BACKGROUND Elevated viral load (VL) early after antiretroviral therapy (ART) initiation appears frequently in pregnant and postpartum women living with human immunodeficiency virus; however the relative contributions of pre-ART drug resistance mutations (DRMs) vs nonadherence in the etiology of elevated VL are unknown. METHODS Within a cohort of women initiating ART during pregnancy in Cape Town, South Africa, we compared women with elevated VL after initial suppression (cases, n = 80) incidence-density matched to women who maintained suppression over time (controls, n = 87). Groups were compared on pre-ART DRMs and detection of antiretrovirals in stored plasma. RESULTS The prevalence of pre-ART DRMs was 10% in cases and 5% in controls (adjusted odds ratio [aOR], 1.53 [95% confidence interval {CI}, .4-5.9]); all mutations were to nonnucleoside reverse transcriptase inhibitors. At the time of elevated VL, 19% of cases had antiretrovirals detected in plasma, compared with 87% of controls who were suppressed at a matched time point (aOR, 131.43 [95% CI, 32.8-527.4]). Based on these findings, we estimate that <10% of all elevated VL in the cohort may be attributable to pre-ART DRMs vs >90% attributable to ART nonadherence. CONCLUSIONS DRMs account for a small proportion of all elevated VL among women occurring in the 12 months after ART initiation during pregnancy in this setting, with nonadherence appearing to drive most episodes of elevated VL. Alongside the drive for access to more robust antiretroviral agents in resource-limited settings, there is an ongoing need for effective strategies to support ART adherence in this patient population.

中文翻译：

---

抗逆转录病毒的依从性，病毒载量增加和人类免疫缺陷病毒感染的妇女在妊娠中开始治疗的耐药突变：巢式病例对照研究。

背景技术抗逆转录病毒疗法（ART）启动后早期的病毒载量（VL）在患有人免疫缺陷病毒的孕妇和产后妇女中经常出现。然而，尚不清楚ART前耐药性突变（DRM）与非依从性在VL升高的病因中的相对贡献。方法在南非开普敦的一组孕期发起抗逆转录病毒治疗的女性人群中，我们比较了初次抑制后VL升高的女性（病例，n = 80），其发病率与长期保持抑制的女性相匹配（对照组，n = 87）。 ）。比较了各组在ART DRM之前和血浆中抗逆转录病毒药的检测情况。结果病例中，ART前DRM的患病率为10％，而对照组为5％（校正后的优势比[aOR]，1.53 [95％置信区间{CI} ，. 4-5.9]）；所有突变均为非核苷类逆转录酶抑制剂。在VL升高时，血浆中检测到抗逆转录病毒药物的病例为19％，而在相同时间点被抑制的对照组为87％（aOR，131.43 [95％CI，32.8-527.4]）。基于这些发现，我们估计队列中所有升高的VL中<10％可能归因于ART DRM前，而90％以上归因于ART不依从。结论在这种情况下，DRM占怀孕期间开始ART的12个月内所有妇女VL升高的一小部分，不依从似乎是导致大多数VL升高的原因。在资源有限的环境中，除了寻求获得更强大的抗逆转录病毒药物外，还需要有效的策略来支持抗逆转录病毒药物在该患者人群中的依从性。