Consideration of Postpartum Management in HIV-Positive Haitian Women: An Analysis of CD4 Decline, Mortality, and Follow-Up After Delivery

Background: A previous study at the GHESKIO HIV clinic confirmed that highly active antiretroviral therapy (HAART) prophylaxis reduced mother-to-child transmission (MTCT) and infant mortality in Haiti. This analysis looks at maternal outcomes in this cohort after delivery. Methods: Records of 508 HIV-positive Haitian women who delivered between 1999 and 2005 were analyzed. We examined mortality, loss to follow-up, time to death or HAART initiation, and time of decline of CD4 count to 350 cells/mL. Results: One hundred seventy women reached a CD4 <= 200 or developed clinical AIDS and were started on long-term HAART. The median CD4 count at HAART initiation was 178 (interquartile range, 106-227). CD4 decline was stratified by CD4 at delivery to project the mean months to a CD4 of 350. With an initial CD4 of 350-499 cells/mu L, it was 19 months (95% confidence interval: 14 to 28) while with a CD > 500 cells/mu L, it was 71 months (95% confidence interval: 59 to 88). At study close, 257 women remained in follow-up, with loss to follow-up 3 times less in those on HAART (3.2/100 person-years) than those not on HAART (9.8/100 person-years). Conclusions: The threshold for starting treatment was often missed in HIV-infected women after delivery. Success of follow-up of women after delivery was favorably influenced by being on HAART. Women with high (> 500) initial CD4 counts had a protracted time (5-7 years) before they reach a threshold CD4 count, in contrast to those with CD4 < 500 cells/mu L. Strategies for postpartum treatment of women should be informed by the speed with which they are likely to progress.