2 Hepatitis C). 5.6.4 ART can be continued in all women who commenced HAART for PMTCT with a CD4 cell count of between 350 and 500 cells/μL during pregnancy. Grading: 2C On the basis of the above cohort data the Department of Health and Social Services (2011) [108] and International AIDS Society (2010) guidelines [109] for treating adults have now altered their recommendation Angiogenesis inhibitor and advise treating all adults with a CD4 cell count <500 cells/μL. Moreover,

two recent retrospective reviews in women discontinuing ART postpartum found an increased risk of death or opportunistic infection among women stopping therapy after delivery. The Tennessee study reviewed patients who discontinued therapy postpartum

(mean nadir CD4 cell count 332 cells/μL) in an observational cohort of mothers from 1997 to 2008 [100]. Despite being a small cohort (n = 123), the findings indicated an increased rate of AIDS-defining events and death, and non-AIDS-defining events and death, were more frequent in those discontinuing (n = 54) than in those continuing (n = 69), although this was not statistically Hydroxychloroquine nmr significant. This is the only study that has examined the use of HAART on clinical outcomes in women with high CD4 cell counts. However, there were many potential confounders. In a further retrospective study on mothers discontinuing therapy between 1997 and 2005 [102], more opportunistic infections

and deaths were found in those who discontinued; however, this was a small, uncontrolled review where 46% had previous ART exposure and 36% a pre-ART much CD4 cell count of <350 cells/μL. Lastly, in a large cohort of women who were enrolled in South America and followed up for 6–12 weeks after discontinuation of ART given to prevent MTCT, significant falls in the CD4 cell percentage were seen as would be expected [101]. Other studies have shown no detrimental effects on disease progression in discontinuing treatment postnatally. Data from ACTG 185 [99] through 18 months postpartum and from follow-up of women enrolled in the ACTG 076 study [110] suggest that for many women with CD4 cell counts >350 cells/μL, limited exposure to zidovudine monotherapy does not have an impact on disease progression or response to later therapy. However, again these studies enrolled a heterogeneous group of women many of whom had CD4 cell counts <350 cells/μL who received zidovudine monotherapy during pregnancy. More persuasively, among women with CD4 cell counts >350 cells/μL followed in the Women and Infants Transmission Study (WITS) cohort, there were no significant differences in CD4 cell count or disease progression at 1 year among those who did or did not continue ART after delivery [103].