Page 389 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 2 of 8 Original Research

Transient viraemia is defined as an episode of LLV that occurs Preconception antiretroviral therapy (PCART) is more
in the presence of effective ART and is confirmed by viral effective than ART commenced after conception in reducing
suppression before and after the period of viraemia, with MTCT, and it is associated with substantial decreases in
measurements taken at least 30 days apart. 10,11 Although MTCT. 27,28 Recently, zero transmission rates have been
29
30
transient viraemia has been attributed to immune activation reported from South Africa and Burkina Faso. Although
of latently infected cells, resulting in release of HIV RNA Omole et al. reported a significantly higher rate of viraemia
particles with ongoing replication of both antiretroviral- in pregnant South African women compared with non-
sensitive and antiretroviral-resistant virus, recent studies pregnant women in the period 2007–2008, current opinion
12
31
suggest that immune activation may in fact be established holds that pregnancy itself does not impact adversely on VL,
before ART initiation and persist during viral suppression whether via physiological or socio-behavioural mechanisms,
and is therefore not responsible for LLV. High pretreatment including adherence. 23,32,33
13
VL has been associated with higher incidence of transient
11
viraemia as viral reservoirs tend to be higher. Transient No single study has prospectively followed South African
viraemia is associated with increased risk of viral resistance patients on PCART, differentiated transient from persistent
and eventual virological failure, particularly if recurrent. 11,14,15 viraemia and attempted to correlate these with factors such
as adherence and socio-economic indicators. This study was
The United Nations Programme on HIV/AIDS set a goal of therefore undertaken to quantify the rate of HIV viraemia in
90% of viral suppression in patients receiving ART by 2020. 16,17 pregnant women on PCART, to determine the proportion of
Current South African performance falls short of this. Recent women with transient viraemia versus persistent viraemia,
prospective studies of patients receiving ART have found to determine factors associated with viraemia and to
LLV rates varying from 18% to 31%. 7,17,18 Approximately half determine birth HIV status of children born to women on
of these patients with LLV eventually develop virological PCART.
treatment failure. When maternal viraemia is completely
7
suppressed throughout pregnancy, the rate of MTCT is Methods
reduced to below 0.5%, whereas the rate of transmission in
19
the absence of therapy lies between 15% and 45%. 7,20 Study design
We conducted a cross-sectional observational study where
In the mother receiving ART, higher perinatal transmission we studied a group of pregnant HIV-positive women who
rates occur with LLV than when the VL is below 50 copies/mL, attended the ANC of a primary healthcare facility in the
15
and the risk is increased where episodes of viraemia occur semirural KwaDukuza District of KwaZulu-Natal.
during the pregnancy. Adequate VL suppression reduces the Participants were enrolled between November 2016 and
21
MTCT risk during vaginal delivery to a level where caesarean April 2017. Pregnant women aged 18 years of age or older
section offers no advantage. 22 who had received ART for a minimum of 24 weeks before
conception and whose gestational age did not exceed
Data from low, middle and high-income countries show that 30 weeks were invited to participate. Patients on second-line
by 2011, only about 72% of pregnant women achieved the ART were excluded.
desirable adherence of 80% to ARVs, with adherence
deteriorating in the post-partum period. 8,23,24 Though On the assumption that the proportion of patients with
previous studies of viraemia in pregnant South African viraemia at first presentation is 13%, as previously reported
women receiving ART were cross-sectional, Myer et al. in Cape Town, we predicted that a sample size of 89 patients
34
studied a group of pregnant HIV-positive women initiated was necessary to determine the prevalence of viraemia in
25
on ART prospectively. They reported that 23% failed to our participants with a 95% confidence level and an error
achieve viral suppression during pregnancy. Of the 77% who margin of 7%.
were initially suppressed, 6% subsequently developed
viraemia, half of whom proved transient whereas the other Data collection
half developed virological treatment failure. The study noted
a striking loss of suppression in the post-partum period. A blood sample for baseline VL was drawn at the first
Only 70% of the original cohort that started on ART during antenatal booking visit. Data were collected by questionnaire,
pregnancy maintained consistent viral suppression up to administered by the primary researcher (VN), who is fluent
12 months post-partum. 26 in Zulu, which facilitated the process as all participants were
first-language Zulu speakers. Questions were designed to
Reported rates of detectable VL at the time of delivery in cover past ART history, past PMTCT treatment exposure,
patients on ART vary. Cragg et al. reported a rate of 3% in sexual history, partner’s HIV status and exposure to ART,
women who enter ANC already on ART, while Myer et al. reproductive health history and a range of socio-economic
27
reported a rate of 27% in patients who initiated ART during indicators. The questionnaire was piloted by the researcher. A
25
pregnancy. A South African study has shown a correlation structured self-adherence questionnaire adapted from the
between maternal VL at birth and transmission, with the risk AIDS Counselling and Treatment Group baseline adherence
being 0.25%, 2% and 8.5%, respectively, with VLs lower than questionnaire with a visual analogue scale (VAS) was
35
50, of 50–1000 and more than 1000 copies/mL. 25 administered as a measure of adherence. All participants

http://www.sajhivmed.org.za 382 Open Access