AZT monotherapy vs. combination ART for prevention of vertical transmission in Ukraine

Impact of expanded access to combination antiretroviral therapy in pregnancy: results from a cohort study in Ukraine.

Bailey H, Townsend CL, Semenenko I, Malyuta R, Cortina-Borja M, Thorne C; Ukraine European Collaborative Study Group in EuroCoord., Bull World Health Organ. 2013;91(7):491-500. doi: 10.2471/BLT.12.114405

Objectives: To investigate the scale-up of antenatal combination antiretroviral therapy (cART) in Ukraine since this became part of the national policy for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV).

Methods: Data on 3 535 HIV-positive pregnant women who were enrolled into the Ukraine European Collaborative Study in 2008-2010 were analysed. Factors associated with receipt of zidovudine monotherapy (AZTm) - rather than cART - and rates of mother-to-child transmission (MTCT) of HIV were investigated.

Findings: cART coverage increased significantly, from 22% of deliveries in 2008 to 61% of those in 2010. After adjusting for possible confounders, initiation of antenatal AZTm - rather than cART - was associated with cohabiting (versus being married; adjusted prevalence ratio, aPR: 1.09; 95% confidence interval, CI: 1.02-1.16), at least two previous live births (versus none; aPR: 1.22; 95% CI: 1.11-1.35) and a diagnosis of HIV infection during the first or second trimester (versus before pregnancy; aPR: 1.11; 95% CI: 1.03-1.20). The overall MTCT rate was 4.1% (95% CI: 3.4-4.9); 42% (49/116) of the transmissions were from the 8% (n = 238) of women without antenatal ART. Compared with AZTm, cART was associated with a 70% greater reduction in the risk of MTCT (adjusted odds ratio: 0.30; 95% CI: 0.16-0.56).

Conclusion: Between 2008 and 2010, access to antenatal cART improved substantially in Ukraine, but implementation of the World Health Organization's Option-B policy was slow. For MTCT to be eliminated in Ukraine, improvements in the retention of women in HIV care and further roll-out of Option B are urgently needed.

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Editor’s notes:  Elimination of infant infections by 2015 is a global target. The guideline for PMTCT has moved from using Option A (AZT monotherapy or AZTm) and Option B (combination ART in pregnancy or cART) to the most recent recommendation in 2013 of Option B+ (initiation of life-long ART for all HIV-infected pregnant women).  

Coverage of cART in Ukraine increased significantly over the study period.  The majority of women who did not receive any ART were either diagnosed before conception and lost to care or were diagnosed before delivery.  cART was associated with a significantly lower risk of MTCT than AZTm even after adjusting for duration of ART and despite women with advanced disease more likely to be given cART . Women were diagnosed during pregnancy were however, more likely to get AZTm probably because there was less opportunity to counsel them about cART.  Notably, those who were co-habiting or had had two or more previous pregnancies were also less likely to receive cART.  This group had a lower educational status, a factor associated with AZTm receipt.  Underlying contextual factors such as practical and financial barriers to attending for care in this group may explain why they may have received AZTm, as clinicians are less likely to prescribe cART to infrequent attenders. 

This study demonstrates that engagement with and retention in care of women is a pre-requisite for successful scale-up of cART. This is going to be an even more important consideration if Option B+ is to be successfully implemented.

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