 [30%]), rebound viraemia (55 [53%]),
and persistent viraemia (18 [17%]). Women with sustained post-partum suppression were
older at conception (22·9 years, IQR 19·4–25·9) than those with rebound viraemia (20·4
years, 18·8–22·2), or persistent post-partum viraemia (19·0 years, 17·7–20·5). Pre-conception
viraemia and immune suppression were also strong risk factors for post-partum viraemia.
Interpretation
Despite success achieving viral load suppression during pregnancy, women living with
perinatal HIV infection have a high risk of post-partum viraemia. Younger age at conception,
pre-conception viraemia, and pre-conception immune suppression could identify women
in this population most likely to benefit from post-partum adherence interventions.
Funding
National Institutes of Health.
