The most common mode of HIV acquisition shifted over time from in

The most common mode of HIV acquisition shifted over time from injecting drug use (IDU) to heterosexual acquisition. The proportion of severely immunosuppressed women (CD4 counts <200 cells/μL) at delivery more than halved over time (χ2trend=5.7, P=0.017,

df=8), while the proportion with HIV RNA load above vs. below 1000 copies/mL decreased significantly (χ2trend=145.3, P<0.02, df=4) (Table 1). The changing pattern of mode of delivery, together with trends in antenatal ART use and MTCT rates, between 1985 and 2007 is shown in Figure 1. The proportion of vaginal deliveries decreased significantly Protein Tyrosine Kinase inhibitor over the study period as a whole (χ2trend=989.4, P<0.001), but reached its lowest level Transferase inhibitor (10%) in 2002–2004, increasing in the most recent time period to 34%. The elective CS rate declined since 2000 (Fig. 1). Overall, 1.7% of vaginal deliveries (39 of 2326) were instrumental, all but two of which occurred in the earliest time period. The emergency CS rate increased in the

HAART era, but peaked in 1998–2001, decreasing in 2005–2007. Among women delivering before 1994, three-quarters delivered vaginally and 99% received no ART (Table 1 and Fig. 1). Figure 1 shows the rapid implementation of use of zidovudine monotherapy during the 4 years following the ACTG076 trial results in 1994, and the subsequent uptake of HAART. In the HAART era, 119 women (10%) did not receive Acesulfame Potassium (HA)ART, of whom 34% delivered vaginally, 23% by emergency CS and 43% by elective CS; among the 2526 women on HAART, 511 (20%) delivered vaginally, 414 (16%) by emergency CS and 1601 (63%) by elective CS. There was a distinct pattern in mode of delivery across different geographic regions,

with a relatively rapid decline in elective CS rates in Belgium/Netherlands/UK since 1999 but virtually no drop until 2006 in the two other European regions (Fig. 2). In univariable analysis of factors associated with elective CS delivery (Table 2), geographic area, ART type, prematurity and viral load were all significantly associated with likelihood of delivering by elective CS in one or both periods. The multivariable results demonstrated a significantly reduced likelihood of elective CS delivery in Belgium/Netherlands/UK vs. Italy/Spain, with the most pronounced difference seen in 2003–2007 with a 93% decreased risk. Women delivering in Germany/Denmark/Sweden were more likely to have an elective CS than women from Italy/Spain, but this increase was only significant in 1998–2002. Use of antenatal mono- or dual therapy was associated with an independent 1.6-times-increased likelihood of elective CS in 1998–2002 and a nearly three-times increase in 2003–2007 compared with HAART (Table 2).

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