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BACKGROUND: Whereas HAART initiated at CD4 cell counts 351-450 cells/ml reduces mortality compared with starting at lower CD4 levels there is currently no evidence for the advantages of initiating treatment at CD4 cell counts greater than 450 cells/ml. METHODS: Mortality hazard as a function of CD4 cell count was estimated among postpartum HIV-positive women in Zimbabwe using HIV-negative women as the reference group. RESULTS: Mortality within 24 months postpartum was 54 times higher among women with CD4 cell counts less than 200 cells/ml fell to 5.4 times higher for those with CD4 cell counts 400-600 cells/ml but fell little thereafter. For CD4 cell counts greater than 600 cells/ml the hazard was 6.2 (95% confidence interval 3.2-11.9). CONCLUSION: Early HAART initiation for all HIV-positive pregnant women may benefit individual mothers and infants and simultaneously reduce population HIV incidence.

OBJECTIVE: To test whether post-partum vitamin A supplementation can reduce incident HIV among post-partum women and identify risk factors for HIV incidence. DESIGN: Randomized, placebo-controlled trial METHODS: Between November 1997 and January 2001, 14,110 women were randomly administered 400,000 IU vitamin A or placebo within 96 h post-partum. HIV incidence was monitored among 9562 HIV-negative women. RESULTS: Cumulative incidence was 3.4% [95% confidence interval (CI), 3.0-3.8] and 6.5% (95% CI, 5.7-7.4) over 12 and 24 months post-partum, respectively. Vitamin A supplementation had no impact on incidence [hazard ratio (HR), 1.08; 95% CI, 0.85-1.38]. However, among 398 women for whom baseline serum retinol was measured, those with levels indicative of deficiency (< 0.7 micromol/l, 9.2% of those measured) were 10.4 (95% CI, 3.0-36.3) times more likely to seroconvert than women with higher concentrations. Furthermore, among women with low serum retinol, vitamin A supplementation tended to be protective against incidence (HR, 0.29; 95% CI, 0.03-2.60; P = 0.26), although not significantly so, perhaps due to limited statistical power. Severe anaemia (haemoglobin < 70 g/l) was associated with a 2.7-fold (95%CI, 1.2-6.1) greater incidence. Younger women were at higher risk of HIV infection: incidence declined by 5.7% (2.8-8.6) with each additional year of age. CONCLUSION: Among post-partum women, a single large-dose vitamin A supplementation had no effect on incidence, although low serum retinol was a risk factor for seroconversion. Further investigation is required to determine whether vitamin A supplementation of vitamin-A-deficient women or treatment of anaemic women can reduce HIV incidence.