Maia Lesosky1, Janet M Raboud2, Tracy Glass1, Sean S Brummel3, Andrea L Ciaranello4, Judith S Currier5, Shaffiq Essajee6, Diane V Havlir7, Catherine A Koss7, Anthony Ogwu8, Roger L Shapiro9, Elaine J Abrams10, Landon Myer1. 1. Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa. 2. Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada. 3. The Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston. 4. Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. 5. University of California Los Angeles, Los Angeles, California. 6. UNICEF, New York, New York. 7. University of California San Francisco, San Francisco, California, USA. 8. Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana. 9. Harvard Medical School and Harvard School of Public Health, Boston, Massachusetts. 10. ICAP at Columbia University, Mailman School of Public Health, and Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA.
Abstract
BACKGROUND: Intensified viral load monitoring for pregnant and breastfeeding women has been proposed to help address concerns around antiretroviral therapy (ART) adherence, viraemia and transmission risk, but there have been no systematic evaluations of existing policies. METHODS: We used an individual Monte Carlo simulation to describe longitudinal ART adherence and viral load from conception until 2 years' postpartum. We applied national and international guidelines for viral load monitoring to the simulated data. We compared guidelines on the percentage of women receiving viral load monitoring and the percentage of women monitored at the time of elevated viral load. RESULTS: Coverage of viral load monitoring in pregnancy and breastfeeding varied markedly, with between 14% and 100% of women monitored antenatally and 38-98% monitored during breastfeeding. Specific recommendations for testing at either a fixed gestation or a short, fixed period after ART initiation achieved more than 95% testing in pregnancy but this was much lower (14-83%) among guidelines with no special stipulations. By the end of breastfeeding, only a small proportion of simulated episodes of elevated viral load more than 1000 copies/ml were successfully detected by monitoring (range, 20-50%). DISCUSSION: Although further research is needed to understand optimal viral load frequency and timing in this population, these results suggest that current policies yield suboptimal detection of elevated viral load in pregnant and breastfeeding women.
BACKGROUND: Intensified viral load monitoring for pregnant and breastfeeding women has been proposed to help address concerns around antiretroviral therapy (ART) adherence, viraemia and transmission risk, but there have been no systematic evaluations of existing policies. METHODS: We used an individual Monte Carlo simulation to describe longitudinal ART adherence and viral load from conception until 2 years' postpartum. We applied national and international guidelines for viral load monitoring to the simulated data. We compared guidelines on the percentage of women receiving viral load monitoring and the percentage of women monitored at the time of elevated viral load. RESULTS: Coverage of viral load monitoring in pregnancy and breastfeeding varied markedly, with between 14% and 100% of women monitored antenatally and 38-98% monitored during breastfeeding. Specific recommendations for testing at either a fixed gestation or a short, fixed period after ART initiation achieved more than 95% testing in pregnancy but this was much lower (14-83%) among guidelines with no special stipulations. By the end of breastfeeding, only a small proportion of simulated episodes of elevated viral load more than 1000 copies/ml were successfully detected by monitoring (range, 20-50%). DISCUSSION: Although further research is needed to understand optimal viral load frequency and timing in this population, these results suggest that current policies yield suboptimal detection of elevated viral load in pregnant and breastfeeding women.
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