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Poliektov NE, Badell ML. Antiretroviral Options and Treatment Decisions During Pregnancy. Paediatr Drugs 2023; 25:267-282. [PMID: 36729360 DOI: 10.1007/s40272-023-00559-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/03/2023]
Abstract
The majority of pediatric human immunodeficiency virus (HIV) infections are the result of vertical transmissions that occur during pregnancy, childbirth, and breastfeeding. The treatment of all pregnant persons living with HIV remains a global health initiative. Early and consistent use of antiretroviral therapy throughout pregnancy and childbirth drastically reduces the risk of perinatal transmission of HIV, resulting in fewer children living with the disease worldwide. Given that the maternal HIV viral load is the strongest predictor of perinatal transmission, suppressive antiretroviral treatment during pregnancy is the principal means to eliminate transmission of HIV from mother to child. With the use of combined antiretroviral therapy, typically with dual-nucleoside reverse transcriptase inhibitors plus an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, HIV-infected mothers can now achieve virologic suppression to undetectable levels and yield a perinatal transmission rate of less than 2%. Important considerations of HIV treatment in pregnancy include the safety and efficacy of antiretroviral drugs, altered pregnancy-related pharmacokinetics, potential for birth defects or adverse neonatal outcomes, and individualized delivery planning based on maternal viral load. This practical review article summarizes the options, considerations, and recommendations for antiretroviral treatment in pregnancy to reduce perinatal HIV transmission and optimize health outcomes for mothers and infants worldwide.
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Affiliation(s)
- Natalie E Poliektov
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Martina L Badell
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA.
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2
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Schneidman J, Lee T, Sauve L, Brophy J, Bitnun A, Singer J, Money D, Kakkar F, Boucoiran I. Type and timing of antiretroviral therapy during pregnancy: Impact on risk of preterm delivery and small-for-gestational age births in Canada, a retrospective cohort study. Int J Gynaecol Obstet 2023. [PMID: 36707102 DOI: 10.1002/ijgo.14705] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 01/03/2023] [Accepted: 01/27/2023] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the impact of type and timing of antiretroviral therapy (ART) on the risk of preterm delivery (PTD) and small-for-gestational age (SGA) birth among pregnant women and people living with HIV in Canada. METHODS Data for this retrospective cohort study were analyzed from the Canadian Perinatal HIV Surveillance Program from 1990 to 2020. The association between ART and risk of PTD (<37 weeks) and SGA birth (<10th percentile) was explored using mixed effects logistic regression and time-dependent Cox proportional hazards models. RESULTS Overall, there were 14.9% (654 of 4379) PTD and 18.5% (732 of 3947) SGA cases. A higher risk of PTD was observed with nonnucleoside reverse transcriptase inhibitor-(adjusted hazard ratio [aHR], 1.73; P = 0.019) and boosted protease inhibitor- (aHR, 186; P = 0.007) based regimens compared with integrase strand transfer inhibitor (INSTI)-based regimens. ART initiation prior to conception was associated with a lower risk of SGA birth compared with ART initiation after conception at 1 to 14 weeks (adjusted odds ratio [aOR], 0.69; P = 0.024) and > 14 weeks (aOR, 0.70; P = 0.005). CONCLUSION INSTI-based ART regimens were associated with lower risk of PTD compared with other regimens, and ART initiation before conception was associated with a lower risk of SGA birth. These findings, with overall safety data, should be considered when providing pregnancy counseling to people living with HIV.
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Affiliation(s)
- Jillian Schneidman
- Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Terry Lee
- CIHR Canadian HIV Trials Network, Vancouver, British Columbia, Canada
| | - Laura Sauve
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.,Women's Health Research Institute, Vancouver, British Columbia, Canada
| | - Jason Brophy
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Ari Bitnun
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Joel Singer
- CIHR Canadian HIV Trials Network, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, British Columbia, Vancouver, Canada
| | - Deborah Money
- Women's Health Research Institute, Vancouver, British Columbia, Canada.,Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fatima Kakkar
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Isabelle Boucoiran
- School of Public Health, Université de Montréal, Montreal, Quebec, Canada.,Department of Obstetrics and Gynecology, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
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Perinatal Exposure to HIV Infection: The Experience of Craiova Regional Centre, Romania. Healthcare (Basel) 2022; 10:healthcare10020308. [PMID: 35206923 PMCID: PMC8871740 DOI: 10.3390/healthcare10020308] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 02/05/2023] Open
Abstract
Background and objectives: HIV infection in pregnant women can be responsible for a number of consequences during pregnancy, such as: maternal anaemia, miscarriage, low birth weight, and preterm birth. The objectives of this study were to determine the maternal–foetal transmission rate of HIV among pregnant women living with HIV from Craiova Regional Centre in order to assess the risk factors for mother-to-child transmission of HIV and to identify the characteristics of newborns perinatally exposed to HIV. Materials and methods: A retrospective study was conducted between 1 January 2011 and 31 December 2020, including children born to HIV-positive mothers. Results: The studied group included 138 newborns and was divided into two subgroups: group A, which included 10 HIV-infected infants; and group B, which included 128 uninfected infants. The mother-to-child transmission rate was 3.5% for women to whom all prophylaxis standards were applied. We found a statistically significant correlation between the level of maternal HIV viremia and perinatal HIV transmission (p = 0.01). Preterm birth and low birth weight were associated with perinatal transmission of the infection. Conclusions: Perinatal transmission of HIV infection during our study was associated with inconsistent application of screening for HIV infection among pregnant women, lack of antiretroviral therapy, poor adherence to treatment, and detectable HIV viral load during pregnancy.
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Hodel EM, Marzolini C, Waitt C, Rakhmanina N. Pharmacokinetics, Placental and Breast Milk Transfer of Antiretroviral Drugs in Pregnant and Lactating Women Living with HIV. Curr Pharm Des 2020; 25:556-576. [PMID: 30894103 DOI: 10.2174/1381612825666190320162507] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Remarkable progress has been achieved in the identification of HIV infection in pregnant women and in the prevention of vertical HIV transmission through maternal antiretroviral treatment (ART) and neonatal antiretroviral drug (ARV) prophylaxis in the last two decades. Millions of women globally are receiving combination ART throughout pregnancy and breastfeeding, periods associated with significant biological and physiological changes affecting the pharmacokinetics (PK) and pharmacodynamics (PD) of ARVs. The objective of this review was to summarize currently available knowledge on the PK of ARVs during pregnancy and transport of maternal ARVs through the placenta and into the breast milk. We also summarized main safety considerations for in utero and breast milk ARVs exposures in infants. METHODS We conducted a review of the pharmacological profiles of ARVs in pregnancy and during breastfeeding obtained from published clinical studies. Selected maternal PK studies used a relatively rich sampling approach at each ante- and postnatal sampling time point. For placental and breast milk transport of ARVs, we selected the studies that provided ratios of maternal to the cord (M:C) plasma and breast milk to maternal plasma (M:P) concentrations, respectively. RESULTS We provide an overview of the physiological changes during pregnancy and their effect on the PK parameters of ARVs by drug class in pregnancy, which were gathered from 45 published studies. The PK changes during pregnancy affect the dosing of several protease inhibitors during pregnancy and limit the use of several ARVs, including three single tablet regimens with integrase inhibitors or protease inhibitors co-formulated with cobicistat due to suboptimal exposures. We further analysed the currently available data on the mechanism of the transport of ARVs from maternal plasma across the placenta and into the breast milk and summarized the effect of pregnancy on placental and of breastfeeding on mammal gland drug transporters, as well as physicochemical properties, C:M and M:P ratios of individual ARVs by drug class. Finally, we discussed the major safety issues of fetal and infant exposure to maternal ARVs. CONCLUSIONS Available pharmacological data provide evidence that physiological changes during pregnancy affect maternal, and consequently, fetal ARV exposure. Limited available data suggest that the expression of drug transporters may vary throughout pregnancy and breastfeeding thereby possibly impacting the amount of ARV crossing the placenta and secreted into the breast milk. The drug transporter's role in the fetal/child exposure to maternal ARVs needs to be better understood. Our analysis underscores the need for more pharmacological studies with innovative study design, sparse PK sampling, improved study data reporting and PK modelling in pregnant and breastfeeding women living with HIV to optimize their treatment choices and maternal and child health outcomes.
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Affiliation(s)
- E M Hodel
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Division of Paediatric Pharmacology & Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - C Marzolini
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - C Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - N Rakhmanina
- Department of Pediatrics, The George Washington University, School of Medicine & Health Sciences, Washington, DC, United States.,Division of Infectious Diseases, Children's National Medical Center, Washington, DC, United States.,Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States
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Dinh TH, Mushavi A, Shiraishi RW, Tippett Barr B, Balachandra S, Shambira G, Nyakura J, Zinyowera S, Tshimanga M, Mugurungi O, Kilmarx PH. Impact of Timing of Antiretroviral Treatment and Birth Weight on Mother-to-Child Human Immunodeficiency Virus Transmission: Findings From an 18-Month Prospective Cohort of a Nationally Representative Sample of Mother-Infant Pairs During the Transition From Option A to Option B+ in Zimbabwe. Clin Infect Dis 2019; 66:576-585. [PMID: 29401270 DOI: 10.1093/cid/cix820] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 09/14/2017] [Indexed: 01/17/2023] Open
Abstract
Background Preventing mother-to-child transmission of human immunodeficiency virus transmission (MTCT) depends on early initiation of antiretroviral therapy (ART). We report the 18-month MTCT risk during the transition from Option A to Option B+ in Zimbabwe, and assess whether ART preconception could eliminate MTCT in breastfeeding populations. Methods In 2013, we consecutively recruited a nationally representative sample of 6051 infants aged 4-12 weeks and their mothers from 151 immunization clinics using a multistage stratified cluster sampling method. We identified 1172 human immunodeficiency virus (HIV)-exposed infants and evaluated them at baseline and every 3 months until the child became HIV-infected, died, or reached age 18 months. Results The cumulative MTCT risk through 18 months postdelivery was 7.0%. Of the HIV-infected mothers, 35.3% started ART preconception, 28.9% during pregnancy, and 9.7% after delivery, and 16.0% received zidovudine during pregnancy. Compared to mothers without antiretroviral drug use, MTCT among those starting ART preconception and during pregnancy was lower by 88% (adjusted hazard ratio [aHR], 0.12; 95% confidence interval [CI], .06-.24) and 75% (aHR, 0.25; 95% CI, .14-.45), respectively. HIV-exposed infants with birth weight <2.5 kg (low birth weight) were 2.6-fold more likely to acquire HIV infection compared to those with birth weight ≥2.5 kg (aHR, 2.57; 95% CI, 1.44-4.59). Controlling for other factors, breastfeeding was not significantly associated with MTCT. Conclusions ART preconception has the highest impact on reducing MTCT, indicating that HIV-infected, reproductive-age women should be prioritized in "treat-all" strategies. HIV-infected mothers without ART use should be identified at the first immunization visit and treatment initiated to reduce postdelivery MTCT. MTCT risk is higher in mothers with low-birth-weight deliveries.
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Affiliation(s)
- Thu-Ha Dinh
- Center for Global Health, Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Angela Mushavi
- AIDS and TB Department, Ministry of Health and Child Care of Zimbabwe
| | - Ray W Shiraishi
- Center for Global Health, Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Beth Tippett Barr
- Center for Global Health, Division of Global HIV and Tuberculosis, US Centers for Disease Control and Prevention-Zimbabwe
| | - Shirish Balachandra
- Center for Global Health, Division of Global HIV and Tuberculosis, US Centers for Disease Control and Prevention-Zimbabwe
| | | | | | - Sekesai Zinyowera
- National Microbiology Reference Laboratory, Ministry of Health and Child Care of Zimbabwe, Harare
| | | | - Owen Mugurungi
- AIDS and TB Department, Ministry of Health and Child Care of Zimbabwe
| | - Peter H Kilmarx
- Center for Global Health, Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia.,Center for Global Health, Division of Global HIV and Tuberculosis, US Centers for Disease Control and Prevention-Zimbabwe
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Roh ME, Shiboski S, Natureeba P, Kakuru A, Muhindo M, Ochieng T, Plenty A, Koss CA, Clark TD, Awori P, Nakalambe M, Cohan D, Jagannathan P, Gosling R, Havlir DV, Kamya MR, Dorsey G. Protective Effect of Indoor Residual Spraying of Insecticide on Preterm Birth Among Pregnant Women With HIV Infection in Uganda: A Secondary Data Analysis. J Infect Dis 2019; 216:1541-1549. [PMID: 29029337 DOI: 10.1093/infdis/jix533] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/29/2017] [Indexed: 11/14/2022] Open
Abstract
Background Recent evidence demonstrated improved birth outcomes among human immunodeficiency virus (HIV)-uninfected pregnant women protected by indoor residual spraying of insecticide (IRS). Evidence regarding its impact on HIV-infected pregnant women is lacking. Methods Data were pooled from 2 studies conducted before and after an IRS campaign in Tororo, Uganda, among HIV-infected pregnant women who received bed nets, daily trimethoprim-sulfamethoxazole, and combination antiretroviral therapy at enrollment. Exposure was the proportion of pregnancy protected by IRS. Adverse birth outcomes included preterm birth, low birth weight, and fetal or neonatal death. Multivariate Poisson regression with robust standard errors was used to estimate risk ratios. Results Of 565 women in our analysis, 380 (67%), 88 (16%), and 97 (17%) women were protected by IRS for 0%, >0% to 90%, and >90% of their pregnancy, respectively. Any IRS protection significantly reduced malaria incidence during pregnancy and placental malaria risk. Compared with no IRS protection, >90% IRS protection reduced preterm birth risk (risk ratio, 0.35; 95% confidence interval, .15-.84), with nonsignificant decreases in the risk of low birth weight (0.68; .29-1.57) and fetal or neonatal death (0.24; .04-1.52). Discussion Our exploratory analyses support the hypothesis that IRS may significantly reduce malaria and preterm birth risk among pregnant women with HIV receiving bed nets, daily trimethoprim-sulfamethoxazole, and combination antiretroviral therapy.
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Affiliation(s)
- Michelle E Roh
- Departments of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco.,Global Health Group, Malaria Elimination Initiative, San Francisco
| | - Stephen Shiboski
- Departments of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Paul Natureeba
- Infectious Diseases Research Collaboration, Makerere University College of Health Sciences, Kampala, Uganda
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Makerere University College of Health Sciences, Kampala, Uganda
| | - Mary Muhindo
- Infectious Diseases Research Collaboration, Makerere University College of Health Sciences, Kampala, Uganda
| | - Teddy Ochieng
- Infectious Diseases Research Collaboration, Makerere University College of Health Sciences, Kampala, Uganda
| | - Albert Plenty
- Center for AIDS Prevention Studies, University of California, San Francisco
| | - Catherine A Koss
- Departments of Medicine, University of California, San Francisco
| | - Tamara D Clark
- Departments of Medicine, University of California, San Francisco
| | - Patricia Awori
- Infectious Diseases Research Collaboration, Makerere University College of Health Sciences, Kampala, Uganda
| | - Miriam Nakalambe
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Deborah Cohan
- Departments of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | | | - Roly Gosling
- Departments of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco.,Global Health Group, Malaria Elimination Initiative, San Francisco
| | - Diane V Havlir
- Departments of Medicine, University of California, San Francisco
| | - Moses R Kamya
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Grant Dorsey
- Departments of Medicine, University of California, San Francisco
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Placental Mitochondrial Toxicity, Oxidative Stress, Apoptosis, and Adverse Perinatal Outcomes in HIV Pregnancies Under Antiretroviral Treatment Containing Zidovudine. J Acquir Immune Defic Syndr 2017; 75:e113-e119. [PMID: 28234688 DOI: 10.1097/qai.0000000000001334] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To determine whether mitochondrial, oxidative, and apoptotic abnormalities in placenta derived from HIV and combined antiretroviral therapy (cART) containing zidovudine (AZT) could be associated with adverse perinatal outcome. DESIGN Cross-sectional, controlled, observational study. METHODS We studied obstetric results and mitochondrial, oxidative, and apoptotic state in placenta of 24 treated HIV-infected and 32 -uninfected pregnant women. We measured mitochondrial DNA (mtDNA) content by quantitative reverse transcriptase-polymerase chain reaction (mtND2/n18SrRNA), oxidative stress by the spectrophotometric quantification of lipid peroxidation and apoptosis by Western blot analysis of active caspase-3 respect to β-actin content and analysis of the terminal deoxynucleotidyl transferase dUTP nick end labeling. RESULTS Global adverse perinatal outcome (defined as preterm delivery or/and small newborns for gestational age) was significantly increased in HIV pregnancies [or 6.7 (1.3-33.2); P < 0.05]. mtDNA content in HIV-infected women was significantly depleted (39.20% ± 2.78%) with respect to controls (0.59 ± 0.03 vs. 0.97 ± 0.07; P < 0.001). A significant 29.50% ± 9.14% increase in oxidative stress was found in placentas of HIV-infected women (23.23 ± 1.64 vs. 17.94 ± 1.03; P < 0.01). A trend toward 41.18% ± 29.41% increased apoptosis active caspase-3/β-actin was found in HIV patients (0.48 ± 0.10 vs. 0.34 ± 0.05; P = not significant), confirmed by transferase dUTP nick end labeling assay. Adverse perinatal outcome did not correlate mitochondrial, oxidative, or apoptotic findings. CONCLUSIONS Placentas of HIV-infected pregnant women under AZT cART showed evidence of mtDNA depletion, increased oxidative stress levels, and apoptosis suggestive of secondary mitochondrial failure, potential base of associated adverse perinatal outcome. Despite the fact that further demonstration of causality would need new approaches and bigger sample sizes, AZT-sparing cART should be considered in the context of pregnancy.
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Zash R, Jacobson DL, Diseko M, Mayondi G, Mmalane M, Essex M, Petlo C, Lockman S, Makhema J, Shapiro RL. Comparative Safety of Antiretroviral Treatment Regimens in Pregnancy. JAMA Pediatr 2017; 171:e172222. [PMID: 28783807 PMCID: PMC5726309 DOI: 10.1001/jamapediatrics.2017.2222] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
IMPORTANCE Maternal antiretroviral treatment (ART) started before conception may increase the risk for adverse birth outcomes among women with human immunodeficiency virus (HIV) infection, but whether the risk differs by ART regimen is unknown. OBJECTIVE To compare the risk for selected birth outcomes by maternal ART regimen. DESIGN, SETTING, AND PARTICIPANTS This observational birth outcomes surveillance study compared all live births and stillbirths with a gestational age of at least 24 weeks in 8 geographically dispersed government hospitals throughout Botswana (approximately 45% of births nationwide). Data were collected from August 15, 2014, through August 15, 2016. EXPOSURES Births among HIV-infected women who started 3-drug ART regimens before their last menstrual period and did not switch or stop ART in pregnancy were considered to be ART exposed from conception. MAIN OUTCOMES AND MEASURES The primary outcomes were any adverse birth outcome, including stillbirth, preterm birth (<37 weeks), small size for gestational age (SGA; <10th percentile of weight for gestational age) or neonatal death (<28 days from delivery), and any severe adverse outcome, including very preterm birth (<32 weeks), very SGA (<3rd percentile of weight for gestational age), stillbirth, and neonatal death. RESULTS Information was available for 47 027 of 47 124 births (99.8%) at surveillance maternity hospitals (mean [SD] age of mothers, 26.86 [6.45] years). Among 11 932 HIV-exposed infants, 5780 (48.4%) were ART exposed from conception. Adverse birth outcomes were more common among HIV-exposed infants than HIV-unexposed infants (39.6% vs 28.9%; adjusted relative risk [ARR], 1.40; 95% CI, 1.36-1.44). The risk for any adverse birth outcome was lower among infants exposed from conception to tenofovir disoproxil fumarate, emtricitabine, and efavirenz (TDF-FTC-EFV) (901 of 2472 [36.4%]) compared with TDF-FTC and nevirapine (NVP) (317 of 760 [41.7%]; ARR, 1.15; 95% CI, 1.04-1.27); TDF-FTC and lopinavir-ritonavir (TDF-FTC-LPV-R) (112 of 231 [48.5%]; ARR, 1.31; 95% CI, 1.13-1.52); zidovudine, lamivudine, and NPV (ZDV-3TC-NVP) (647 of 1365 [47.4%]; ARR, 1.30; 95% CI, 1.20-1.41); or ZDV-3TC-LPV-R (75 of 167 [44.9%]; ARR, 1.21; 95% CI, 1.01-1.45). The risk for any severe adverse outcome was also lower among infants exposed from conception to TDF-FTC-EFV (303 of 2472 [12.3%]) compared with TDF-FTC-NVP (136 of 760 [17.9%]; ARR, 1.44; 95% CI, 1.19-1.74), TDF-FTC-LPV-R (45 of 231 [19.5%]; ARR, 1.58; 95% CI, 1.19-2.11), ZDV-3TC-NVP (283 of 1365 [20.7%]; ARR, 1.68; 95% CI, 1.44-1.96), or ZDV-3TC-LPV-R (39 of 167 [23.4%]; ARR, 1.93; 95% CI, 1.43-2.60) from conception. Compared with TDF-FTC-EFV, all other regimens were associated with higher risk for SGA; ZDV-3TC-NVP was associated with higher risk of stillbirth, very preterm birth, and neonatal death; and ZDV-3TC-LPV-R was associated with higher risk for preterm birth, very preterm birth, and neonatal death. CONCLUSIONS AND RELEVANCE Among infants exposed to ART from conception, TDF-FTC-EFV was associated with a lower risk for adverse birth outcomes than other ART regimens.
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Affiliation(s)
- Rebecca Zash
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Denise L. Jacobson
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Modiegi Diseko
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Gloria Mayondi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Max Essex
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Chipo Petlo
- Botswana Ministry of Health, Gaborone, Botswana
| | - Shahin Lockman
- Division of Infectious Disease, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Roger L. Shapiro
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Uthman OA, Nachega JB, Anderson J, Kanters S, Mills EJ, Renaud F, Essajee S, Doherty MC, Mofenson LM. Timing of initiation of antiretroviral therapy and adverse pregnancy outcomes: a systematic review and meta-analysis. Lancet HIV 2016; 4:e21-e30. [PMID: 27864000 DOI: 10.1016/s2352-3018(16)30195-3] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 08/28/2016] [Accepted: 08/30/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although lifelong combination antiretroviral therapy (ART) is recommended for all individuals with HIV, few data exist for pregnancy outcomes associated with ART initiation before conception. We assessed adverse pregnancy outcomes associated with ART initiated before conception compared with that of ART started after conception. METHODS We did a systematic review of studies from low-income, middle-income, and high-income countries by searching the Cochrane Central Register of Controlled Trials, Embase, LILACS, MEDLINE, Toxline, Web of Knowledge, and WHO Global Index Medicus and trials in progress (International Clinical Trials Registry Platform) for randomised trials, quasi-randomised trials, and prospective cohort studies done between Jan 1, 1980, and June 1, 2016, in which timing of ART initiation in pregnant women living with HIV was reported. We used the risk ratio (RR) and corresponding 95% CIs as the primary measure to assess the association between the selected outcomes and ART initiation before conception versus after conception. We used a random-effects model to pool risk ratios. FINDINGS We included 11 studies with 19 189 mother-infant pairs. Women who started ART before conception were significantly more likely to deliver preterm (pooled RR 1·20, 95% CI 1·01-1·44) or very preterm (1·53, 1·22-1·92), or to have low-birthweight infants (1·30, 1·04-1·62) than were those who began ART after conception. Few data exist for neonatal mortality. The risk of very low birthweight, small for gestational age, severe small for gestational age, stillbirth, and congenital anomalies did not differ significantly between women who were taking ART before conception and those who began ART after conception. INTERPRETATION The benefits of ART for maternal health and prevention of perinatal transmission outweigh risks, but data for the extent and severity of these risks are scarce and of low quality. As use of ART before conception rapidly increases globally, monitoring for potential adverse pregnancy outcomes will be crucial. FUNDING WHO.
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Affiliation(s)
- Olalekan A Uthman
- Warwick Medical School, University of Warwick, Coventry, UK; Department of Public Health (IHCAR), Karolinska Institute, Stockholm, Sweden; Centre for Evidence-based Health Care, Stellenbosch University, South Africa
| | - Jean B Nachega
- Department of Medicine and Centre for Infectious Diseases, Stellenbosch University, South Africa; Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA; Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Jean Anderson
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steve Kanters
- University of British Columbia, Vancouver, BC, Canada; Precision Global Health, Vancouver, BC, Canada
| | | | | | | | - Meg C Doherty
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; World Health Organization, Geneva, Switzerland
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Soriano-Arandes A, Noguera-Julian A, López-Lacort M, Soler-Palacín P, Mur A, Méndez M, Mayol L, Vallmanya T, Almeda J, Carnicer-Pont D, Casabona J, Fortuny C. Pregnancy as an opportunity to diagnose human-immunodeficiency virus immigrant women in Catalonia. Enferm Infecc Microbiol Clin 2016; 36:9-15. [PMID: 27609632 DOI: 10.1016/j.eimc.2016.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/13/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Mother-to-child transmission (MTCT) is relevant in the global epidemiology of human-immunodeficiency virus (HIV), as it represents the main route of infection in children. The study objectives were to determine the rate of HIV-MTCT and its epidemiological trend between the Spanish-born and immigrant population in Catalonia in the period 2000-2014. METHODS A prospective observational study of mother-child pairs exposed to HIV, treated in 12 hospitals in Catalonia in the period 2000-2014. HIV-MTCT rate was estimated using a Bayesian logistic regression model. R and WinBUGS statistical software were used. RESULTS The analysis included 909 pregnant women, 1,009 pregnancies, and 1,032 children. Data on maternal origin was obtained in 79.4% of women, of whom 32.7% were immigrants, with 53.0% of these from sub-Saharan Africa. The overall HIV-MTCT rate was 1.4% (14/1,023; 95% CI; 0.8-2.3). The risk of MTCT-HIV was 10-fold lower in women with good virological control (P=.01), which was achieved by two-thirds of them. The proportion of immigrants was significantly higher in the period 2008-2014 (P<.0001), for the HIV-diagnosis (P<.0001), and antiretroviral administration (P=.02) during pregnancy, and for undetectable viral load next to delivery (P<.001). There were no differences in the rate of MTCT-HIV among Spanish-born and immigrant women (P=.6). CONCLUSIONS There is a gradual increase in HIV pregnant immigrants in Catalonia. Although most immigrant women were diagnosed during pregnancy, the rate of MTCT-HIV was no different from the Spanish-born women.
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Affiliation(s)
- Antoni Soriano-Arandes
- Unidad de Enfermedades Infecciosas e Inmunodeficiencias Pediátricas, Servicio de Pediatría, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España.
| | - Antoni Noguera-Julian
- Unidad de Infectologia, Servei de Pediatria, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - Mónica López-Lacort
- FISABIO, Centro de Salud Pública de la Generalitat de Valencia, Valencia, España
| | - Pere Soler-Palacín
- Unidad de Enfermedades Infecciosas e Inmunodeficiencias Pediátricas, Servicio de Pediatría, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - Antonio Mur
- Hospital Universitari del Mar, Universidad Autónoma de Barcelona, Barcelona, España
| | - María Méndez
- Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | - Lluís Mayol
- Hospital Universitari Josep Trueta, Girona, España
| | | | - Jesús Almeda
- Centre d'Estudis Epidemiològics sobre les ITS i SIDA de Catalunya (CEEISCAT), Catalunya, España
| | - Dolors Carnicer-Pont
- Centre d'Estudis Epidemiològics sobre les ITS i SIDA de Catalunya (CEEISCAT), Catalunya, España
| | - Jordi Casabona
- Centre d'Estudis Epidemiològics sobre les ITS i SIDA de Catalunya (CEEISCAT), Catalunya, España
| | - Claudia Fortuny
- Unidad de Infectologia, Servei de Pediatria, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
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Mesfin YM, Kibret KT, Taye A. Is protease inhibitors based antiretroviral therapy during pregnancy associated with an increased risk of preterm birth? Systematic review and a meta-analysis. Reprod Health 2016; 13:30. [PMID: 27048501 PMCID: PMC4822312 DOI: 10.1186/s12978-016-0149-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 03/09/2016] [Indexed: 11/23/2022] Open
Abstract
Background Antiretroviral therapy is recommended during pregnancy to decrease the risk of perinatal transmission of HIV-1 infection and to improve maternal health. However, some studies have reported that antiretroviral treatment (ART) containing protease inhibitors (PI) is associated with an increased risk of preterm birth. In contrast, other studies have reported no increased risk. This meta-analysis was conducted to derive a more reliable estimate of the association between the prenatal use of PI based ART regimen and preterm birth. Methods A systemic review and meta-analysis was conducted using published studies which were identified through a computerized search using the Medline/PubMed database, Google Scholar and Health Inter Network Access to Research Initiative (HINARI). The analysis was undertaken using STATA version 11.0 software and studies were described by forest plot. Heterogeneity across studies was checked using Cochran Q test and I2 test. An adjusted odd ratio with 95 % confidence intervals [95 % CI] was pooled using a random effects model. Results The Cochrane Q test (Q test p = 0.051) showed a good homogeneity among studies. However, medium heterogeneity was observed in up to 46 % of the sample using the I2 test (I2 = 46.5 %). The Egger weighted regression method (p = 0.04) showed evidence of publication bias, but Begg rank correlation statistics (p = 0.47) did not show evidence of publication bias. The pooled analysis of 10 studies showed that protease based ART exposure during pregnancy was associated with an increased risk of preterm birth (pooled odds ratio 1.32 (95 % CI, 1.04 to 1.59). Conclusions This meta-analysis revealed that the PI based ART exposure during pregnancy is significantly associated with an increased risk of preterm birth. There should be strong cautions against initiating ART during pregnancy and PI based ARV should be replaced by others drug regime. Protease inhibitor ART drugs should not be included as part of therapy during pregnancy.
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Affiliation(s)
- Yonatan Moges Mesfin
- Department of Public Health, College of Medical and Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Kelemu Tilahun Kibret
- Department of Public Health, College of Medical and Health Science, Haramaya University, Harar, Ethiopia.
| | - Amsalu Taye
- Department of Public Health, College of Medical and Health Science, Haramaya University, Harar, Ethiopia
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Moodley T, Moodley D, Sebitloane M, Maharaj N, Sartorius B. Improved pregnancy outcomes with increasing antiretroviral coverage in South Africa. BMC Pregnancy Childbirth 2016; 16:35. [PMID: 26867536 PMCID: PMC4750240 DOI: 10.1186/s12884-016-0821-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 01/31/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Universal multi drug antiretroviral treatment in pregnancy is a global priority in our bid to eliminate paediatric HIV infections although few studies have documented the impact of antiretroviral coverage on overall pregnancy outcomes. METHODS We conducted a maternity audit at a large regional hospital in South Africa during July-December 2011 and January-June 2014 with an aim to determine an association between pregnancy outcomes and the ARV treatment guidelines implemented during those specific periods. During 2011, women received either Zidovudine/sd Nevirapine or Stavudine/Lamivudine/Nevirapine if CD4+ count was < 350 cells/ml. During 2014, all HIV positive pregnant women were eligible for a fixed dose combination (FDC) of triple ARVs (Tenofovir/Emtracitabine/Efavirenz). RESULTS In 2011, 622 (35.9%) of 1732 HIV positive pregnant women received triple antiretrovirals (D4T/3TC/NVP) and in 2014, 2104 (94.8%) of 2219 HIV positive pregnant women received the fixed dose combination (TDF/FTC/EFV). We observed a reduction in the proportion of unregistered pregnancies, caesarean delivery rate, still birth rate, very low birth weight rate, and very premature delivery rate in 2014. In a bivariate analysis of all 9,847 deliveries, unregistered pregnancies (2.2%) and HIV infection (37.8%) remained significant risk factors for SB(OR 6.36 and 1.43 respectively), PTD(OR 4.23 and 1.26 respectively),LBW (OR 4.07 and 1.26 respectively) and SGA(OR 2.17 and 1.151 respectively). In a multivariable analysis of HIV positive women only, having received AZT/NVP or D4T/3TC/NVP or EFV/TDF/FTC as opposed to not receiving any ARV was significantly associated with reduced odds of a SB (OR 0.08, 0.21 and 0.18 respectively), PTD (OR 0.52, 0.68 and 0.56 respectively) and LBW(0.37, 0.61 and 0.52 respectively). CONCLUSION An improvement in birth outcomes is likely associated with the increased coverage of triple antiretroviral treatment for pregnant women. And untreated HIV infected women and women who do not seek antenatal care should be considered most at risk for poor birth outcomes.
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Affiliation(s)
- Theron Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa.
| | - Dhayendre Moodley
- Womens Health and HIV Research Unit, Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa.
| | - Motshedisi Sebitloane
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa.
| | - Niren Maharaj
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa.
| | - Benn Sartorius
- Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Ground Floor, George Campbell Building, Durban, South Africa.
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Tookey PA, Thorne C, van Wyk J, Norton M. Maternal and foetal outcomes among 4118 women with HIV infection treated with lopinavir/ritonavir during pregnancy: analysis of population-based surveillance data from the national study of HIV in pregnancy and childhood in the United Kingdom and Ireland. BMC Infect Dis 2016; 16:65. [PMID: 26847625 PMCID: PMC4743413 DOI: 10.1186/s12879-016-1400-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 01/27/2016] [Indexed: 02/03/2023] Open
Abstract
Background The National Study of HIV in Pregnancy and Childhood (NSHPC) conducts comprehensive population-based surveillance of pregnancies in women with HIV infection in the United Kingdom/Ireland. Use of antepartum antiretroviral therapy (ART) for prevention of mother-to-child transmission (MTCT) and to treat maternal infection, if required, is standard practise in this population; lopinavir/ritonavir (LPV/r) is commonly used. The study objective was to examine the use of LPV/r among pregnant women with HIV infection to describe maternal and foetal outcomes. Methods The NSHPC study collected maternal, perinatal and paediatric data through confidential and voluntary obstetric and paediatric reporting schemes. Pregnancies reported to the NSHPC by June 2013, due to deliver 2003–2012 and with LPV/r exposure were included in this analysis, using pregnancy as the unit of observation. Results Four thousand eight hundred sixty-four LPV/r-exposed pregnancies resulting in 4702 deliveries in 4118 women were identified. Maternal region of birth was primarily sub-Saharan Africa (77 %) or United Kingdom/Ireland (14 %). Median maternal age at conception was 30 years. LPV/r was initiated preconception in 980 (20 %) and postconception in 3884 (80 %) pregnancies; median duration of antepartum LPV/r exposure was 270 and 107 days, respectively. Viral load close to delivery was <50 copies/mL in 73 % and <1000 copies/mL in 94 % of women. 63 % of deliveries were by caesarean section (elective, 62 %; emergency, 38 %). Among singleton live births, 13 % were <37 weeks of gestation (2.5 % <32 weeks) and 15 % had birth weight <2500 g (2.3 % <1500 g). MTCT rates were 1.1 (2003–2007) and 0.5 % (2008–2012). 134 live born children (2.9 %) had ≥1 congenital abnormality. Conclusions The results of this analysis using real-world data from a large number of pregnant women with HIV infection in the United Kingdom and Ireland who received LPV/r-containing ART regimens demonstrate that these regimens have a good safety profile and are effective for viral suppression during pregnancy, with associated low rates of MTCT.
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Affiliation(s)
- Pat A Tookey
- UCL Institute of Child Health, University College London, 30 Guilford St, London, WC1N 1EH, UK.
| | - Claire Thorne
- UCL Institute of Child Health, University College London, 30 Guilford St, London, WC1N 1EH, UK.
| | - Jean van Wyk
- AbbVie Inc, 1 North Waukegan Road, North Chicago, IL, 60064, USA.
| | - Michael Norton
- AbbVie Inc, 1 North Waukegan Road, North Chicago, IL, 60064, USA.
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Papp E, Balogun K, Banko N, Mohammadi H, Loutfy M, Yudin MH, Shah R, MacGillivray J, Murphy KE, Walmsley SL, Silverman M, Serghides L. Low Prolactin and High 20-α-Hydroxysteroid Dehydrogenase Levels Contribute to Lower Progesterone Levels in HIV-Infected Pregnant Women Exposed to Protease Inhibitor-Based Combination Antiretroviral Therapy. J Infect Dis 2016; 213:1532-40. [PMID: 26740274 DOI: 10.1093/infdis/jiw004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/29/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND It has been reported that pregnant women receiving protease inhibitor (PI)-based combination antiretroviral therapy (cART) have lower levels of progesterone, which put them at risk of adverse birth outcomes, such as low birth weight. We sought to understand the mechanisms involved in this decline in progesterone level. METHODS We assessed plasma levels of progesterone, prolactin, and lipids and placental expression of genes involved in progesterone metabolism in 42 human immunodeficiency virus (HIV)-infected and 31 HIV-uninfected pregnant women. In vitro studies and a mouse pregnancy model were used to delineate the effect of HIV from that of PI-based cART on progesterone metabolism. RESULTS HIV-infected pregnant women receiving PI-based cART showed a reduction in plasma progesterone levels (P= .026) and an elevation in placental expression of the progesterone inactivating enzyme 20-α-hydroxysteroid dehydrogenase (20α-HSD; median, 2.5 arbitrary units [AU]; interquartile range [IQR], 1.00-4.10 AU), compared with controls (median, 0.89 AU; IQR, 0.66-1.26 AU;P= .002). Prolactin, a key regulator of 20α-HSD, was lower (P= .012) in HIV-infected pregnant women. We observed similar data in pregnant mice exposed to PI-based cART. In vitro inhibition of 20α-HSD activity in trophoblast cells reversed PI-based cART-induced decreases in progesterone levels. CONCLUSIONS Our data suggest that the decrease in progesterone levels observed in HIV-infected pregnant women exposed to PI-based cART is caused, at least in part, by an increase in placental expression of 20α-HSD, which may be due to lower prolactin levels observed in these women.
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Affiliation(s)
- Eszter Papp
- Toronto General Research Institute, University Health Network
| | - Kayode Balogun
- Toronto General Research Institute, University Health Network
| | - Nicole Banko
- Toronto General Research Institute, University Health Network
| | | | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital Department of Medicine
| | | | | | | | | | - Sharon L Walmsley
- Toronto General Research Institute, University Health Network Department of Medicine
| | | | - Lena Serghides
- Toronto General Research Institute, University Health Network Women's College Research Institute, Women's College Hospital Department of Immunology, University of Toronto
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15
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Tudor AM, Mărdărescu M, Petre C, Neagu Drăghicenoiu R, Ungurianu R, Tilişcan C, Oţelea D, Cambrea SC, Tănase DE, Schweitzer AM, Ruţă S. Birth outcome in HIV vertically-exposed children in two Romanian centers. Germs 2015; 5:116-24. [PMID: 26716100 DOI: 10.11599/germs.2015.1079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 09/26/2015] [Accepted: 09/30/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND The Romanian HIV epidemic is characterized by a high prevalence among children born in the late '80s, perinatally infected. The impact of long-term treatment on their offspring is unknown. We evaluated the influence of prenatal care on the rate of premature birth among the HIV-exposed children of heavily treated HIV-infected mothers in two Romanian centers. METHODS We retrospectively analyzed data on all patients born by HIV-infected mothers between 2006 and 2012 followed up in two main regional centers. We compared the rate of premature birth and the differences between the sites regarding children and maternal demographic characteristics and antiretroviral exposure in pregnant women. RESULTS A total of 358 children born to 315 women were enrolled between 2006-2012, 262 children from the National Institute for Infectious Diseases "Prof. Dr. Matei Balş" Bucharest (NIID) and 96 children from the Clinical Infectious Diseases Hospital Constanţa (IDHC). Gender rate in newborns and mean age in mothers were similar. We recorded statistically significant differences between centers in the rate of HIV vertical transmission (16.8% vs. 6.2%, p=0.002) and prematurity (25.2 vs. 14.6%, p=0.023). The most used antiretroviral combination during pregnancy in IDHC was boosted lopinavir and fixed dose zidovudine-lamivudine (66% of cases), while in NIID a greater diversity of antiretrovirals were used. Women from IDHC were more frequently treated during pregnancy (83.3% vs. 68.6%, p=0.004). HCV coinfection and illegal drug use were associated with prematurity in the NIID cohort (p=0.037, p=0.024). CONCLUSION We found a higher rate of premature birth and HIV infection in NIID. In IDHC we found a higher rate of low birth weight in children and a higher rate of heavily treated women. Prematurity was associated with hepatitis C infection and illegal drug use in the NIID cohort.
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Affiliation(s)
- Ana Maria Tudor
- MD, PhD, Pediatric Department, National Institute for Infectious Diseases "Prof Dr Matei Balş", Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mariana Mărdărescu
- MD, PhD, Pediatric Department, National Institute for Infectious Diseases "Prof Dr Matei Balş", Bucharest, Romania
| | - Cristina Petre
- MD, Pediatric Department, National Institute for Infectious Diseases "Prof Dr Matei Balş", Bucharest, Romania
| | - Ruxandra Neagu Drăghicenoiu
- MD, Pediatric Department, National Institute for Infectious Diseases "Prof Dr Matei Balş", Bucharest, Romania
| | - Rodica Ungurianu
- MD, Pediatric Department, National Institute for Infectious Diseases "Prof Dr Matei Balş", Bucharest, Romania
| | - Cătălin Tilişcan
- MD, PhD, National Institute for Infectious Diseases "Prof Dr Matei Balş" Carol Davila, University of Medicine and Pharmacy, Bucharest, Romania
| | - Dan Oţelea
- MD, PhD, National Institute for Infectious Diseases "Prof Dr Matei Balş", Bucharest, Romania
| | - Simona Claudia Cambrea
- MD, PhD Pediatric Department, Infectious Diseases Hospital Constanţa, Faculty of Medicine, Ovidius University of Constanţa, Romania
| | | | - Ana Maria Schweitzer
- Psychologist, Executive Director Baylor Black Sea Foundation, Constanţa, Romania
| | - Simona Ruţă
- MD, PhD, Ştefan S. Nicolau Institute of Virology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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17
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Vreeman RC, Scanlon ML, McHenry MS, Nyandiko WM. The physical and psychological effects of HIV infection and its treatment on perinatally HIV-infected children. J Int AIDS Soc 2015; 18:20258. [PMID: 26639114 PMCID: PMC4670835 DOI: 10.7448/ias.18.7.20258] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/25/2015] [Accepted: 09/02/2015] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION As highly active antiretroviral therapy (HAART) transforms human immunodeficiency virus (HIV) into a manageable chronic disease, new challenges are emerging in treating children born with HIV, including a number of risks to their physical and psychological health due to HIV infection and its lifelong treatment. METHODS We conducted a literature review to evaluate the evidence on the physical and psychological effects of perinatal HIV (PHIV+) infection and its treatment in the era of HAART, including major chronic comorbidities. RESULTS AND DISCUSSION Perinatally infected children face concerning levels of treatment failure and drug resistance, which may hamper their long-term treatment and result in more significant comorbidities. Physical complications from PHIV+ infection and treatment potentially affect all major organ systems. Although treatment with antiretroviral (ARV) therapy has reduced incidence of severe neurocognitive diseases like HIV encephalopathy, perinatally infected children may experience less severe neurocognitive complications related to HIV disease and ARV neurotoxicity. Major metabolic complications include dyslipidaemia and insulin resistance, complications that are associated with both HIV infection and several ARV agents and may significantly affect cardiovascular disease risk with age. Bone abnormalities, particularly amongst children treated with tenofovir, are a concern for perinatally infected children who may be at higher risk for bone fractures and osteoporosis. In many studies, rates of anaemia are significantly higher for HIV-infected children. Renal failure is a significant complication and cause of death amongst perinatally infected children, while new data on sexual and reproductive health suggest that sexually transmitted infections and birth complications may be additional concerns for perinatally infected children in adolescence. Finally, perinatally infected children may face psychological challenges, including higher rates of mental health and behavioural disorders. Existing studies have significant methodological limitations, including small sample sizes, inappropriate control groups and heterogeneous definitions, to name a few. CONCLUSIONS Success in treating perinatally HIV-infected children and better understanding of the physical and psychological implications of lifelong HIV infection require that we address a new set of challenges for children. A better understanding of these challenges will guide care providers, researchers and policymakers towards more effective HIV care management for perinatally infected children and their transition to adulthood.
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Affiliation(s)
- Rachel C Vreeman
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya;
| | - Michael L Scanlon
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Megan S McHenry
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Winstone M Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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HCV-HIV coinfected pregnant women: data from a multicentre study in Italy. Infection 2015; 44:235-42. [PMID: 26507133 DOI: 10.1007/s15010-015-0852-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 10/05/2015] [Indexed: 12/18/2022]
Abstract
PURPOSE To provide information about main pregnancy outcomes in HIV-HCV coinfected women and about the possible interactions between HIV and HCV in this particular population. METHODS Data from a multicenter observational study of pregnant women with HIV, conducted in Italian University and Hospital Clinics between 2001 and 2015, were used. Eligibility criteria for analysis were HCV coinfection and at least one detectable plasma HCV-RNA viral load measured during pregnancy. Qualitative variables were compared using the Chi-square or the Fisher test and quantitative variables using the Mann-Whitney U test. The Spearman's coefficient was used to evaluate correlations between quantitative variables. RESULTS Among 105 women with positive HCV-RNA, median HCV viral load was substantially identical at the three trimesters (5.68, 5.45, and 5.86 log IU/ml, respectively), and 85.7 % of the women had at least one HCV-RNA value >5 log IU/ml. Rate of preterm delivery was 28.6 % with HCV-RNA <5 log IU/ml and 43.2 % with HCV-RNA >5log (p = 0.309). Compared to women with term delivery, women with preterm delivery had higher median HCV-RNA levels (third trimester: 6.00 vs. 5.62 log IU/ml, p = 0.037). Third trimester HIV-RNA levels were below 50 copies/ml in 47.7 % of the cases. No cases of vertical HIV transmission occurred. Rate of HCV transmission was 9.0 % and occurred only with HCV-RNA levels >5 log IU/ml. CONCLUSIONS Coinfection with HIV and HCV has relevant consequences in pregnancy: HIV coinfection is associated with high HCV-RNA levels that might favour HCV transmission, and HCV infection might further increase the risk of preterm delivery in women with HIV. HCV/HIV coinfected women should be considered a population at high risk of adverse outcomes.
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López M, Figueras F, Coll O, Goncé A, Hernández S, Loncá M, Vila J, Gratacós E, Palacio M. Inflammatory Markers Related to Microbial Translocation Among HIV-Infected Pregnant Women: A Risk Factor of Preterm Delivery. J Infect Dis 2015; 213:343-50. [PMID: 26265778 DOI: 10.1093/infdis/jiv416] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 08/03/2015] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND This study was performed to assess the role of lipopolysaccharide modulators as a marker of microbial translocation among human immunodeficiency virus (HIV)-infected women during pregnancy and to evaluate their association with preterm delivery. METHODS The study had a prospective cohort design and was performed at the Hospital Clínic in Barcelona, Spain. Thirty-six pregnant women with and 36 without HIV infection, matched on the basis of age and parity, were included. Maternal blood samples were obtained during the first trimester, during the third trimester, and at delivery. Levels of soluble CD14 (sCD14), human lipopolysaccharide-binding protein (LBP), immunoglobulin M endotoxin core antibodies to lipopolysaccharide (EndoCAb), and interleukin 6 (IL-6) were determined. Fetal cord blood levels of sCD14, LBP, and IL-6 were determined. Results were compared between groups. RESULTS First trimester sCD14 and LBP levels and third trimester sCD14 levels were significantly higher in the HIV-infected group. HIV-infected women with preterm births and spontaneous preterm births had significantly increased levels of sCD14 throughout pregnancy and significantly increased levels of LBP during the first trimester, compared with HIV-infected women with delivery at term or with HIV-negative women. On multivariate analysis, an independent association was observed between first trimester sCD14 levels and preterm delivery among HIV-infected women. CONCLUSIONS This is the first study to assess inflammatory markers related to microbial translocation during pregnancy among HIV-infected women. Higher levels of sCD14 and LBP were observed in HIV-infected pregnant women and were associated with preterm delivery.
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Affiliation(s)
- Marta López
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, Centre for Biomedical Research on Rare Diseases (CIBER-ER)
| | - Francesc Figueras
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, Centre for Biomedical Research on Rare Diseases (CIBER-ER)
| | - Oriol Coll
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, Centre for Biomedical Research on Rare Diseases (CIBER-ER)
| | - Anna Goncé
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, Centre for Biomedical Research on Rare Diseases (CIBER-ER)
| | - Sandra Hernández
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, Centre for Biomedical Research on Rare Diseases (CIBER-ER)
| | - Montse Loncá
- Infectious Diseases Department, Hospital Clinic, IDIBAPS
| | - Jordi Vila
- Department of Microbiology, Hospital Clinic, CRESIB, University of Barcelona, Spain
| | - Eduard Gratacós
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, Centre for Biomedical Research on Rare Diseases (CIBER-ER)
| | - Montse Palacio
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, Centre for Biomedical Research on Rare Diseases (CIBER-ER)
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Li N, Sando MM, Spiegelman D, Hertzmark E, Liu E, Sando D, Machumi L, Chalamilla G, Fawzi W. Antiretroviral Therapy in Relation to Birth Outcomes among HIV-infected Women: A Cohort Study. J Infect Dis 2015; 213:1057-64. [PMID: 26265780 DOI: 10.1093/infdis/jiv389] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 06/15/2015] [Indexed: 11/14/2022] Open
Abstract
Although the beneficial effects of antiretroviral (ARV) therapy for preventing mother-to-child transmission are indisputable, studies in developed and developing countries have reported conflicting findings on the association between ARV exposure and adverse birth outcomes. We conducted a prospective observational study at 10 human immunodeficiency virus (HIV) care and treatment centers in Dar es Salaam, Tanzania. Multivariate log-binomial regression was used to investigate the associations between ARV use and adverse birth outcomes among HIV-negative HIV-exposed infants. Our findings demonstrate an increased risk of adverse birth outcomes associated with the use of highly active antiretroviral therapy during pregnancy. Further studies are needed to investigate the underlying mechanisms and identify the safest ARV regimens for use during pregnancy.
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Affiliation(s)
- Nan Li
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health (HSPH), Boston, Massachusetts
| | | | - Donna Spiegelman
- Departments of Epidemiology, HSPH, Boston, Massachusetts Biostatistics, HSPH, Boston, Massachusetts
| | | | - Enju Liu
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health (HSPH), Boston, Massachusetts
| | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Lameck Machumi
- Management and Development for Health, Dar es Salaam, Tanzania
| | | | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health (HSPH), Boston, Massachusetts Departments of Epidemiology, HSPH, Boston, Massachusetts Nutrition, HSPH, Boston, Massachusetts
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Kakkar F, Boucoiran I, Lamarre V, Ducruet T, Amre D, Soudeyns H, Lapointe N, Boucher M. Risk factors for pre-term birth in a Canadian cohort of HIV-positive women: role of ritonavir boosting? J Int AIDS Soc 2015; 18:19933. [PMID: 26051165 PMCID: PMC4458515 DOI: 10.7448/ias.18.1.19933] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 04/12/2015] [Accepted: 05/06/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The risk of pre-term birth (PTB) associated with the use of protease inhibitors (PIs) during pregnancy remains a subject of debate. Recent data suggest that ritonavir boosting of PIs may play a specific role in the initiation of PTB, through an effect on the maternal-fetal adrenal axis. The primary objective of this study is to compare the risk of PTB among women treated with boosted PI versus non-boosted PIs during pregnancy. METHODS Between 1988 and 2011, 705 HIV-positive women were enrolled into the Centre Maternel et Infantile sur le SIDA mother-infant cohort at Centre Hospitalier Universitaire Sainte-Justine in Montreal, Canada. Inclusion criteria for the study were: 1) attendance at a minimum of two antenatal obstetric visits and 2) singleton live birth, at 24 weeks gestational or older. The association between PTB (defined as delivery at <37 weeks gestational age), antiretroviral drug exposure and maternal risk factors was assessed retrospectively using logistic regression. RESULTS A total of 525 mother-infant pairs were included in the analysis. Among them, PI-based combination anti-retroviral therapy was used in 37.4%, boosted PI based in 24.4%, non-nucleoside reverse transcriptase inhibitor (NNRTI) or nucleoside reverse transcriptase inhibitor based in 28.1%, and no treatment was given in 10.0% of cases. Overall, 13.5% of women experienced PTB. Among women treated with antiretroviral therapy, the risk of PTB was significantly higher among women who received boosted versus non-boosted PI (OR 2.01, 95% CI 1.02-3.97). This remained significant after adjusting for maternal age, delivery CD4 count, hepatitis C co-infection, history of previous PTB, and parity (aOR 2.17, 95% CI 1.05-4.51). There was no increased risk of PTB with the use of unboosted PIs as compared to NNRTI- or NRTI-based regimens. CONCLUSION While previous studies on the association between PTB and PI use have generally considered all PIs the same, our results would indicate a possible role of ritonavir boosting as a risk factor for PTB. Further work is needed to understand the pathophysiologic mechanisms involved, and to identify the safest ARV regimens to be used in pregnancy.
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Affiliation(s)
- Fatima Kakkar
- Division of Infectious Diseases, CHU Sainte-Justine, Montréal, Canada
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
- Centre maternel et infantile sur le SIDA, CHU Sainte-Justine, Montreal, Canada;
| | - Isabelle Boucoiran
- Centre maternel et infantile sur le SIDA, CHU Sainte-Justine, Montreal, Canada
- Department of Obstetrics and Gynecology, Université de Montréal, CHU Sainte-Justine, Montreal, Canada
| | - Valerie Lamarre
- Division of Infectious Diseases, CHU Sainte-Justine, Montréal, Canada
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
- Centre maternel et infantile sur le SIDA, CHU Sainte-Justine, Montreal, Canada
| | - Thierry Ducruet
- Unité de recherche clinique appliquée, CHU Sainte-Justine, Montréal, Canada
| | - Devendra Amre
- Centre de recherche du CHU Sainte-Justine, Montréal, Canada
| | - Hugo Soudeyns
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
- Centre de recherche du CHU Sainte-Justine, Montréal, Canada
- Department of Microbiology, Infectious Diseases and Immunology, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Normand Lapointe
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
- Centre maternel et infantile sur le SIDA, CHU Sainte-Justine, Montreal, Canada
| | - Marc Boucher
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
- Centre maternel et infantile sur le SIDA, CHU Sainte-Justine, Montreal, Canada
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Sibiude J, Warszawski J, Blanche S. Tolerance of the newborn to antiretroviral drug exposure in utero. Expert Opin Drug Saf 2015; 14:643-54. [PMID: 25727366 DOI: 10.1517/14740338.2015.1019462] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The prevention of mother-to-child HIV-1 transmission by antiretroviral drug treatment is remarkably effective. The risk of transmission to the child is now almost zero for women optimally treated during pregnancy. The rapid expansion of this prophylactic treatment has led the World Health Organization to aspire to the virtual elimination of mother-to-child transmission and pediatric AIDS over the next few years. In 2014, more than 900,000 women worldwide were treated with antiretroviral drugs during pregnancy. The issue of fetal and neonatal antiretroviral drug tolerance is therefore extremely important. AREAS COVERED This review focuses on the possible impact of in utero exposure to antiretroviral drug on newborn health. To restrict analysis to this period is justified by the specificities of transplacental drug exposure and fetal vulnerability. Relevant data are available from trials and observational cohorts. The significance of various bio-markers detectable at birth is still unresolved, but merits a careful evaluation. Long-term assessment is associated with various logistical difficulties. EXPERT OPINION The health of 'exposed but not infected' children poses no major problem in the immense majority of cases, but a series of biological, clinical and imaging-based warning signs have emerged indicating the need for careful attention to be paid to this issue. Some effects that are straightforward to manage in industrialized countries may have more severe consequences in countries in which access to effective healthcare is limited. Nucleoside/nucleotide analogs are potentially genotoxic to mitochondrial and nuclear DNA, and the principal question to be addressed concerns their potential long-term effects.
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Affiliation(s)
- Jeanne Sibiude
- Hôpital Louis Mourier, Service de Gynécologie et d'Obstétrique, Assistance Publique -Hôpitaux de Paris (APHP) , Colombes , France
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Risk factors for preterm birth among HIV-infected pregnant Ugandan women randomized to lopinavir/ritonavir- or efavirenz-based antiretroviral therapy. J Acquir Immune Defic Syndr 2015; 67:128-35. [PMID: 25072616 DOI: 10.1097/qai.0000000000000281] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Protease inhibitor-based antiretroviral therapy (ART) has been associated with preterm birth in some studies. We examined risk factors for preterm birth among women randomized to lopinavir/ritonavir (LPV/r)- or efavirenz (EFV)-based ART. METHODS This was a planned secondary analysis of the PROMOTE-Pregnant Women and Infants Study, an open-label, randomized controlled trial comparing the risk of placental malaria among HIV-infected, ART-naive pregnant Ugandan women assigned to initiate LPV/r- or EFV-based ART at 12-28 weeks gestation. Gestational age was determined based on last menstrual period and ultrasound biometry. All women received bednets and trimethoprim-sulfamethoxazole. Stillbirths, spontaneous abortions, and multiple gestations were excluded from the primary analysis. Potential risk factors for preterm birth (<37 weeks gestation) were evaluated by univariate and multivariate logistic regression. RESULTS Three hundred fifty-six women were included in this analysis. At enrollment, median gestational age was 21 weeks and median CD4 cell count was 368 cells per cubic millimeter. 14.7% of deliveries in the EFV arm and 16.2% in the LPV/r arm were preterm. Preterm birth was associated with gestational weight gain below 0.1 kg/week versus 0.1 kg/week or more [odds ratio (OR) = 2.49; 95% confidence interval (CI): 1.38 to 4.47; P = 0.003]. Neither ART regimen of LPV/r versus EFV (OR = 1.12; 95% CI: 0.63 to 2.00; P = 0.69) nor placental malaria (OR = 0.74; 95% CI: 0.38 to 1.44; P = 0.37) was associated with preterm birth. CONCLUSIONS LPV/r was not associated with an increased risk of preterm birth compared with EFV. However, interventions are needed to address modifiable risk factors for preterm birth, such as nutritional status (ClinicalTrials.gov, NCT00993031).
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Liuzzi G, Pinnetti C, Floridia M, Tamburrini E, Masuelli G, Dalzero S, Sansone M, Giacomet V, Degli Antoni AM, Guaraldi G, Meloni A, Maccabruni A, Alberico S, Portelli V, Ravizza M. Pregnancy Outcomes in HIV-Infected Women of Advanced Maternal Age. HIV CLINICAL TRIALS 2014; 14:110-9. [DOI: 10.1310/hct1403-110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Santini-Oliveira M, Grinsztejn B. Adverse drug reactions associated with antiretroviral therapy during pregnancy. Expert Opin Drug Saf 2014; 13:1623-52. [PMID: 25390463 DOI: 10.1517/14740338.2014.975204] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Antiretroviral (ARV) drug use during pregnancy significantly reduces mother-to-child HIV transmission, delays disease progression in the women and reduces the risk of HIV transmission to HIV-serodiscordant partners. Pregnant women are susceptible to the same adverse reactions to ARVs as nonpregnant adults as well as to specific pregnancy-related reactions. In addition, we should consider adverse pregnancy outcomes and adverse reactions in children exposed to ARVs during intrauterine life. However, studies designed to assess the safety of ARV in pregnant women are rare, usually with few participants and short follow-up periods. AREAS COVERED In this review, we discuss studies reporting adverse reactions to ARV drugs, including maternal toxicity, adverse pregnancy outcomes and the consequences of exposure to ARV in infants. We included results of observational studies, both prospective and retrospective, as well as randomized clinical trials, systematic reviews and meta-analyses. EXPERT OPINION The benefits of ARV use during pregnancy outweigh the risks of adverse reactions identified to date. More studies are needed to assess the adverse effects in the medium- and long term in children exposed to ARVs during pregnancy, as well as pregnant women using lifelong antiretroviral therapy and more recently available drugs.
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Affiliation(s)
- Marilia Santini-Oliveira
- Evandro Chagas National Institute of Infectious Diseases, Clinical Research in STD & AIDS Laboratory, Oswaldo Cruz Foundation , Rio de Janeiro , Brazil
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Floridia M, Pinnetti C, Ravizza M, Frisina V, Cetin I, Fiscon M, Sansone M, Antoni AD, Guaraldi G, Vimercati A, Guerra B, Placido G, Dalzero S, Tamburrini E. Rate, predictors, and consequences of late antenatal booking in a national cohort study of pregnant women with HIV in Italy. HIV CLINICAL TRIALS 2014; 15:104-15. [PMID: 24947534 DOI: 10.1310/hct1503-104] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the prevalence and consequences of late antenatal booking (13 or more weeks gestation) in a national observational study of pregnant women with HIV. METHODS The clinical and demographic characteristics associated with late booking were evaluated in univariate analyses using the Mann-Whitney U test for quantitative data and the chi-square test for categorical data. The associations that were found were re-evaluated in multivariable logistic regression models. Main outcomes were preterm delivery, low birthweight, nonelective cesarean section, birth defects, undetectable (<50 copies/mL) HIV plasma viral load at third trimester, delivery complications, and gender-adjusted and gestational age-adjusted Z scores for birthweight. RESULTS Rate of late booking among 1,643 pregnancies was 32.9%. This condition was associated with younger age, African provenance, diagnosis of HIV during pregnancy, and less antiretroviral exposure. Undetectable HIV RNA at third trimester and preterm delivery were significantly more prevalent with earlier booking (67.1% vs 46.3%, P < .001, and 23.2% vs 17.6, P = .010, respectively), whereas complications of delivery were more common with late booking (8.2% vs 5.0%, P = .013). Multivariable analyses confirmed an independent role of late booking in predicting detectable HIV RNA at third trimester (adjusted odds ratio [AOR], 1.7; 95% CI, 1.3-2.3; P < .001) and delivery complications (AOR, 1.8; 95% CI, 1.2-2.8; P = .005). CONCLUSIONS Late antenatal booking was associated with detectable HIV RNA in late pregnancy and with complications of delivery. Measures should be taken to ensure an earlier entry into antenatal care, particularly for African women, and to facilitate access to counselling and antenatal services. These measures can significantly improve pregnancy management and reduce morbidity and complications in pregnant women with HIV.
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Affiliation(s)
- M Floridia
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - C Pinnetti
- I.N.M.I. Lazzaro Spallanzani, Rome, Italy
| | - M Ravizza
- Department of Obstetrics and Gynaecology, DMSD San Paolo Hospital Medical School, University of Milan, Milan, Italy
| | - V Frisina
- Department of Obstetrics and Neonatology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - I Cetin
- Department of Obstetrics and Gynaecology, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - M Fiscon
- Department of Pediatrics, University of Padova, Padova, Italy
| | - M Sansone
- Department of Obstetrics and Gynaecology, University Federico II of Naples, Naples, Italy
| | - A Degli Antoni
- Department of Infectious Diseases and Hepatology, Azienda Ospedaliera di Parma, Parma, Italy
| | - G Guaraldi
- Department of Medical Specialties, Infectious Diseases Clinic, University of Modena and Reggio Emilia, Modena, Italy
| | - A Vimercati
- Department of Obstetrics and Gynaecology, University of Bari and Policlinic Hospital, Bari, Italy
| | - B Guerra
- University of Bologna and St. Orsola Malpighi General Hospital, Bologna, Italy
| | - G Placido
- Unit of Infectious Diseases, Pescara General Hospital, Pescara, Italy
| | - S Dalzero
- Department of Obstetrics and Gynaecology, DMSD San Paolo Hospital Medical School, University of Milan, Milan, Italy
| | - E Tamburrini
- Department of Infectious Diseases, Catholic University, Rome, Italy
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Barral MFM, de Oliveira GR, Lobato RC, Mendoza-Sassi RA, Martínez AMB, Gonçalves CV. Risk factors of HIV-1 vertical transmission (VT) and the influence of antiretroviral therapy (ART) in pregnancy outcome. Rev Inst Med Trop Sao Paulo 2014; 56:133-8. [PMID: 24626415 PMCID: PMC4085844 DOI: 10.1590/s0036-46652014000200008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 09/02/2013] [Indexed: 11/22/2022] Open
Abstract
In the absence of intervention, the rate of vertical transmission of HIV
can range from 15-45%. With the inclusion of antiretroviral drugs during pregnancy
and the choice of delivery route this amounts to less than 2%. However ARV use during
pregnancy has generated several questions regarding the adverse effects of the
gestational and neonatal outcome. This study aims to analyze the risk factors for
vertical transmission of HIV-1 seropositive pregnant women living in Rio Grande and
the influence of the use of ARVs in pregnancy outcome. Among the 262 pregnant women
studied the rate of vertical transmission of HIV was found to be 3.8%. Regarding the
VT, there was a lower risk of transmission when antiretroviral drugs were used and
prenatal care was conducted at the referral service. However, the use of ART did not
influence the outcome of pregnancy. However, initiation of prenatal care after the
first trimester had an influence on low birth weight, as well as performance of less
than six visits increased the risk of prematurity. Therefore, the risk factors
analyzed in this study appear to be related to the realization of inadequate
pre-natal and maternal behavior.
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Short CES, Taylor GP. Antiretroviral therapy and preterm birth in HIV-infected women. Expert Rev Anti Infect Ther 2014; 12:293-306. [PMID: 24502750 DOI: 10.1586/14787210.2014.885837] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The use of combination antiretroviral therapy for the prevention of mother to child transmission of HIV infection has achieved vertical HIV transmission rates of <1%. The use of these drugs is not without risk to the mother and infant. Pregnant women with HIV-infection are at high risk of preterm birth (PTB <37 weeks), with 2-4-fold the risk of uninfected women. There is accumulating evidence that certain combinations are associated with higher rates of PTB that others or no antiretroviral treatment. Understanding the pathogenesis of PTB in this group of women will be essential to target preventative strategies in the face of increasing HIV prevalence and rapidly expanding mother-to-child-transmission prevention programmes.
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Affiliation(s)
- Charlotte-Eve S Short
- Section of Infectious Diseases, Imperial College London, Wright Fleming Institute, St Mary's Hospital Campus, Norfolk Place, London, W2 1PG, UK
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Short CES, Douglas M, Smith JH, Taylor GP. Preterm delivery risk in women initiating antiretroviral therapy to prevent HIV mother-to-child transmission. HIV Med 2013; 15:233-8. [DOI: 10.1111/hiv.12083] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2013] [Indexed: 11/29/2022]
Affiliation(s)
- C-ES Short
- Section of Infectious Diseases; Imperial College; London UK
- St Mary's Hospital; Imperial College Healthcare NHS Trust; London UK
| | - M Douglas
- St Mary's Hospital; Imperial College Healthcare NHS Trust; London UK
| | - JH Smith
- St Mary's Hospital; Imperial College Healthcare NHS Trust; London UK
| | - GP Taylor
- Section of Infectious Diseases; Imperial College; London UK
- St Mary's Hospital; Imperial College Healthcare NHS Trust; London UK
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Watts DH, Mofenson LM. Antiretrovirals in pregnancy: a note of caution. J Infect Dis 2012; 206:1639-41. [PMID: 23066163 PMCID: PMC3499111 DOI: 10.1093/infdis/jis581] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Indexed: 11/14/2022] Open
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Watts DH, Williams PL, Kacanek D, Griner R, Rich K, Hazra R, Mofenson LM, Mendez HA. Combination antiretroviral use and preterm birth. J Infect Dis 2012. [PMID: 23204173 DOI: 10.1093/infdis/jis728] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Use of antiretroviral drugs (ARVs) during pregnancy has been associated with higher risk of preterm birth. METHODS The Pediatric HIV/AIDS Cohort Study network's Surveillance Monitoring for ART Toxicities study is a US-based cohort of human immunodeficiency virus (HIV)-exposed uninfected children. We evaluated maternal ARV use during pregnancy and the risk of any type of preterm birth (ie, birth before 37 completed weeks of gestation), the risk of spontaneous preterm birth (ie, preterm birth that occurred after preterm labor or membrane rupture, without other complications), and the risk of small for gestational age (SGA; ie, a birth weight of <10th percentile for gestational age). Multivariable logistic regression models were used to evaluate the association of ARVs and timing of exposure, while adjusting for maternal characteristics. RESULTS Among 1869 singleton births, 18.6% were preterm, 10.2% were spontaneous preterm, and 7.3% were SGA. A total of 89% used 3-drug combination ARV regimens during pregnancy. In adjusted models, the odds of preterm birth and spontaneous preterm birth were significantly greater among mothers who used protease inhibitors during the first trimester (adjusted odds ratios, 1.55 and 1.59, respectively) but not among mothers who used nonnucleoside reverse-transcriptase inhibitor or triple-nucleoside regimens during the first trimester. Combination ARV exposure starting later in pregnancy was not associated with increased risk. No associations were observed between SGA and exposure to combination ARV regimens. CONCLUSIONS Protease inhibitor use early in pregnancy may be associated with increased risk for prematurity.
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Affiliation(s)
- D Heather Watts
- Pediatric, Adolescent, and Maternal AIDS Branch, Eunice Kennedy Shriver National Institute for Child Health and Human Development, Bethesda, Maryland, USA.
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Read JS, Huo Y, Patel K, Mitchell M, Scott GB. Laboratory Abnormalities Among HIV-Exposed, Uninfected Infants: IMPAACT Protocol P1025. J Pediatric Infect Dis Soc 2012; 1:92-102. [PMID: 23687574 PMCID: PMC3656554 DOI: 10.1093/jpids/pis036] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 01/30/2012] [Indexed: 11/13/2022]
Abstract
BACKGROUND Infant laboratory abnormalities have been associated with exposure to antiretrovirals and to trimethoprim/sulfamethoxazole (TMP/SMX). METHODS We analyzed data from International Maternal Pediatric Adolescent AIDS Clinical Trials Group (IMPAACT) Protocol P1025, a prospective cohort study of human immunodeficiency virus type 1 (HIV)-infected women and their infants. Live-born, singleton, HIV-uninfected infants with at least 6 months of follow-up who represented the first pregnancy on study of HIV-infected mothers with at least 1 prenatal visit, CD4 count, and viral load during pregnancy and who used at least 1 antiretroviral during pregnancy were eligible for inclusion in this analysis. RESULTS The study population comprised 1524 infants. During the first 6 months of life, 7.4% of laboratory serious adverse events (SAEs) were related to glucose, 7.2% were related to hemoglobin, 8.7% were related to absolute neutrophil count, and 4.0% were related to total lymphocyte count. The likelihood of laboratory SAEs decreased with increasing age for hemoglobin, absolute neutrophil count, and glucose. Infant preterm birth and current receipt of antiretroviral(s) were the factors with the strongest associations with laboratory SAEs. CONCLUSIONS The overall frequency of laboratory SAEs was low and decreased with age. Preterm infants are at higher risk of hemoglobin- and total lymphocyte count-related SAEs.
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Affiliation(s)
- Jennifer S Read
- Pediatric, Adolescent, and Maternal AIDS Branch, Center for Research for Mothers and Children, National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Yanling Huo
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts
| | - Kunjal Patel
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Marcia Mitchell
- Department of Pediatrics, Jackson Memorial Hospital, Miami, Florida
| | - Gwendolyn B Scott
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
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Thorne C, Townsend CL. A New Piece in the Puzzle of Antiretroviral Therapy in Pregnancy and Preterm Delivery Risk. Clin Infect Dis 2012; 54:1361-3. [DOI: 10.1093/cid/cis202] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Claire Thorne
- MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, University College London, United Kingdom
| | - Claire L. Townsend
- MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, University College London, United Kingdom
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Meloni A, Floridia M, Alberico S, Tamburrini E, Pinnetti C, Bucceri A, Masuelli G, Viganò A, Liuzzi G, Antoni AD, Guaraldi G, Spinillo A, Marocco R, Dalzero S, Ravizza M. Glucose plasma levels and pregnancy outcomes in women with HIV. HIV CLINICAL TRIALS 2011; 12:299-312. [PMID: 22189149 DOI: 10.1310/hct1206-299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is limited information on the relation between glucose levels in pregnancy and adverse perinatal outcomes in HIV-infected pregnant women. OBJECTIVE To evaluate the potential impact of fasting glucose levels on pregnancy outcomes in a large sample of pregnant women with HIV from a national study, adjusting for potential confounders. METHODS Data from the Italian National Program on Surveillance on Antiretroviral Treatment in Pregnancy were used. The main outcomes evaluated in univariate and multivariable analyses were birthweight for gestational age>90th percentile (large for gestational age [LGA]), nonelective cesarean delivery, and preterm delivery. Glucose measurements were considered both as continuous and as categorical variables, following the HAPO study definition. RESULTS Overall, 1,032 cases were eligible for the analysis. In multivariable analyses, a birthweight>90th percentile was associated with increasing fasting plasma glucose levels (adjusted odds ratio [AOR] per unitary (mg/dL) increase, 1.04; 95% CI, 1.01-1.06; P=.005), a higher body mass index, and parity of 1 or higher. A lower risk of LGA was associated with smoking and African ethnicity. A higher fasting plasma glucose category was significantly associated with LGA occurrence, and AORs for the glucose categories of 90-94 mg/ dL and 95-99 mg/dL were 3.34 (95% CI, 1.09-10.22) and 6.26 (95% CI, 1.82-21.58), respectively. Fasting plasma glucose showed no association with nonelective cesarean section [OR per unitary increase, 1.00; 95% CI, 0.98-1.02] or preterm delivery [OR per unitary increase, 1.00; 95% CI, 0.99-1.02]. CONCLUSIONS In pregnant women with HIV, glucose values below the threshold usually defining hyperglycemia are associated with an increased risk of delivering LGA infants. Other conditions may independently contribute to adverse perinatal outcomes in women with HIV and should be considered to identify pregnancies at risk.
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Affiliation(s)
- Alessandra Meloni
- Department of Obstetrics and Gynaecology, S. Giovanni di Dio Hospital, Cagliari, Italy
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Sturt AS, Read JS. Antiretroviral use during pregnancy for treatment or prophylaxis. Expert Opin Pharmacother 2011; 12:1875-85. [PMID: 21534886 DOI: 10.1517/14656566.2011.584062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Antiretrovirals are recommended for all pregnant women either for treatment of HIV-1 infection or for prevention of mother-to-child transmission. Distinguishing between HIV-1-infected pregnant women who meet treatment criteria and those who do not (who use antiretrovirals during pregnancy for prophylaxis) is accomplished by assessing the HIV-1 disease stage and has important implications regarding when antiretroviral drugs are initiated during pregnancy, what drugs are used and antiretroviral use after delivery. AREAS COVERED This review addresses antiretroviral use by HIV-1-infected women during pregnancy. Specifically, the review focuses on antiretroviral therapy for HIV-1-infected pregnant women who meet criteria for treatment and antiretroviral prophylaxis for HIV-1-infected pregnant women (to prevent mother-to-child transmission of HIV-1). The review primarily addresses antiretroviral use in resource-rich settings, but use in resource-poor settings is briefly addressed. EXPERT OPINION Antiretrovirals represent only one component of the overall management of HIV-1 infected pregnant women and, therefore, cannot be viewed in isolation from other components of optimal care for HIV-1-infected women and from other efficacious interventions to prevent mother-to-child transmission of HIV-1. Antiretrovirals can be used safely and effectively during pregnancy. We concur with current guidelines regarding the threshold that differentiates which women need antiretroviral therapy for HIV-1 infection for their own health versus those who need prophylaxis to prevent transmission of HIV-1 infection to their child. We thus recommend that lifelong antiretroviral therapy be initiated in patients with an AIDS-defining illness, a CD4 count < 350 cells/mm(3) or other co-morbid conditions such as acute opportunistic infections, HIV-1-associated nephropathy or hepatitis B co-infection. Irrespective of whether or not antiretrovirals are used during pregnancy, or whether antiretrovirals during pregnancy are used for treatment or prophylaxis, all infants of HIV-1-infected women should receive antiretroviral post-exposure prophylaxis.
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Affiliation(s)
- Amy S Sturt
- Medicine/Infectious Diseases, Santa Clara Valley Medical Center, Ira Greene PACE Clinic, 751 S. Bascom Avenue, San Jose, CA 95128 , USA
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Broom J, Sowden D. Premature labour precipitated by highly active antiretroviral therapy: an adverse reaction in a newly diagnosed HIV-positive patient. Sex Health 2011; 8:436-8. [DOI: 10.1071/sh10071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 01/16/2011] [Indexed: 11/23/2022]
Abstract
A pregnant woman was diagnosed with HIV infection at 29 weeks’ gestation. Antiretroviral therapy (ART) of lopinavir–ritonavir and zidovudine–lamivudine was initiated. Ten days later, a hypersensitivity reaction occurred, followed by preterm delivery of the infant 3 days later at 30 weeks’ gestation. Hypersensitivity reactions to ART should prompt urgent consideration of a change in ART to avoid the potential for adverse pregnancy outcomes.
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Read JS. Prevention of mother-to-child transmission of HIV: antiretroviral strategies. Clin Perinatol 2010; 37:765-76, viii. [PMID: 21078449 DOI: 10.1016/j.clp.2010.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The World Health Organization's Strategic Approaches to the Prevention of HIV Infection in Infants includes 4 components: primary prevention of HIV-1 infection; prevention of unintended pregnancies among HIV-1-infected women; prevention of transmission of HIV-1 infection from mothers to children; and provision of ongoing support, care, and treatment to HIV-1-infected women and their families. This review focuses on antiretrovirals for secondary prevention of HIV-1 infection-prevention of HIV-1 transmission from an HIV-1-infected woman to her child. Antiretroviral strategies to prevent the mother-to-child transmission of HIV-1 in nonbreastfeeding populations comprise antiretroviral treatment of HIV-1-infected pregnant women needing antiretrovirals for their own health, antiretroviral prophylaxis for HIV-1-infected pregnant women not yet meeting criteria for treatment, and antiretroviral prophylaxis for infants of HIV-1-infected mothers. The review primarily addresses antiretroviral strategies for nonbreastfeeding, HIV-1-infected women and their infants in resource-rich settings, such as the United States. Antiretroviral strategies to prevent antepartum, intrapartum, and early postnatal transmission in resource-poor settings are also addressed, albeit more briefly.
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Affiliation(s)
- Jennifer S Read
- Pediatric, Adolescent, and Maternal AIDS Branch, Center for Research for Mothers and Children, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Boulevard, Bethesda, MD 20892-7510, USA.
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Rudin C, Spaenhauer A, Keiser O, Rickenbach M, Kind C, Aebi-Popp K, Brinkhof MWG. Antiretroviral therapy during pregnancy and premature birth: analysis of Swiss data. HIV Med 2010; 12:228-35. [PMID: 20726902 DOI: 10.1111/j.1468-1293.2010.00876.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is an ongoing debate as to whether combined antiretroviral treatment (cART) during pregnancy is an independent risk factor for prematurity in HIV-1-infected women. OBJECTIVE The aim of the study was to examine (1) crude effects of different ART regimens on prematurity, (2) the association between duration of cART and duration of pregnancy, and (3) the role of possibly confounding risk factors for prematurity. METHOD We analysed data from 1180 pregnancies prospectively collected by the Swiss Mother and Child HIV Cohort Study (MoCHiV) and the Swiss HIV Cohort Study (SHCS). RESULTS Odds ratios for prematurity in women receiving mono/dual therapy and cART were 1.8 [95% confidence interval (CI) 0.85-3.6] and 2.5 (95% CI 1.4-4.3) compared with women not receiving ART during pregnancy (P=0.004). In a subgroup of 365 pregnancies with comprehensive information on maternal clinical, demographic and lifestyle characteristics, there was no indication that maternal viral load, age, ethnicity or history of injecting drug use affected prematurity rates associated with the use of cART. Duration of cART before delivery was also not associated with duration of pregnancy. CONCLUSION Our study indicates that confounding by maternal risk factors or duration of cART exposure is not a likely explanation for the effects of ART on prematurity in HIV-1-infected women.
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Affiliation(s)
- C Rudin
- Division of Infectious Diseases, University Children's Hospital, Basel, Switzerland.
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Patel K, Shapiro DE, Brogly SB, Livingston EG, Stek AM, Bardeguez AD, Tuomala RE. Prenatal protease inhibitor use and risk of preterm birth among HIV-infected women initiating antiretroviral drugs during pregnancy. J Infect Dis 2010; 201:1035-44. [PMID: 20196654 PMCID: PMC2946359 DOI: 10.1086/651232] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Conflicting results have been reported among studies of protease inhibitor (PI) use during pregnancy and preterm birth. Uncontrolled confounding by indication may explain some of the differences among studies. METHODS In total, 777 human immunodeficiency virus (HIV)-infected pregnant women in a prospective cohort who were not receiving antiretroviral (ARV) treatment at conception were studied. Births <37 weeks gestation were reviewed, and deliveries due to spontaneous labor and/or rupture of membranes were identified. Risk of preterm birth and low birth weight (<2500 g) were evaluated by using multivariable logistic regression. RESULTS Of the study population, 558 (72%) received combination ARV with PI during pregnancy, and a total of 130 preterm births were observed. In adjusted analyses, combination ARV with PI was not significantly associated with spontaneous preterm birth, compared to ARV without PI (odds ratio [OR], 1.22; 95% confidence interval [CI], 0.70-2.12). Sensitivity analyses that included women who received ARV prior to pregnancy also did not identify a significant association (OR, 1.34; 95% CI, 0.84-2.16). Low birth weight results were similar. CONCLUSIONS No evidence of an association between use of combination ARV with PI during pregnancy and preterm birth was found. Our study supports current guidelines that promote consideration of combination ARV for all HIV-infected pregnant women.
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Affiliation(s)
- Kunjal Patel
- Department of Epidemiology, Harvard School of Public Health, Boston Massachusetts 02115, USA.
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Martin F, Taylor GP. The safety of highly active antiretroviral therapy for the HIV-positive pregnant mother and her baby: is 'the more the merrier'? J Antimicrob Chemother 2009; 64:895-900. [DOI: 10.1093/jac/dkp303] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Floridia M, Ravizza M, Bucceri A, Lazier L, Viganò A, Alberico S, Guaraldi G, Anzidei G, Guerra B, Citernesi A, Sansone M, Baroncelli S, Tamburrini E. Factors influencing gestational age-adjusted birthweight in a national series of 600 newborns from mothers with HIV. HIV CLINICAL TRIALS 2009; 9:287-97. [PMID: 18977717 DOI: 10.1310/hct0905-287] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Few studies have assessed the determinants of birthweight in newborns from HIV-positive mothers in analyses that adjusted for different gestational age at delivery. METHOD We calculated gestational age-adjusted birthweight Z-score values in a national series of 600 newborns from women with HIV and in 600 newborns from HIV-negative women matched for gender and gestational age. The determinants of Z-score values in newborns from HIV-positive mothers were assessed in univariate and multivariate regression analyses. RESULTS Compared to newborns from HIV-negative women, newborns from HIV-positive women had significantly lower absolute birthweight (2799 vs. 2887 g; p = .007) and birthweight Z score (-0.430 vs. -0.222; p < .001). Among newborns from mothers with HIV, the maternal characteristics associated with significantly lower Z-score values in univariate analyses were recent substance use (Z-score difference [ZSD] 0.612, 95% CI 0.359-0.864, p < .001), smoking >10 cigarettes/day (ZSD 0.323, 95% CI 0.129-0.518, p = .001), absence of pregnancies in the past (ZSD 0.200, 95% CI 0.050-0.349, p = .009), no antiretroviral treatment in the past (ZSD 0.186, 95% CI 0.044-0.327, p = .010), and Caucasian ethnicity compared to Hispanic (ZSD 0.248, 95% CI 0.022-0.475, p = .032). Body mass index (BMI) at conception and maternal glycemia levels during pregnancy were also significantly related to birthweight Z scores. Glycemia, BMI, and recent substance use maintained a significant association with Z-score values in multivariate analyses. In the multivariate analysis, the only factors significantly associated with Z-score values below the 10th percentile were recent substance use (adjusted odds ratio [AOR] 3.17, 95% CI 1.15-8.74) and smoking (AOR 2.26, 95% CI 1.13-4.49). DISCUSSION We identified several factors associated with gestational age-adjusted birthweight in newborns from women with HIV. Smoking and substance use have a significant negative impact on intrauterine growth, which adds to an independent HIV-related effect on birthweight. Prevention and information on this issue should be reinforced in women with HIV of childbearing age to reduce the risk of negative outcomes in their offspring.
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Affiliation(s)
- Marco Floridia
- Department of Drug Research and Evaluation, Istituto Superiore di Sanità (ISS), Rome, Italy.
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Patel D, Thorne C, Newell ML. Response to Kourtis et al. 'Use of antiretroviral therapy in pregnant HIV-infected women and the risk of premature delivery: a meta-analysis'. AIDS 2007; 21:1656-7; author reply1657-8. [PMID: 17630567 DOI: 10.1097/qad.0b013e32826fb753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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