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Factors Associated with Mother-to-Child Transmission of HIV-1 Despite a Maternal Viral Load <500 Copies/mL at Delivery: A Case-Control Study Nested in the French Perinatal Cohort (EPF-ANRS CO1)

  1. Roland Tubiana1,2,
  2. Jerome Le Chenadec3,11,
  3. Christine Rouzioux4,5,
  4. Laurent Mandelbrot6,13,
  5. Karima Hamrene7,
  6. Catherine Dollfus8,
  7. Albert Faye9,
  8. Constance Delaugerre4,
  9. Stephane Blanche5,10,
  10. Josiane Warszawski3,7,11,12, and
  11. ANRS French Perinatal Cohort (ANRS CO1/CO11)a
  1. 1Département des Maladies Infectieuses et Tropicales, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Pitié Salpêtrière, Hopital Necker
  2. 2Institut National de la Santé et de la Recherche Médicale (INSERM) U943, Hopital Necker
  3. 3Institut National Etudes Démographiques, Hopital Necker
  4. 4Laboratoire de Virologie, AP-HP, Hopital Necker
  5. 5EA 3620, Université Paris Descartes, Paris Diderot
  6. 6Université Paris 7, Paris Diderot
  7. 7Service de Santé Publique et Épidémiologie, AP-HP, Hopital Bicêtre, Paris
  8. 8Service d'Hématologie et d'Oncologie Pédiatrique, AP-HP, Hôpital Trousseau, Paris
  9. 9Service de Pédiatrie Générale, AP-HP, Hôpital Robert Debré, Paris
  10. 10Unité d'Immunologie Hématologie Pédiatrique, AP-HP, Hôpital Necker, Paris
  11. 11INSERM U822, Le Kremlin-Bicêtre, Colombes, France
  12. 12Faculté de Médecine Paris-Sud, Université Paris-Sud, Le Kremlin-Bicêtre, Colombes, France
  13. 13Service de Gynécologie-Obstétrique, AP-HP, Hôpital Louis Mourier, Colombes, France
  1. Reprints or correspondence: Dr Josiane Warszawski, INSERM, INED U822, 82, rue du Général Leclerc, 94 276 Le Kremlin Bicêtre cedex, France (josiane.warszawski{at}inserm.fr)
 
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Abstract

Background. The rate of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) type 1 is as low as 0.5% in non–breast-feeding mothers who delivered at term while receiving antiretroviral therapy with a plasma viral load <500 copies/mL. This situation accounted for 20% of the infected children born during the period 1997–2006 in the French Perinatal Cohort. We aimed to identify factors associated with such residual transmission risk.

Methods. We performed a case-control study nested in the aforementioned subpopulation of the French Perinatal Cohort.

Results. Nineteen case patients (transmitters) and 60 control subjects (nontransmitters) were included. Case patients and control subjects did not differ by geographical origin, gestational age at HIV diagnosis, type of antiretroviral therapy received, or elective Cesarean delivery. Case patients were less often receiving treatment at the time that they conceived pregnancy than control subjects (16% vs 45%; P=.017). A lower proportion of case patients had a viral load <500 copies/mL, compared with control subjects, at 14 weeks (0% vs 38.1%; P=.02), 28 weeks (7.7% vs 62.1%; P=.005), and 32 weeks: (21.4% vs 71.1%; P=.004). The difference remained significant when we restricted analysis to the 10 of 16 intrapartum transmission cases. In a multivariate analysis at 30±4 weeks adjusted for viral load, CD4+ T cell count, and time at antiretroviral therapy initiation, viral load was the only factor independently associated with MTCT of HIV (adjusted odds ratio, 23.2; 95% confidence interval, 3.5–553; P<.001).

Conclusions. Early and sustained control of viral load is associated with a decreasing residual risk of MTCT of HIV-1. Guidelines should take into account not only CD4+ T cell count and risk of preterm delivery, but also baseline HIV-1 load for deciding when to start antiretroviral therapy during pregnancy.

A remarkable decrease in the rate of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV)–1 has been obtained in industrialized coun-tries [1–4]. We recently showed [5] that the rate of MTCT of HIV-1 among mothers who delivered in the French Perinatal Cohort during the period 1997–2004 was 1.3% (95% confidence interval [CI], 1.0–1.6) and that the rate of MTCT increased with viral load, very premature delivery, and short duration of antiretroviral therapy (ART). However, MTCT of HIV-1 did occur, even in the context of full-term deliveries and a mater-nal viral load <400 copies/mL, without breast-feeding. The duration of antenatal ART was the only factor associated with such cases, which were referred to as “residual transmissions” [1, 5]. Most publications on the relation between maternal plasma viral load and MTCT considered only the viral load determined at delivery, and recommendations for initiating ART during pregnancy do not take into account baseline maternal viral load [3, 6–13]. To better investigate which factors may explain residual MTCT, we conducted a case-control study nested in the French Perinatal Cohort (EPF).

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Subjects and Methods

The ANRS French Perinatal Cohort (CO1/CO11). Since 1986, the French Perinatal Cohort has prospectively enrolled HIV-infected women delivering in 90 centers throughout France. The protocol was detailed elsewhere [5]. Mothers and children were observed according to recommended standards of care, which are regularly published and updated [14]. No specific recommendations for immunovirological evaluation, HIV-1 treatment, and obstetrical care were made for women included in the cohort. This cohort study was approved, according to French laws, by the Cochin Hospital Institutional Review Board and the French computer database watchdog commission (Commission Nationale de l'Informatique et des Libertés).

Study population. We conducted a case-control survey among persons in a French Perinatal Cohort subsample who met the following criteria: (1) the mother was HIV-1 infected and delivered in French Perinatal Cohort sites in mainland France during the period from 1 January 1997 through 31 December 2006; (2) ART was administered during pregnancy, regardless of the type of ART and time of initiation; (3) gestational age at delivery was at least 37 weeks; (4) the last viral load determined before or at delivery was <500 copies/mL; (5) there was no evidence of breast-feeding; and (6) the HIV-1 status of the child was established.

An infant was considered to be infected with HIV-1 if the virus was detected by virological testing (HIV-1 DNA or HIV-1 RNA polymerase chain reaction [PCR]) of 2 separate samples or if anti–HIV-1 antibodies persisted after 18 months of age. The timing of transmission was considered to be in utero if the result of the HIV-1 DNA or RNA PCR during the first week of life was positive or to be intrapartum if the test result was negative [15, 16].

An infant was considered to be noninfected if virological test results were negative for 2 separate samples, at least 1 of which was obtained after termination of neonatal prophylactic treatment or if the serological test result was negative after 18 months. Laboratory tests were performed on site, as described elsewhere [5, 17–19].

Among the eligible population, as defined above, we selected all HIV-1–infected children (case patients) and 3 HIV-1–uninfected children (control subjects) born to mothers enrolled in the French Perinatal Cohort just before or after each case patient in the same maternity. For 3 control-subject mothers who participated in a clinical trial [20], we added an extra mother-child pair. Overall, 19 case patients and 60 control subjects were included. We used the threshold of 500 copies/mL to define “controlled” plasma HIV-1 RNA level at delivery for different reasons. First, the sensitivity of PCR assays increased from 1996 to 2006, and stored samples were not always available to retest with a 50-copy/mL cutoff. Second, we previously found no difference in MTCT rates when we considered thresholds of 50 copies/mL (0.4%; 95% CI, 0.1–0.9) versus 500 copies/mL (0.6%; 95% CI, 0.3–1.0) [5]. Moreover, recent French guidelines use the 500-copy/mL cutoff to recommend elective Cesarean delivery for women who are receiving combination ART [11].

Data collection. We reviewed medical files for all case patients and control subjects to monitor available data and to collect supplementary data that were not in the original French Perinatal Cohort case-report forms. Information available for analyses were geographical origin, gestational age at booking, history of HIV-1 infection, all plasma levels of HIV-1 RNA and CD4+ T cell counts during pregnancy and the last determinations before pregnancy, all types and numbers of ART regimens received during pregnancy, obstetrical and clinical data, gestational age at delivery, and mode of delivery. Plasma HIV-1 RNA and CD4+ T cell counts were not measured at the same gestational ages for all patients, depending on time at HIV-1 diagnosis, booking, and clinician decision.

First and last ART regimens received during pregnancy were categorized into 3 classes: monotherapy involving a nucleoside reverse-transcriptase inhibitor, almost exclusively zidovudine; dual-drug therapy (ie, 2 nucleoside reverse-transcriptase inhibitors), mostly zidovudine-lamivudine; and highly active antiretroviral therapy (HAART; ⩾3 drugs of any class). Maternal intrapartum prophylaxis was classified as none versus intravenous zidovudine and/or single-dose nevirapine. Neonatal prophylaxis initiated by day 3 was classified as none, zidovudine monotherapy, or combination therapy.

Statistical analysis. Case patients and control subjects were compared for all of the aforementioned factors using exact conditional logistic regression [21]. Evolution of the log10 viral load during pregnancy was described separately in case patients and in control subjects using locally weighted regression (lowess), overall, and among mothers who initiated ART during pregnancy [22]. We estimated the proportion of subjects with a viral load <500 copies/mL and the proportion with a CD4+ T cell count >200 cell/mm3, the median log10 viral load, and the median CD4+ T cell count with interquartile ranges at 14±4 weeks, 28±2 weeks and 32±2 weeks. We also estimated median zenith log10 viral load and nadir CD4+ T cell count during pregnancy.

Viral load and CD4+ T cell count, which were coded as binary and continuous variables, were compared statistically at each instance. Multivariate logistic regression was adjusted for noncollinear variables associated with transmission with P values <.20. Because the immunovirological measures were not performed at the same gestational ages for all patients, as explained in the “Data collection” subsection above, we used the viral load and CD4+ T cell count measured at 30±4 weeks to minimize the number of missing immunovirological data. P<.05 was used to determine statistical significance. Analyses were conducted using SAS software, version 9.1 (SAS Institute). Lowess curves were estimated with R software (R Foundation for Statistical Computing).

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Results

Study population. Among 7425 mother- infant pairs included in the French Perinatal Cohort from January 1997 through December 2006, with an overall MTCT rate of 1.5% (115 of 7425 mother-infant pairs; 95% CI, 1.3%–2.4%), 4281 fulfilled the study criteria. In this subgroup, 22 children were infected (0.5%; 95% CI, 0.3%–0.8%). Three of them were excluded (evidence of breast-feeding for 2 case patients and unclear data for another). Finally, 19 case and 60 control mother-infant pairs were included in the study.

Maternal and obstetrical characteristics. Case patients and control subjects did not significantly differ in term of origin, marital status, alcohol or drug use during pregnancy, gestational age at booking, complications during pregnancy, or gestational age at delivery (table 1). The rate of premature membrane rupture and the mode of delivery did not differ between case patients and control subjects (47% and 48% underwent elective Cesarean deliveries, respectively).

HIV-1 history. The proportion of women diagnosed with HIV-1 infection before pregnancy was similar in both groups (74% of case patients and 68% of control subjects), and 10% had class C infection before pregnancy in each group (table 2). Two case patients and 1 control subject were reported to have primary infection during pregnancy.

ART in pregnancy. Case patients were receiving ART before conceiving less often than were control subjects (15.8% vs 45.0%; P=.017) (table 2). Among them, a similar proportion (10.5% of case patients and 11.7% of control subjects) interrupted therapy during the first trimester. Among the women who initiated ART during pregnancy (16 case patients and 33 control subjects), there was no difference in median gestational age at the commencement of ART (29.5 gestational weeks [range, 6–35 weeks] for case patients and 30.0 weeks [range, 16–34 weeks] for control subjects; P=.47).

Overall, the first ART regimen during pregnancy and the type of ART at delivery were similar in both groups (table 2). Case patients and control subjects had similar rates of intrapartum prophylaxis use (100% vs 98.3%), single-dose nevirapine (5% in both groups), and type of postnatal prophylaxis for infants. Problems of adherence to ART during pregnancy were reported significantly more frequently in the medical file for case patients (7 [37%] of 19) than for control subjects (7 [12%] of 60; P=.005).

HIV-1 RNA levels during pregnancy. As defined by the selection criteria, the viral load nearest to delivery was <500 copies/mL for all mothers. However, the median zenith viral load during pregnancy was significantly higher for case patients than for control subjects (P=.001) (table 2). It was <500 copies/mL for 0 case patients and for 40% of control subjects and was >10,000 copies/mL for 63% of case patients and for 36% of control subjects. The viral load was tested with a threshold of 50 copies/mL in 14 case patients (74%) and 45 control subjects (75%). Among them, 43% of case patients versus 71% of control subjects presented with a viral load <50 copies/mL near delivery (P=.07).

Overall, the viral load was initially higher and decreased more slowly in case patients than in control subjects (Figure 1A). The proportion of women with a viral load <500 copies/mL at 14 weeks was 0% for case patients versus 38% for control subjects (P=.02). At 28 weeks, only 7.7% of case patients versus 62.1% of control subjects had achieved a viral load <500 copies/mL (P=.005). The difference persisted at 32 weeks (table 3). The median viral load was also significantly higher in case patients than in control subjects at weeks 14, 28, and 32 (table 3).

Figure 1
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Figure 1

Evolution of median plasma log10 HIV-1 RNA level during pregnancy estimated by lowess curve (bold line) overall (A; 19 case patients and 60 control subjects) and in mothers initiating antiretroviral therapy during pregnancy (B; 16 case patients and 33 control subjects).

The pattern was similar in the subgroup of 16 case patients and 33 control subjects who initiated ART during pregnancy. Although the gestational age at ART initiation did not differ, the viral load started to decrease later in case patients than in control subjects, as shown by the sharper slope of the viral load curve (Figure 1B). The proportion of women with a viral load <500 copies/mL at 28 weeks was 10% for case patients and 37.5% for control subjects, and at 32 weeks, the proportions were 27.3% for case patients and 60.0% for control subjects (table 3).

CD4+ T cell counts during pregnancy. Maternal CD4+ T cell counts did not differ significantly between case patients and control subjects (table 3), although more case patients had CD4+ T cell counts <200 cells/µL at 32 weeks. No significant difference was found for the nadir CD4+ T cell count during pregnancy between the groups (table 2).

Table 1
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Table 1

Comparison of Maternal and Obstetrical Characteristics between Case Patients (for Whom There Was Transmission of Human Immunodeficiency Virus) and Control Subjects (for Whom No Transmission Occurred)

Table 2
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Table 2

Comparison of Human Immunodeficieny Virus (HIV)–1 Infection History and Strategies for Prevention of Mother-to-Child Transmission between Case Patients (for Whom There Was Transmission of HIV-1) and Control Subjects (for Whom No Transmission Occurred)

Timing of MTCT. HIV-1 RNA PCR or DNA quantification were performed on samples taken within 7 days of life for 16 of the 19 infected children (table 4). HIV-1 was detected in 6 infants (37.5%) who were considered to have had in utero transmission and was not detected in 10 infants (62.5%) who were considered to have had intrapartum transmission, because none were breast-fed. When comparing the 10 children infected intrapartum and their control subjects, the pattern was the same as for the overall population: the proportion of infants with a viral load <500 copies/mL at 28 and 32 weeks was significantly lower for case patients than for control subjects. The same trend was also observed for in utero transmission, although differences did not reach statistical significance, likely because of the small numbers.

Table 3
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Table 3

Comparison of Evolution of Viral Load and CD4+ T Cell Count during Pregnancy between Case Patients (for Whom There Was Transmission of Human Immunodeficiency Virus) and Control Subjects (for Whom No Transmission Occurred)

Table 4
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Table 4

Comparison of Evolution of Viral Load and CD4+ T Cell Count during Pregnancy between Case Patients (for Whom There Was Transmission of Human Immunodeficiency Virus [HIV]–1) and Control Subjects (for Whom No Transmission Occurred), According to Time of HIV-1 Transmission

Multivariate analysis. Multivariate analysis was performed in the overall study population (table 5). Plasma HIV-1 load at 30±4 weeks was found to be significantly associated with transmission, after adjustment for CD4+ T cell count at same time and for timing of ART initiation (before pregnancy, during 2 first trimesters, and during the last trimester). The adjusted odds ratio for transmission associated with a viral load ⩾500 copies/mL versus <500 copies/mL was 23.2 (95% CI, 3.5–553; P<.001). The CD4+ T cell count and the timing of ART initiation did not remain significantly associated with transmission. The results did not change when we excluded the 3 case patients with primary infection during pregnancy (data not shown).

Table 5
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Table 5

Multivariate Analysis: Independent Factors Associated with Residual Mother-to-Child Transmission of Human Immunodeficiency Virus

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Discussion

With progress in multidisciplinary management of HIV-1–infected pregnant women and their neonates, a low rate of MTCT has been obtained during the past decade in countries where such progress could be implemented [1–5]. In recent studies, the main risk factors of transmission in non–breast-feeding populations are high viral load and premature delivery. Together, these factors account for most cases of transmission in our cohort [5], as well as other major cohorts [1, 2, 4].

The rate of “residual” MTCT is as low as 0.5% in term deliveries in which the maternal viral load was <500 copies/mL. Nonetheless, residual transmission accounted for 20% of the HIV-1–infected children in our cohort over the period 1997–2006. Because these cases are considered to be treatment failures, identifying their causes might allow us to prevent them altogether.

In the present study, the only factor that remained independently associated with residual transmission of HIV-1 was early control of the plasma HIV-1 RNA level. Although the maternal viral load was <500 copies/mL at delivery in all mothers, it started to decrease much earlier in control subjects than in case patients. The viral load was significantly lower at 14, 28, and 32 weeks in control subjects than in case patients. Because the gestational age at the time of blood sampling varied between patients, we analyzed measures at 30±4 weeks in the multivariate analysis, using exact conditional logistic regression adapted for small size matched case-control study: although the 95% CI for the adjusted odds ratio was wide, viral load remained significantly and strongly associated with transmission, independent of CD4+ T cell count and of the time at which ART was initiated during pregnancy (adjusted odds ratio, 23.2; 95% CI, 3.5–553; P<.001).

Case patients were much less likely to be receiving therapy before conceiving than were control subjects (16% vs 45%), which may partly explain why the viral load was controlled later. None of the case patients had a viral load <500 copies/mL during the entire pregnancy, compared with 40% of control subjects. In mothers who started ART during pregnancy, the gestational age at initiation of treatment did not differ between the groups (30 weeks), but the viral load also decreased earlier for control subjects. This suggests that delayed ART initiation is not the only reason for late control of the viral load. Poor adherence to treatment was more often noted in case patients. Although adherence was not recorded with a standardized method, it was specified by the physicians during prenatal visits and thus could not be biased by the HIV-1 status of the child. Incomplete or delayed adherence may play a role in the delayed control of the viral load observed in the transmitters.

Ten infants were considered to have been infected intrapartum. Compared with their control subjects, the maternal viral load was also significantly higher at 14, 28, and 32 gestational weeks. The role of maternal viral load during pregnancy on MTCT could be expected for in utero transmissions [23–27], whereas it was more unexpected for intrapartum transmission from women with a low viral load at delivery. On one hand, we cannot exclude that exposure to antenatal HAART may decrease the sensitivity of PCR in the first days after birth, thus overestimating intrapartum transmission [28]. On the other hand, control of the plasma viral load at delivery does not reflect exactly HIV-1 replication in the compartments involved in the vertical transmission during delivery. Shedding of HIV-1 in the genital tract was described in women with low or undetectable viral load who were receiving ART [29–31] and has been identified as a risk factor for vertical transmission [32]. Recent studies have reported that HIV-1 RNA remained detectable in genital secretions in 35% of case patients after 28 days of HAART [33] and in 5% after 18 weeks [34]. It might be speculated that prolonged control of viral replication during ART may optimize the reduction of HIV-1 genital shedding. Further investigation is needed to confirm this hypotheses. In our study, the delayed and sharper slope of plasma viral load in case patients than in control subjects reflects a higher exposure to HIV-1 during the pregnancy for the mother and could be associated with a lesser protection against HIV-1 transmission for the infant during delivery.

The cutoff value of 500 copies/mL that we used to define virological “control” is greater than the currently used threshold. Among women whose delivery samples were tested with more-sensitive techniques, the proportion with a viral load <50 copies/mL was lower for case patients than for control subjects, although the trend did not reach statistical significance. In addition, the MTCT rate in mothers with viral load <50 copies/mL in our cohort was 0.4% [5], confirming that there is no threshold under which no residual transmission can occur.

Case patients and control subjects did not differ for geographical origin, late booking, complications during the pregnancy, gestational age at HIV-1 diagnosis, or type of first and last ART. There was no difference in the mode of delivery, use of intravenous zidovudine during labor or delivery, or postnatal prophylaxis. Control subjects were matched with case patients by obstetrical center and date of delivery to limit bias due to variations in obstetrical and medical management. However, because of small number of infected children, this case-control survey has limited power to identify any factors that may have a weak impact on MTCT and could explain discrepancies with the results of other studies [2, 9].

Even if our data suggest that control of the maternal viral load during the entire pregnancy with the lowest viral load should offer maximum protection from MTCT, we cannot use our results to define the optimal gestational age at which ART should be started, the optimal gestational age at which viral load should be controlled, or the threshold of viral load to reach. In addition, in a context of very low transmission rate, as achieved in our settings, the benefit of an early ART has to be balanced with potential risk of toxicity for the mother and the infant induced by ART during pregnancy [35–38].

The main finding of this study is that a lack of early and sustained control of maternal HIV-1 load appears strongly associated with residual transmission of HIV-1 to infants born to mothers with low viral load near delivery, independent of the timing of ART initiation and the CD4+ T cell count. This concerns intrapartum as well as in utero transmission. Therefore, to avoid the risk of residual MTCT, the maternal viral load should be controlled well before delivery. The HIV-1 load during pregnancy should be monitored closely in order to take measures soon enough, such as reinforcing adherence, therapeutic dose adjustment, or switching for efficient ART combinations. Guidelines on prevention of HIV-1 MTCT should take into account not only CD4+ T cell count and risk of preterm delivery, but also the baseline maternal plasma viral load for deciding when to start ART during pregnancy.

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The ANRS French Perinatal Cohort

Hôpital d'Aix en Provence* (Tadrist B.); Hôpital Nord, Amiens (Decaux N., Douadi Y., Gondry J., Li Thiao Te V., Schmit J. L.); Hôpital d'Angers (Fournié A.); Hôpital Victor Dupouy, Argenteuil (Allisy C., Brault D.); Hôpital Paris La Roseraie*, Aubervilliers (Rozan M. A.); Hôpital Robert Ballanger, Aulnay (Questiaux E., Zakaria A., Goldenstein C.); Hôpital Saint Claude, Basse-Terre* (Sibille G.); Hôpital de Bastia (Pincemaille O., Rusjan); Hôpital de la Côte Basque, Bayonne (Bonnal F., Cayla C.); Clinique du Blanc Mesnil* (Balde P.); Hôpital Saint Jacques, Besançon (Estavoyer J. M., Maillet R.); Hôpital Avicenne, Bobigny (Bentata M.); Hôpital Jean Verdier, Bondy (Benoist L., Bolie S., Bonier N., Lachassine E., Rodrigues A.); Hôpital Pellegrin, Bordeaux (Douard D., Roux D., Schaeffer V.); Hôpital Ambroise Paré*, Boulogne Billancourt (Zenaty D.); Hôpital Clémenceau, Caen (Brouard J., Goubin P.); Hôpital André Rosemon, Cayenne (Elenga N.); Hôpital Beaujon*, Clichy (De Curtis A.); Hôpital de Creil (Carpentier B., Duval-Arnould M., Kingue-Ekollo C); Hôpital Intercommunal, Créteil (Garrait V., Lemerle S., Pichon C., Richier C., Touboul C.); Hôpital Béclère, Clamart (Bornarel D., Chambrin V., Clech L., Foix L'Hélias L., Labrune P., Schoen H.); Hôpital Louis Mourier, Colombes (Crenn-Hebert C., Floch-Tudal C., Mazy F., Hery E., Meier C.); Hôpital de Compiègne* (Lagrue A.); Hôpital d'enfants, Dijon (Martha S., Reynaud I.); Hôpital de Dourdan* (Ercoli V.); Hôpital de Dreux* (Denavit M. F.); Hôpital des Feugrais*, Elbeuf (Lahsinat K.); Hôpital Intercommunal, Evreux (Allouche C., Touré K.); Hôpital Francilien Sud, Evry-Corbeil (Chevron, Devidas A., Granier M., Guignier M., Lakhdari Y., Marchand C., May A., Nguyen R., Turpault I.); Hôpital de Fontainebleau (Routier C.); Hôpital Victor Fouche, Fort de France (Hatchuel Y., William C.); Hôpital de Gonesse* (Balde P.); Hôpital Jean Rostand, Ivry (Jault T., Jrad I.); Hôpital de Lagny (Chalvon Demersay A., Froguel E., Gourdel B.); Hôpital du Lamentin* (Monlouis M.); Hôpital Les Oudairies, La Roche sur Yon (Aubry O., Brossier J. P., Esnault J. L., Leautez S., Perré P., Suaud I.); Hôpital de La Seyne sur Mer (Chamouilli J. M.); Hôpital Louis Domergue, La Trinité* (Hugon N.); Hôpital André Mignot, Le Chesnay (Hentgen V., Messaoudi F.); Hôpital de Bicêtre, Le Kremlin-Bicêtre (Fourcade C., Fridman S., Peretti D.); Hôpital Jeanne de Flandres, Lille (D'angelo S., Hammou Y., Mazingue F.); Hôpital Dupuytren*, Limoges (De lumley L.); Hôpital de Longjumeau (Bailly-Salin P., Turpault I., Seaume H.); Hôpital Hôtel Dieu-Hôpital Debrousse, Lyon (Bertrand Y., Bertrand S., Brochier C., Cotte L., Kebaçli K., Tache N., Roussouly M. J., Thoirain V.); Hôpital François Quesnay, Mantes La Jolie (Delanete A., Doumet A., Granier F., Salomon J. L.); Hôpital la Conception, Marseille (Cravello L.); Hôpital La Timone Marseille (Thuret I.); Hôpital de Meaux (Karaoui L., Lefèvre V.); Hôpital de Meulan* (Seguy D.); Hôpital Marc Jacquet, Melun (Le Lorier B.); Hôpital Intercommunal, Montfermeil (Dehlinger M., Echard M., Mullard C., Talon P.); Hôpital Arnaud de Villeneuve, Montpellier (Benos P., Guigue N., Lalande M.); Hôpital Intercommunal, Montreuil (Heller-Roussin B., Riehl C.,Winter); Maternité Régionale A. Pinard, Nancy (Hubert C.); Hôpital de Nanterre* (Karoubi P.); Hôpital de Nantes (Brunet-François C., Mechinaud, Reliquet V.) Hôpital de Neuilly sur Seine* (Berterottiere D.); Hôpital l'Archet-Fondation Lenval, Nice (Bongain A., Deville A., Galiba E. Monpoux F.,); Hôpital Caremeau, Nîmes (Dendale-Nguyen J.); Hôpital Orléans (Arsac P.); Hôpital d'Orsay (Chanzy S., De Gennes C., Isart V.); Hôpital Bichat, Paris (Bastian H., Batallan A., Matheron S.); Hôpital Boucicaut*, Paris (Lafay Pillet M. C.); Hôpital Cochin-Port Royal, Paris (Boudjoudi N., Firtion G., Fouchet M., Goupil I., Pannier A.); Hôpital Lariboisière, Paris (Ayral D., Ciraru-Vigneron N., Mouchnino G.); Hôpital des Métallurgistes*, Paris (Rami M.); Institut Mutualiste Montsouris*, Paris (Carlus Moncomble C.); Hôpital Necker, Paris (Boucly S., Blanche S., Maignan A., Parat S., Rouzioux C.,Viard J. P., Yamgnane A.); Hôpital Notre Dame du Bon Secours, Paris (Aufrant C.); Hôpital Pitié Salpêtrière, Paris (Bonmarchand M., De Montgolfier I., Edeb N., Lemercier D., Marcel S., Pauchard M., Tubiana R.); Hôpital Robert Debré, Paris (Faye A., Garion D., Leveille S., Levine M., Ottenwalter A., Recoules A.); Hôpital Saint-Antoine, Paris (Bui E., Carbonne B., Meyohas, Rodriguez J.); Hôpital Hôpital Saint Michel, Paris (Aufrant C.); Hôpital Tenon, Paris (Hervé F., Lebrette M. G.); Hôpital Trousseau, Paris (Dollfus C., Tabone M. D., Vaudre G., Wallet A.); Hôpital Marechal Joffre, Perpignan (Bachelard G., Medus M.); Hôpital Les Abymes, Pointe-à-Pitre (Bataille H.); Hôpital de Poissy-Saint-Germain en Laye* (Rousset M. C.); Hôpital René Dubos, Pontoise (Mouchnino G.); Hôpital Américain, Reims (Munzer M.); Hôpital Charles Nicolle, Rouen (Brossard V.); Hôpital de Saint-Denis (Allemon M. C., Bolot P., Dandris S., Ekoukou D., Ghibaudo N., Khuong M. A.,); Hôpital Nord, Saint Etienne (Billiemaz K.); Hôpital de Saint Martin (Bissuel F., Walter V.); Hôpital Esquirol*, Saint-Maurice (Robin M.); Hôpital de Sèvres* (Segard L.); Hôpital de Haute Pierre-Hôpital Civil, Strasbourg (Cheneau M., Entz-Werle N., Favreau J., Partisani M.); C. M. C. Foch, Suresnes* (Botto C.); Hôpital Chalu-cet, Toulon (Hittinger G.); Hôpital Paule de Viguier, Tou-louse (Antras M., Armand E., Berrebi A., Tricoire J.) Hôpi-tal Bretonneau, Tours (Besnier J. M., Nau P.); Hôpital Bra-bois, Vandoeuvre les Nancy (Neimann L.); Hôpital Paul Brousse*,Villejuif (Dussaix E.); Hôpital de Villeneuve Saint Georges (Chacé A., Guillot F., Matheron I., Tilouche S.).

*Closed centers.

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Acknowledgments

We thank all mothers who agreed to participate in this study. We also thank Linda Assoul, Valérie Benhammou, Naçma Bouallag, Leila Boufassa, Nacima Chernai, Paulette Huynh, Carine Jasseron, Nadia Kessaci, Corinne Laurent, Jacques Ngondi, Marlène Peres, Elisa Ramos, Thierry Wack, and Jean-Paul Teglas.

Financial support. Agence Nationale de Recherche sur le SIDA et les Hépatites virales (ANRS).

Potential conflicts of interest. All authors: no conflicts.

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Footnotes

  • ↵a Members of the ANRS French Perinatal Cohort are listed at the end of the text.

  • Received July 29, 2009.
  • Accepted October 15, 2009.
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  1. Clin Infect Dis. (2010) 50 (4): 585-596. doi: 10.1086/650005
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