CROI 2017 Abstract e-Book

Abstract eBook

Oral Abstracts

24 INTEGRATION OF POSTNATAL SERVICES IMPROVES MCH AND ART OUTCOMES: A RANDOMISED TRIAL Landon Myer 1 , Tamsin Phillips 1 , Allison Zerbe 2 , Kirsty Brittain 1 , Stanzi M. Le Roux 1 , Robert Remien 3 , Claude A. Mellins 3 , James A. McIntyre 4 , Elaine J. Abrams 2 , for the Maternal Child Health - Antiretroviral Therapy (MCH-ART) Study 1 Univ of Cape Town, Cape Town, South Africa, 2 Columbia Univ, New York, NY, USA, 3 New York State Psychiatric Inst, New York, NY, USA, 4 Anova Hlth Inst, Johannesburg, South Africa Background: There are global concerns about postpartumwomen’s engagement in antiretroviral therapy (ART) services and resulting viral suppression (VS). Integration of ART into the maternal and child health (MCH) platform is routine during prenatal care but postnatal services have received little attention. We evaluated the impact of an integrated MCH-ART service on mother and infant outcomes. Methods: From Jun 2013-Dec 2014 we enrolled consecutive HIV-infected mother-infant pairs (MIP) immediately postpartum if mothers were 18+ years of age, initiated ART in the recent pregnancy at the local MCH service and were breastfeeding (BF). MIP were randomised to either: (i) postnatal retention in the integrated MCH-ART service for the duration of BF (intervention) or (ii) immediate referral to adult ART services for mothers and separate routine ‘well baby’ services for infants (control; local standard of care). The primary outcome was a combined endpoint of maternal engagement in HIV care (frommedical record review) and VS<50 copies/mL at 12m postpartum (measured separately from routine care). Results: Overall, 472 women were randomised at a median of 5d postpartum (median age 28y; median pre-ART CD4 354 cells/uL; median duration of prenatal ART 18w; 76% and 94% of women with VS<50 and <1000 copies/mL at randomisation, respectively); characteristics did not differ by trial arm. 87% of MIP completed the study outcome visit at 12m postpartumwith no difference in completion by arm. By design women in the intervention arm spent longer in the integrated MCH-ART service (8.7m vs 0.3m in control arm). The median duration of BF was significantly longer in intervention vs control (9.0m vs 3.1m, p<0.001). Among mothers in the control arm referred to adult ART services, 56%met the combined endpoint of engagement in care and VS<50 copies/mL compared to 77% of intervention mothers randomised to stay in the integrated MCH-ART service until the end of BF (absolute risk difference 21%; 95% CI: 12-30%; p<0.001). In secondary analyses the intervention improved sustained VS over time to <50 and <1000 copies/mL (Figure). MTCT by 12mwas low (0.55%) and did not differ by arm (p=0.740); other infant outcomes were similar by arm. Conclusion: Integrated MCH-ART services during the postnatal period lead to significant improvements in women’s engagement in HIV care and viral suppression while extending breastfeeding, providing a simple, effective intervention to promote maternal and child health outcomes in the context of HIV.

Oral Abstracts

25 ADVERSE BIRTH OUTCOMES DIFFER BY ART REGIMEN FROM CONCEPTION IN BOTSWANA Rebecca Zash 1 , Denise Jacobson 2 , Modiegi Diseko 3 , Gloria Mayondi 3 , Mompati Mmalane 3 , Chipo Petlo 4 , Max Essex 2 , Shahin Lockman 5 , Joseph Makhema 3 , Roger L. Shapiro 2 1 Beth Israel Deaconess Med Cntr, Boston, MA, USA, 2 Harvard Univ, Boston, USA, 3 Botswana Harvard AIDS Inst Partnership, Gaborone, Botswana, 4 Ministry of Hlth, Botswana, Gaborone, Botswana, 5 Brigham and Women’s Hosp, Boston, MA, USA Background: Infants exposed to 3-drug antiretroviral therapy (ART) from conception have increased risk of adverse birth outcomes, but it is not known whether risk differs by ART regimen. We evaluated adverse birth outcomes by exposure to different ART regimens from conception. Methods: We extracted obstetric records at 8 government hospitals in Botswana. Since 2012, Botswana guidelines have recommended TDF/FTC/EFV for adults with CD4<350 and all pregnant women; those stable on other regimens were not switched. Outcomes included stillbirth (SB), preterm delivery (PTD)(<37 weeks), small for gestational age (SGA) (<10th%), neonatal death (NND)(<28 days), and a combined endpoint of any adverse outcome. For singleton births, the adjusted risk ratio (aRR) of each outcome was determined using log binomial regression to evaluate the effect of HIV and ART exposures, adjusting for maternal age, parity and education. Results: From August 2014 to August 2016, 47180 infants were born at surveillance maternities, representing ~45% of all births in Botswana. Information was available for 47083 (99.8%): 34615 (74%) infants were HIV-unexposed, 11932 (25%) were HIV-exposed, and 479 (1%) unknown. Among HIV-exposed infants, 6178 (52%) were continuously ART-exposed from the time of conception, 4557 (38%) were ART-exposed starting in pregnancy, 1059 (9%) had no antiretroviral exposure, and 138 (1%) had unknown timing or exposure. Combined adverse birth outcomes were more common among all HIV-exposed infants than HIV-unexposed infants (34% vs. 24%, p<0.001). In adjusted models among singletons ART-exposed from conception, TDF/FTC/EFV was associated with the lowest risk for combined adverse birth outcomes (p<0.001). Compared with TDF/3TC/EFV, all other regimens were associated with higher risk of SGA; ZDV/3TC/NVP was associated with higher risk of SB, PTD and NND; and ZDV/3TC/LPV/r was associated with higher risk of PTD and NND (Table 1). Median CD4 (available for 25% exposed from conception) was 500 cells/mm3 (IQR 385, 683), and did not influence magnitude or direction of combined adverse outcomes when added to the model; nadir CD4 was not available. Time from ART start to conception, and neural tube defects by ART exposure, will be evaluated in future analyses. Conclusion: Specific ART regimens used in pregnancy may impact adverse birth outcomes. Among infants exposed to ART from conception, TDF/FTC/EFV was associated with the fewest adverse birth outcomes.

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CROI 2017