CD4+ Cell Count Testing More Effective Than HIV Disease Clinical Staging in Identifying Pregnant and Postpartum Women Eligible for Antiretroviral Therapy in Resource-Limited Settings

Objective: Identifying antiretroviral therapy (ART) eligible HIV-infected (HIV+) pregnant women and rapidly initiating treatment preserves maternal health and prevents mother-to-child transmission. However, there have been few investigations of the performance of ART eligibility criteria in pregnant and postpartum women in resource-limited settings. Methods: Pregnant and recently postpartum HIV+ women received CD4(+) cell count and World Health Organization (WHO) clinical staging at enrollment into the mother-to-child transmission Plus Initiative. We compared immunologic and clinical criteria based on 2009 WHO ART treatment guidelines (WHO stage 3/4 or CD4(+) cell count <= 350 cells/mm(3)) in identifying ART eligible women. Results: Among 6036 women (62% antepartum, 38% postpartum), 2915 (48%) were ART eligible. Only 23% had WHO stage 3 or 4 disease, whereas 94% met CD4(+) cell count criterion. Among 5356 women with WHO stage 1 or 2 disease, 2235 (42%) had CD4(+) <= 350 cells per cubic millimeter. Change of CD4(+) cell count ART eligibility threshold from <= 200 to <= 350 cells per cubic millimeter increased the proportion of ART eligible women from 21% to 45%. Conclusions: Use of CD4(+) cell count criterion is superior to clinical staging in identifying pregnant and postpartum HIV+ women eligible for ART. Improving access to CD4(+) testing is essential to identify and treat eligible women, optimizing maternal and child health outcomes.