Antiretroviral drugs for preventing mother-to-child transmission of HIV in sub-Saharan Africa: balancing efficacy and infant toxicity

Virulence and Replicative Fitness of HIV-1 Transmitted/Founder (T/F) Viruses Harbouring Drug Resistance-Associated Mutation

The biological characteristics of early transmitted/founder (T/F) variants are crucial factors for viral transmission and constitute key determinants for the development of better therapeutics and vaccine strategies. The present study aimed to generate T/F viruses and to characterize their biological properties. For this purpose, we constructed 18 full-length infectious molecular clones (IMCs) of HIV from recently infected infants. All the clones were characterized genotypically through whole genome sequencing and phenotypically for infectivity, replication kinetics, co-receptor usage, as well as their susceptibility to neutralizing antibodies and entry inhibitors using standard virological assays. Genotypic analysis revealed that all the T/F clones were of non-recombinant subtype C, but some of them harboured the Y181C drug resistance mutation associated with resistance to the non-nucleoside reverse transcriptase inhibitor (NNRTI) class of antiretroviral drugs. In vitro studies showed that while all the IMCs were capable of replicating in PBMCs and utilized the CCR5 co-receptor for cellular entry, the drug-resistant variants had significantly lower replicative capacity and per particle infectivity than the drug-sensitive viruses. Both exhibited similar sensitivities to a standard panel of broadly neutralizing monoclonal antibodies and viral entry inhibitors. These findings suggest that despite their diminished replicative fitness, the drug-resistant T/F variants retain transmission fitness and remain susceptible to neutralizing antibody-based interventions and viral entry inhibitors.

Effects of the timing of maternal antiretroviral therapy initiation, CD4 count, and HIV viral load on birth outcomes in the Eastern Cape province of South Africa: A secondary data analysis

BACKGROUND

Antiretroviral therapy (ART) use during pregnancy is essential to prevent vertical transmission of HIV, but it may also increase the risk of adverse birth outcomes. This study investigated the impact of both maternal HIV infection and the timing of ART initiation on birth outcomes in women living with HIV in South Africa.

METHODS

This secondary data analysis examined the dataset from an earlier cohort study involving 1709 pregnant women living with HIV who delivered their babies at three major maternity centres in the Eastern Cape province of South Africa between September 2015 and May 2018. The associations between adverse birth outcomes (stillbirth, preterm birth, very preterm birth, and low birth weight) and the timing of maternal ART initiation, peripartum CD4 count, and HIV viral load were examined using logistic regression analysis.

RESULTS

The observed rates of stillbirth, preterm birth, very preterm birth, and low birth weight were 1.4%, 33.5%, 5.4% and 18.0%, respectively. In the multivariable analysis, low birth weight was associated with ART initiated during the second trimester (adjusted odds ratio [aOR] 1.38; 95% confidence interval [CI], 1.03-1.85), low-level viraemia (21-999 copies/ml) (aOR, 1.62; 95% CI, 1.17-2.22), and high-level viraemia (≥1000 copies/ml) (aOR, 1.66; 95% CI, 1.66-2.38) during the peripartum period. Preterm birth was associated with low-level viraemia (aOR, 1.44; 95% CI, 1.16-1.79) and a CD4 count of less than 200 cells/mm3 (aOR, 1.35; 95% CI, 1.01-1.82). Very preterm birth was associated with detectable maternal viraemia.

CONCLUSION

Adverse birth outcomes are common among pregnant women living with HIV, especially those with unsuppressed viraemia. Clinicians and programme managers should prioritise timeous ART initiation and virological suppression in all pregnant women living with HIV.

The Phenomenon of Antiretroviral Drug Resistance in the Context of Human Immunodeficiency Virus Treatment: Dynamic and Ever Evolving Subject Matter

Human immunodeficiency virus (HIV) is a significant global health issue that affects a substantial number of individuals across the globe, with a total of 39 million individuals living with HIV/AIDS. ART has resulted in a reduction in HIV-related mortality. Nevertheless, the issue of medication resistance is a significant obstacle in the management of HIV/AIDS. The unique genetic composition of HIV enables it to undergo rapid mutations and adapt, leading to the emergence of drug-resistant forms. The development of drug resistance can be attributed to various circumstances, including noncompliance with treatment regimens, insufficient dosage, interactions between drugs, viral mutations, preexposure prophylactics, and transmission from mother to child. It is therefore essential to comprehend the molecular components of HIV and the mechanisms of antiretroviral medications to devise efficacious treatment options for HIV/AIDS.

The Vital Role of Public Health Nurses in Perinatal HIV Prevention and Elimination

Perinatal HIV transmission remains a significant public health challenge, with an estimated 160,000 children newly infected with HIV each year. Public health nurses play a critical role in the prevention and elimination of perinatal HIV transmission through targeted interventions such as identification of pregnant women with HIV, referral and linkage to care, provision of antiretroviral therapy, and follow-up and retention in care for both mothers and infants. However, significant barriers to successful implementation exist, including stigma and discrimination, limited access to healthcare services, socioeconomic factors, and limited resources. Addressing these barriers will require a multifaceted approach that includes policy changes, community engagement, and targeted support and resources for affected families. In this review article, we provide an overview of the epidemiology of perinatal HIV transmission, current strategies for prevention and elimination, and the vital role of public health nurses in these efforts. We will also discuss the barriers to the successful implementation of public health nurse interventions and the future directions for research and practice in this field. Ultimately, the goal of perinatal HIV prevention and elimination can only be achieved through a sustained and collaborative effort across multiple sectors and stakeholders, with public health nurses playing a crucial role in this effort.

The mother-to-child transmission of HIV-1 and profile of viral reservoirs in pediatric population: A systematic review with meta-analysis of the Cameroonian studies

BACKGROUND

The mother-to-child transmission of HIV-1 (MTCT) remains on the major route of HIV-transmission among pediatric populations in Africa. Though a prevention of MTCT (PMTCT) high-priority country, data on the MTCT burdens in Cameroon remains fragmented.

OBJECTIVE

We sought to assess the pooled MTCT rate, its risk-factors, and to characterize viral reservoirs of infected-children in Cameroon.

METHODS

All relevant observational cohort and cross-sectional studies conducted in Cameroon were searched from PubMed, African Journals Online, Google scholar, ScienceDirect and academic medical education databases. Heterogeneity and publication bias were respectively assessed by the I2 statistic and the Egger/funnel plot test. Meta-analysis was performed using the random effects model. MTCT rate >5% was considered as "high". This review was registered in the Prospero database, CRD42021224497.

RESULTS

We included a total of 29 studies and analyzed 46 684 children born from HIV-positive mothers. The overall rate of MTCT was 7.00% (95% CI = 6.07-8.51). According to regions, the highest burden was in Adamaoua-region (17.51% [95% CI:14.21-21.07]) with only one study found. PMTCT option-B+ resulted in about 25% reduction of MTCT (8.97% [95% CI: 8.71-9.24] without option-B+ versus 2.88% [95% CI: 5.03-9.34] with option-B+). Regarding risk-factors, MTCT was significantly associated with the absence of PMTCT-interventions both in children (OR:5.40 [95% CI: 2.58-11.27]) and mothers (OR: 3.59 [95% CI: 2.15-5.99]). Regarding viral reservoirs, a pro-viral DNA mean of 3.34±1.05 log10/mL was observed among 5/57 children and archived HIV drug resistance mutations were identified in pro-viral DNA marker among 21/79 infected-children.

CONCLUSION

In spite of the dropdown in MTCT following option-B+ implementation, MTCT remains high in Cameroon, with substantial disparities across regions. Thus, in this era of option-B+, achieving MTCT elimination requires interventions in northern-Cameroon. The variation in pro-viral load in infected-children underlines the relevance of characterizing viral reservoirs for possible infection control in tropical settings.

Investigation of mother-to-child transmission of HIV in pregnancy and among HIV-exposed infants accessing care at a PMTCT clinic in southwest Nigeria

BACKGROUND

Over 90% of infant acquired immunodeficiency syndrome (AIDS) cases have been through mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV). Consequent to this, prevention of mother-to-child transmission (PMTCT) programs have instituted as dual purposes for prevention of HIV transmission from mother to child and enrollment of infected pregnant women and their families into antiretroviral treatment (ART) program. However, there are still some breakthrough infections and challenges. Therefore, this study was designed to assess risk of HIV transmission among HIV-exposed infants on follow-up at a PMTCT clinic in an antiretroviral (ARV) referral health facility in southwest Nigeria.

METHODS

A cohort of 60 purposively recruited consenting pregnant women referred to PMTCT HIV clinic in Ibadan, southwest Nigeria were enrolled and followed up for 1 year (2015-2016). A well-structured epidemiological questionnaire was used to capture all relevant information. Data were then analyzed by SPSS version 21 (St. Louis, MO, USA), while bivariate and multivariate analyses were used to identify associations.

RESULTS

A total of 44 mothers and their infants were available for the analysis with an attrition rate of 26.7%. The mean age of mothers at enrollment to follow-up was 32.9 years (SD = 4.2 years). Two (4.5%, 95% CI: 7.2-12.3%) of the infants were HIV positive by DNA PCR test. There was no linear relationship between age of the mothers with CD4 count or viral load both before and after delivery but there was a significant positive relationship with year on ARV (r = 0.318, 95% CI: 0.024-0.562). Infants of rural dwelling mothers were at 3.39 (adjusted odds ratio (AOR) = 3.39, 95% CI: 1.32, 2.29) times higher risk of vertical HIV transmission compared to those of urban dwelling mothers. Infants delivered at home had 2.61(AOR = 2.61, 95% CI: 1.59, 7.91) times higher risk of MTCT compared to those delivered at health institution. Mixed feeding was also another important predictor in which the risk of MTCT was about two (AOR = 2.21, 95% CI: 0.68, 9.97) times higher compared to exclusive breastfeeding.

CONCLUSIONS

There was a high risk of MTCT of HIV among exposed infants on follow-up at the PMTCT clinic of Adeoyo Maternity Teaching referral hospital. Our findings will assist health policy makers in providing important information capable of enhancing assurance HIV control in such population and in raising the standard of PMTCT program in Nigeria.

A systematic review and meta-analysis of vertical transmission route of HIV in Ethiopia

BACKGROUND

The burden of mother-to-child transmission rate of HIV is high and risk factors are common in Ethiopia. This systematic review and meta-analysis intended to provide the pooled estimation of mother-to-child transmission rate and its risk factors in Ethiopia.

METHODS

We searched PubMed, Google Scholar, EMBASE and Web of Science electronic databases for all available references. We included observational studies including case-control, cohort, and cross-sectional studies. The search was further limited to studies conducted in Ethiopia and publish in English. Heterogeneity was checked using the I² statistic. Egger's test and the funnel plot were used to assess publication bias. A meta-analysis using a weighted inverse variance random-effects model was performed.

RESULTS

A total of 18 studies with 6253 individuals were included in this systematic review and meta-analysis. Of these, 14 studies with 4624 individuals were used to estimate the prevalence. The estimated pooled prevalence of mother-to-child transmission of HIV was 11.4% (95% CI = 9.1-13.7). The pooled adjusted odds ratio (AOR) of mother-to-child transmission of HIV for the infants from rural area was 3.8 (95% CI = 1.4 to 6.3), infants delivered at home was 3.2 (95% CI = 1.2 to 5.2), infant didn't take antiretroviral prophylaxis was 5.8 (95% CI = 1.5 to 10.3), mother didn't take antiretroviral prophylaxis was 6.1 (95% CI = 2.5 to 9.6), mothers didn't receive PMTCT intervention was 5.1 (95% CI = 1.6, 8.6), and on mixed feeding was 4.3 (95% CI = 1.8 to 6.7).

CONCLUSIONS

This systematic review and meta-analysis showed that mother-to-child transmission rate of HIV was high in Ethiopia. Being from the rural residence, home delivery, not taking antiretroviral prophylaxis, the absence of PMTCT intervention, and mixed infant feeding practices increased the risk of HIV transmission.

TRIAL REGISTRATION

It is registered in the Prospero database: (PROSPERO 2017: CRD42017078232 ).

In-utero exposure to antiretrovirals and neurodevelopment among HIV-exposed-uninfected children in Botswana

OBJECTIVE

Conflicting data exist regarding the impact of in-utero exposure to maternal combination antiretrovirals. We compared neurodevelopmental outcomes between HIV-exposed-uninfected (HEU) children exposed in utero to three-drug combination antiretroviral therapy (ART) vs. zidovudine (ZDV) monotherapy.

DESIGN

Prospective study of child neurodevelopment, nested within two cohorts of HIV-infected mothers and their children in Botswana (one observational, one interventional).

METHODS

The Tshipidi and Mma Bana studies enrolled HIV-infected women during pregnancy and followed their HEU children for 24 months. Mothers took three-drug ART or ZDV during pregnancy. ART-exposed babies were mostly breastfed, and ZDV-exposed were formula-fed. Neurodevelopmental outcomes, measured at 24 months using Bayley Scales of Infant and Toddler Development Third Edition (Bayley-III) and Development Milestones Checklist (DMC), were compared in adjusted linear regression according to antiretroviral exposure.

RESULTS

Of 598 HEU children with valid neurodevelopment assessments, 382 were ART-exposed and 210 were ZDV-exposed. Adjusted mean Bayley-III scores were similar among ART-exposed vs. ZDV-exposed, with adjusted mean differences (95% confidence interval): Bayley-III Cognitive: -0.3 (-1.4, 0.9); Gross Motor: 0.8 (-0.1, 1.7); Fine Motor: 0.5 (-0.2, 1.3); Expressive Language: 0.7 (-0.3, 1.7); Receptive Language: 0.1 (-0.7, 0.8); and DMC Locomotor: 0.0 (-0.5, 0.6); Fine Motor: 0.3 (-0.3, 0.8); Language: -0.1 (-0.5, 0.4); Personal-Social: 0.2 (-0.7, 1.1). Similarly, when restricted to formula-fed children in one cohort (Tshipidi), there were no differences in adjusted mean scores.

CONCLUSION

Neurodevelopmental outcomes at 24 months of age were similar in ART-exposed vs. ZDV-exposed HEU children. Maternal ART with breastfeeding does not appear to have an adverse effect on neurodevelopment.

Operations research in global health: a scoping review with a focus on the themes of health equity and impact

BACKGROUND

Operations research (OR) is a discipline that uses advanced analytical methods (e.g. simulation, optimisation, decision analysis) to better understand complex systems and aid in decision-making. Herein, we present a scoping review of the use of OR to analyse issues in global health, with an emphasis on health equity and research impact. A systematic search of five databases was designed to identify relevant published literature. A global overview of 1099 studies highlights the geographic distribution of OR and common OR methods used. From this collection of literature, a narrative description of the use of OR across four main application areas of global health - health systems and operations, clinical medicine, public health and health innovation - is also presented. The theme of health equity is then explored in detail through a subset of 44 studies. Health equity is a critical element of global health that cuts across all four application areas, and is an issue particularly amenable to analysis through OR. Finally, we present seven select cases of OR analyses that have been implemented or have influenced decision-making in global health policy or practice. Based on these cases, we identify three key drivers for success in bridging the gap between OR and global health policy, namely international collaboration with stakeholders, use of contextually appropriate data, and varied communication outlets for research findings. Such cases, however, represent a very small proportion of the literature found.

CONCLUSION

Poor availability of representative and quality data, and a lack of collaboration between those who develop OR models and stakeholders in the contexts where OR analyses are intended to serve, were found to be common challenges for effective OR modelling in global health.

Infant peripheral blood repetitive element hypomethylation associated with antiretroviral therapy in utero

The use of combination antiretroviral therapy (cART) to prevent HIV mother-to-child transmission during pregnancy and delivery is generally considered safe. However, vigilant assessment of potential risks of these agents remains warranted. Epigenetic changes including DNA methylation are considered potential mechanisms linking the in utero environment with long-term health outcomes. Few studies have examined the epigenetic effects of prenatal exposure to pharmaceutical agents, including antiretroviral therapies, on children. In this study, we examined the methylation status of the LINE-1 and ALU-Yb8 repetitive elements as markers of global DNA methylation alteration in peripheral blood mononuclear cells obtained from newborns participating in the Pediatric HIV/AIDS Cohort Study SMARTT cohort of HIV-exposed, cART-exposed uninfected infants compared to a historical cohort of HIV-exposed, antiretroviral-unexposed infants from the Women and Infants Transmission Study Cohort. In linear regression models controlling for potential confounders, we found the adjusted mean difference of AluYb8 methylation of the cART-exposed compared to the -unexposed was -0.568 (95% CI: -1.023, -0.149) and for LINE-1 methylation was -1.359 (95% CI: -1.860, -0.857). Among those exposed to cART, subjects treated with atazanavir (ATV), compared to those on other treatments, had less AluYb8 methylation (-0.524, 95% CI: -0.025, -1.024). Overall, these results suggest a small but statistically significant reduction in the methylation of these repetitive elements in an HIV-exposed, cART-exposed cohort compared to an HIV-exposed, cART-unexposed historic cohort. The potential long-term implications of these differences are worthy of further examination.

Is protease inhibitors based antiretroviral therapy during pregnancy associated with an increased risk of preterm birth? Systematic review and a meta-analysis

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.

[Study of risk factors for HIV transmission from mother to child in the strategy «option A» in Lubumbashi, Democratic Republic of Congo]

Introduction

L'infection à VIH chez la femme enceinte a pour principal risque la contamination du nouveau-né. L'objectif est de déterminer le taux de transmission du VIH de la mère à l'enfant (TME) dans la ville de Lubumbashi et en évaluer les facteurs de risque.

Méthodes

Il s'agissait d'une étude prospective transversale à visée analytique de 157 accouchées séropositives au VIH et de leurs enfants dans 12 structures sanitaires de Lubumbashi (RDCongo) du 1er octobre 2012 au 31 décembre 2013. Les paramètres sociodémographiques, cliniques et les données relatives aux activités de PTME du VIH ont été étudiés. Les statistiques usuelles ont été utilisées pour analyser les résultats. Le seuil de significativité a été fixé à une valeur de p < 0,05.

Résultats

Le taux de transmission verticale du VIH était de 12,7% (20/157). Il n'y avait pas d'association significative entre les caractéristiques sociodémographiques maternelles telles que l’âge, la parité, le niveau d’étude, la profession et l’état-civil et la TME (p>0,05). La transmission verticale du VIH était significativement associée aux facteurs suivants: le stade clinique 3 de l'OMS (OR=5,18 (1,5-18,1)), la présence d'infection opportuniste (OR=8,7 (2,7-27,8)), le dépistage lors de l'accouchement (OR=6,3 (1,0-39,0)) ou au cours de l'allaitement (OR=7,1 (1,1-76,7)), au taux de CD4 maternel <350/mm3 (OR=2,9 (1,1-7,7)), l'absence de thérapie antirétrovirale chez la mère (OR=19,9 (4,8-81,9)), la naissance avant terme (OR=4,7 (1,4-16,0)), la rupture prématurée de membranes (OR=45,0 (7,4-454,6)), le faible poids de naissance (OR=5,6 (1,9-16,7)), la notion de réanimation néonatale (OR=12,4 (3,8-40,1)), la non administration de la névirapine à la naissance (OR=26,4 (7,6-92,3)) et l'alimentation mixte (OR=12,6 (1,3-115,9)). Le sexe du nourrisson et le mode d'accouchement n’étaient pas non plus associés à la transmission verticale du VIH (p>0,05).

Conclusion

Le taux de TME du VIH demeure fort élevé à Lubumbashi comme dans la plupart de pays en développement où les nouveau-nés continuent d’être infectés par le VIH de manière verticale alors que certains facteurs de transmission sont tout à fait souvent évitables. La réduction de cette transmission passe par une amélioration du système de suivi des grossesses dans notre milieu.

Safety of in utero and neonatal antiretroviral exposure: cognitive and academic outcomes in HIV-exposed, uninfected children 5-13 years of age

BACKGROUND

Long-term effects of in utero and neonatal antiretroviral (ARV) exposure on cognitive and academic development in HIV-exposed, uninfected school-age children are unknown.

METHODS

HIV-exposed, uninfected children, ages 5-13 years, in Pediatric HIV/AIDS Cohort Study Surveillance Monitoring for Antiretroviral Treatment Toxicities, a US-based multisite cohort study, completed age-appropriate Wechsler intelligence and academic scales (WPPSI-III, WASI, WIAT-II-A). Associations between cognitive and academic outcomes and in utero ARV exposure by regimen, class and individual ARVs were evaluated, adjusting for potential confounders.

RESULTS

Children completing WPPSI-IIIs (n = 350) were 49% male, 74% Black, 25% Hispanic; WASI (n = 337) and WIAT-II-A (n = 415) cohorts were similar. The percentage exposed to combination ARV (cARV) was 84% (WPPSI-III), 64% (WASI) and 67% (WIAT-II-A). Among ARV-exposed children, there were no significant associations between any ARV regimen or class and any cognitive or academic outcome. In addition, in both unadjusted models and after adjustment for caregiver IQ, sociodemographic factors and maternal health and substance use during pregnancy, no individual ARV drug was associated with significantly lower cognitive or academic scores. Factors typically associated with lower cognitive and academic scores in the general population, such as prematurity, small for gestational age, maternal alcohol use and lower maternal cognitive status, were also associated with lower scores in this study.

CONCLUSIONS

Overall, the safety of prenatal and neonatal ARV use was supported.

Mitochondrial toxicity in human pregnancy: an update on clinical and experimental approaches in the last 10 years

Mitochondrial toxicity can be one of the most dreadful consequences of exposure to a wide range of external agents including pathogens, therapeutic agents, abuse drugs, toxic gases and other harmful chemical substances. However, little is known about the effects of mitochondrial toxicity on pregnant women exposed to these agents that may exert transplacental activity and condition fetal remodeling. It has been hypothesized that mitochondrial toxicity may be involved in some adverse obstetric outcomes. In the present study, we investigated the association between exposure to mitochondrial toxic agents and pathologic conditions ranging from fertility defects, detrimental fetal development and impaired newborn health due to intra-uterine exposure. We have reviewed data from studies in human subjects to propose mechanisms of mitochondrial toxicity that could be associated with the symptoms present in both exposed pregnant and fetal patients. Since some therapeutic interventions or accidental exposure cannot be avoided, further research is needed to gain insight into the molecular pathways leading to mitochondrial toxicity during pregnancy. The ultimate objective of these studies should be to reduce the mitochondrial toxicity of these agents and establish biomarkers for gestational monitoring of harmful effects.

What is needed to eliminate new pediatric HIV infections: the contribution of model-based analyses

PURPOSE OF REVIEW

Computer simulation models can identify key clinical, operational, and economic interventions that will be needed to achieve the elimination of new pediatric HIV infections. In this review, we summarize recent findings from model-based analyses of strategies for prevention of mother-to-child HIV transmission (MTCT).

RECENT FINDINGS

In order to achieve elimination of MTCT (eMTCT), model-based studies suggest that scale-up of services will be needed in several domains: uptake of services and retention in care (the PMTCT 'cascade'), interventions to prevent HIV infections in women and reduce unintended pregnancies (the 'four-pronged approach'), efforts to support medication adherence through long periods of pregnancy and breastfeeding, and strategies to make breastfeeding safer and/or shorter. Models also project the economic resources that will be needed to achieve these goals in the most efficient ways to allocate limited resources for eMTCT. Results suggest that currently recommended PMTCT regimens (WHO Option A, Option B, and Option B+) will be cost-effective in most settings.

SUMMARY

Model-based results can guide future implementation science, by highlighting areas in which additional data are needed to make informed decisions and by outlining critical interventions that will be necessary in order to eliminate new pediatric HIV infections.

Safety of perinatal exposure to antiretroviral medications: developmental outcomes in infants

BACKGROUND

This study evaluated effects of perinatal exposure to antiretroviral (ARV) medications on neurodevelopment of HIV-exposed, uninfected infants.

METHODS

HIV-exposed, uninfected infants (age 9-15 months) enrolled in Surveillance Monitoring for Antiretroviral Therapy Toxicities, a multisite prospective surveillance study, completed the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III), assessing cognition, language, motor skills, social-emotional development and adaptive behavior. Linear regression models were used to evaluate associations between Bayley-III outcomes in infants with and without perinatal and neonatal ARV exposure, by regimen (combination ARV [cARV] versus non-cARV), type of regimen (defined by drug class) and individual ARVs (for infants with cARV exposure), adjusting for maternal and infant health and demographic covariates.

RESULTS

As of May 2010, 374 infants had valid Bayley-III evaluations. Median age at testing was 12.7 months; 49% male, 79% black and 16% Hispanic. Seventy-nine percent were exposed to regimens containing protease inhibitors (9% of protease inhibitor-containing regimens also included non-nucleoside reverse transcriptase inhibitors), 5% to regimens containing non-nucleoside reverse transcriptase inhibitors (without protease inhibitor) and 14% to regimens containing only nucleoside reverse transcriptase inhibitors. Overall, 83% were exposed to cARV. No Bayley-III outcome was significantly associated with overall exposure to cARV, ARV regimen or neonatal prophylaxis. For individual ARVs, following sensitivity analyses, the adjusted group mean on the Language domain was within age expectations but significantly lower for infants with perinatal exposure to atazanavir (P = 0.01).

CONCLUSIONS

These results support the safety of perinatal ARV use. Continued monitoring for adverse neurodevelopmental outcomes in older children is warranted, and the safety of atazanavir merits further study.

Mother-to-child transmission of HIV and its predictors among HIV-exposed infants at a PMTCT clinic in northwest Ethiopia

Background

Mother-to-child transmission of HIV (MTCT) accounts for more than 90% of pediatric Acquired Immunodeficiency Syndrome (AIDS) cases. Prevention of mother to child transmission (PMTCT) programs are provided for dual benefits i.e. prevention of HIV transmission from mother to child and enrolment of infected pregnant women and their families into antiretroviral treatment (ART). This study assessed risk and predictors of HIV transmission among HIV-exposed infants on follow up at a PMTCT clinic in a referral hospital.

Methods

Institution based retrospective follow up study was carried at Gondar University referral hospital PMTCT clinic. All eligible records of HIV-exposed infants enrolled between September 2005 and July 2011 were included. A midwife nurse collected data using a structured data extraction format. Data were then entered in to EPI INFO Version 3.5.1 statistical software and analyzed by SPSS version 20.0. Both bivariate and multivariate analyses were carried out to identify associations.

Results

A total of 509 infant records were included in the analysis. The median age of infants at enrolment to follow up was 6 weeks (inter quartile range [IQR] = 2 weeks). A total of 51(10%, 95% CI: 7.8% - 13%) infants were infected with HIV. Late enrolment to the exposed infant follow up clinic (Adjusted Odds Ratio [AOR] = 2.89, 95% CI: 1.35, 6.21), rural residence (AOR = 5.05, 95% CI: 2.34, 10.9), home delivery (AOR = 2.82, 95% CI: 1.2, 6.64), absence of maternal PMTCT interventions (AOR = 5.02, 95% CI: 2.43, 10.4) and mixed infant feeding practices (AOR = 4.18, 95% CI: 1.59, 10.99) were significantly and independently associated with maternal to child transmission of HIV in this study.

Conclusions

There is a high risk of MTCT of HIV among exposed infants on follow up at the PMTCT clinic of the University of Gondar referral hospital. The findings of this study will provide valuable information for policy makers to enhance commitment and support for rural settings in the PMTCT scaling-up program.

Married men's perceptions of barriers for HIV-positive pregnant women accessing highly active antiretroviral therapy in rural Uganda

BACKGROUND

The aim of this study was to describe the perceptions of married men about barriers to accessing and accepting highly active antiretroviral therapy (HAART) by pregnant/postnatal women positive for human immunodeficiency virus (HIV) and registered in Kabarole District's Program for the Prevention of HIV from Mother to Child (PMTCT-Plus).

MATERIALS AND METHODS

Our study was a qualitative descriptive exploratory study using thematic analysis. Four focus group discussions were held with a convenience sample of 40 married men.

RESULTS

Lack of disclosure of a positive HIV diagnosis to the partner and stigmatization of persons with HIV were two major obstacles for women in accessing HAART. In addition, men felt that their low knowledge of HAART and their low HIV testing rate also constituted important barriers to these women taking treatment. Men complained that they were not sufficiently involved in the reproductive care of women and that couples' counseling could be a step towards addressing this problem.

CONCLUSION

Barriers to HAART experienced by pregnant/postnatal women need to be addressed in order to improve their uptake of treatment, increase their low treatment coverage, improve their survival, and at the same time dramatically reduce HIV transmission from mother to child.

What will it take to eliminate pediatric HIV? Reaching WHO target rates of mother-to-child HIV transmission in Zimbabwe: a model-based analysis

BACKGROUND

The World Health Organization (WHO) has called for the "virtual elimination" of pediatric HIV: a mother-to-child HIV transmission (MTCT) risk of less than 5%. We investigated uptake of prevention of MTCT (PMTCT) services, infant feeding recommendations, and specific drug regimens necessary to achieve this goal in Zimbabwe.

METHODS AND FINDINGS

We used a computer model to simulate a cohort of HIV-infected, pregnant/breastfeeding women (mean age, 24 y; mean CD4, 451/µl; breastfeeding duration, 12 mo). Three PMTCT regimens were evaluated: (1) single-dose nevirapine (sdNVP), (2) WHO 2010 guidelines' "Option A" (zidovudine in pregnancy, infant nevirapine throughout breastfeeding for women without advanced disease, lifelong combination antiretroviral therapy for women with advanced disease), and (3) WHO "Option B" (pregnancy/breastfeeding-limited combination antiretroviral drug regimens without advanced disease; lifelong antiretroviral therapy with advanced disease). We examined four levels of PMTCT uptake (proportion of pregnant women accessing and adhering to PMTCT services): reported rates in 2008 and 2009 (36% and 56%, respectively) and target goals in 2008 and 2009 (80% and 95%, respectively). The primary model outcome was MTCT risk at weaning. The 2008 sdNVP-based National PMTCT Program led to a projected 12-mo MTCT risk of 20.3%. Improved uptake in 2009 reduced projected risk to 18.0%. If sdNVP were replaced by more effective regimens, with 2009 (56%) uptake, estimated MTCT risk would be 14.4% (Option A) or 13.4% (Option B). Even with 95% uptake of Option A or B, projected transmission risks (6.1%-7.7%) would exceed the WHO goal of less than 5%. Only if the lowest published transmission risks were used for each drug regimen, or breastfeeding duration were shortened, would MTCT risks at 95% uptake fall below 5%.

CONCLUSIONS

Implementation of the WHO PMTCT guidelines must be accompanied by efforts to improve access to PMTCT services, retain women in care, and support medication adherence throughout pregnancy and breastfeeding, to approach the "virtual elimination" of pediatric HIV in Zimbabwe. Please see later in the article for the Editors' Summary.

Impact of antiretroviral therapy on fertility desires among HIV-infected persons in rural Uganda

Background

Little is known about the fertility desires of HIV infected individuals on highly active antiretroviral therapy (HAART). In order to contribute more knowledge to this topic we conducted a study to determine if HIV-infected persons on HAART have different fertility desires compared to persons not on HAART, and if the knowledge about HIV transmission from mother-to-child is different in the two groups.

Methods

The study was a cross-sectional survey comparing two groups of HIV-positive participants: those who were on HAART and those who were not. Semi-structured interviews were conducted with 199 HIV patients living in a rural area of western Uganda. The desire for future children was measured by the question in the questionnaire "Do you want more children in future." The respondents' HAART status was derived from the interviews and verified using health records. Descriptive, bivariate and multivariate methods were used to analyze the relationship between HAART treatment status and the desire for future children.

Results

Results from the multivariate logistic regression model indicated an adjusted odds ratio (OR) of 1.08 (95% CI 0.40-2.90) for those on HAART wanting more children (crude OR 1.86, 95% CI 0.82-4.21). Statistically significant predictors for desiring more children were younger age, having a higher number of living children and male sex. Knowledge of the risks for mother-to-child-transmission of HIV was similar in both groups.

Conclusions

The conclusions from this study are that the HAART treatment status of HIV patients did not influence the desire for children. The non-significant association between the desire for more children and the HAART treatment status could be caused by a lack of knowledge in HIV-infected persons/couples about the positive impact of HAART in reducing HIV transmission from mother-to-child. We recommend that the health care system ensures proper training of staff and appropriate communication to those living with HIV as well as to the general community.

WHO 2010 guidelines for prevention of mother-to-child HIV transmission in Zimbabwe: modeling clinical outcomes in infants and mothers

BACKGROUND

The Zimbabwean national prevention of mother-to-child HIV transmission (PMTCT) program provided primarily single-dose nevirapine (sdNVP) from 2002-2009 and is currently replacing sdNVP with more effective antiretroviral (ARV) regimens.

METHODS

Published HIV and PMTCT models, with local trial and programmatic data, were used to simulate a cohort of HIV-infected, pregnant/breastfeeding women in Zimbabwe (mean age 24.0 years, mean CD4 451 cells/µL). We compared five PMTCT regimens at a fixed level of PMTCT medication uptake: 1) no antenatal ARVs (comparator); 2) sdNVP; 3) WHO 2010 guidelines using "Option A" (zidovudine during pregnancy/infant NVP during breastfeeding for women without advanced HIV disease; lifelong 3-drug antiretroviral therapy (ART) for women with advanced disease); 4) WHO "Option B" (ART during pregnancy/breastfeeding without advanced disease; lifelong ART with advanced disease); and 5) "Option B+:" lifelong ART for all pregnant/breastfeeding, HIV-infected women. Pediatric (4-6 week and 18-month infection risk, 2-year survival) and maternal (2- and 5-year survival, life expectancy from delivery) outcomes were projected.

RESULTS

Eighteen-month pediatric infection risks ranged from 25.8% (no antenatal ARVs) to 10.9% (Options B/B+). Although maternal short-term outcomes (2- and 5-year survival) varied only slightly by regimen, maternal life expectancy was reduced after receipt of sdNVP (13.8 years) or Option B (13.9 years) compared to no antenatal ARVs (14.0 years), Option A (14.0 years), or Option B+ (14.5 years).

CONCLUSIONS

Replacement of sdNVP with currently recommended regimens for PMTCT (WHO Options A, B, or B+) is necessary to reduce infant HIV infection risk in Zimbabwe. The planned transition to Option A may also improve both pediatric and maternal outcomes.

[In-utero antiretroviral exposure and mitochondrial toxicity in a cohort of uninfected infants born to HIV-1-infected women]

INTRODUCTION

In this study, we attempt to find out the percentage of uninfected infants born to HIV-infected women and exposed in-utero and perinatally to Antiretroviral Treatment (ART) that show high lactate levels, or any other mitochondrial damage markers (such as hypertransaminasaemia or hyperamylasaemia), during the first three months of age. We shall also establish whether certain drugs used in-utero are associated with higher lactate, transaminase or amylase levels.

METHODS

We analysed the available data from 623 uninfected infants born in the Spanish FIPSE cohort that were born in the period 2000-2005. The normal values for lactate, transaminases and amylase were set according to AIDS Clinical Groups Trials toxicity tables for infants.

RESULTS

The percentages of children with high lactate levels at 0.5; 1.5 and 3 months of age were 48%, 51.4% and 43% among those infants with available data. Respectively, the percentages of children with high AST values were 13.2; 10.4 and 17.2%. The values for high ALT were 3.3%; 3.4% and 5%. The percentages for hyperamylasaemia were 0%; 0.6% and 2.6%. We found no significant difference among the drugs used in utero for the four analysed biochemical markers along the first three months of age.

CONCLUSIONS

We have found a high proportion of hyperlactataemia among infants exposed in-utero to ART, as shown in other cohorts of similar characteristics. No morbidity or mortality was communicated to the cohort analysis group. No ART drug among those used in-utero was statistically associated with a higher proportion of high lactate levels in these infants.

Antiretroviral therapy (ART) for treating HIV infection in ART-eligible pregnant women

BACKGROUND

This systematic review focuses on antiretroviral therapy (ART) for treating human immunodeficiency virus (HIV) infection in ART-eligible pregnant women. Mother-to-child transmission (MTCT) is the primary means by which children worldwide acquire HIV infection. MTCT occurs during three major timepoints during pregnancy and the postpartum period: in utero, intrapartum, and during breastfeeding. Strategies to reduce MTCT focus on these periods of exposure and include maternal and infant use of ART, caesarean section before onset of labour or rupture of membranes, and complete avoidance of breastfeeding. Where these combined interventions are available, the risk of MTCT is as low as 1-2%. Thus, ART used among mothers who require treatment of HIV for their own health also plays a significant role in decreasing MTCT.This review is one in a series of systematic reviews performed in preparation for the revision of the 2006 World Health Organization (WHO) Guidelines regarding "Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants" and "Antiretroviral therapy (ART) for HIV Infections in Adults and Adolescents." The findings from these reviews were discussed with experts, key stakeholders, and country representatives at the 2009 WHO guideline review meeting. The resulting WHO 2009 "rapid advice" preliminary guidance on adult and adolescent ART now recommends lifelong treatment for all adults with HIV infection and CD4 counts <350 cells/mm(3). These recommendations also apply to pregnant women who are HIV-infected and they place a high value on early ART to benefit the mother's own health (WHO 2009). The "rapid advice" preliminary guidance also aims to minimize side effects for mothers and their infants (WHO 2009).

OBJECTIVES

Our objective was to assess the current literature regarding the treatment of HIV infection in pregnant women who are clinically or immunologically eligible for ART. This review includes an evaluation of the optimal time to start therapy in relation to the woman's laboratory parameters and/or gestational age. It also includes an analysis of which specific antiretroviral medications to start in women who are not yet on ART and which agents to continue in women who are already on ART.

SEARCH STRATEGY

In June 2009, electronic searches were undertaken in these databases: Cochrane's "CENTRAL," EMBASE, PubMed, LILACS, and Web of Science/Web of Social Science. Hand searches were performed of the reference lists of all pertinent reviews and studies identified. Abstracts from relevant conferences were searched. Experts in the field were contacted to locate additional studies. The search strategy was iterative.

SELECTION CRITERIA

We selected randomized controlled trials and observational studies that evaluated pregnant women with HIV infection who were eligible for ART according to criteria defined by the WHO guideline review committee. Studies were included in the systematic review when a comparison group was clearly defined and where the intervention comprised triple ART. For a study to be considered, each medication in the ART regimen needed to be clearly described.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the selected studies for relevance and inclusion. Relevant data was then extracted from included studies, and the risk of bias assessed. In each included study, the relative risk (RR) for the intervention versus the comparison group was calculated for each outcome, as appropriate, with 95% confidence intervals (CIs).

MAIN RESULTS

To our knowledge, there are no randomized controlled trials or observational studies that address the optimal time to start antiretroviral drugs in ART-eligible pregnant women in relation to the woman's laboratory parameters and/or gestational age. The medications to continue in ART-eligible pregnant women who are already receiving ART also have not been evaluated systematically in the current literature. The long-term mortality of HIV-positive pregnant women on ART for their own health, and the long-term virologic or clinical efficacy of ART in treating them, has not been evaluated in randomized clinical trials. In this review, surrogate outcomes for long-term mortality and virologic and clinical efficacy (e.g. MTCT and infant HIV transmission or death) were evaluated to determine the efficacy of specific antiretroviral regimens to start in women who are not yet on ART.Three randomized controlled trials and six observational studies were selected. No studies addressed comparative maternal mortality, which regimens to continue in women already on ART, or the laboratory parameters and gestational age at which to start therapy. The use of zidovudine (AZT), lamivudine (3TC) and lopinavir/ritonavir (LPV-r) starting at 28-36 weeks gestation in a breastfeeding population reduced infant HIV-transmission or death at 12 months compared to a short-course regimen (RR 0.64, 95% CI: 0.44-0.92) (deVincenzi, 2009). Starting AZT, 3TC, and nevirapine (NVP) at 34 weeks in a mixed-feeding population reduced infant HIV-transmission or death at 7 months compared to a short-course regimen (RR 0.39, 95% CI: 0.12-0.85) (Bae, 2008).In the Mma Bana study (a randomized controlled trial in a breastfeeding population) there was no difference in MTCT at six months between the AZT/3TC/LPV-r and AZT, 3TC, and abacavir (ABC) arms (RR 0.17, 95% CI: 0.02-1.44) (Shapiro, 2009). Both regimens also showed 92-95% efficacy in virologic suppression at delivery and during the breastfeeding period. In the Kesho Bora study there was a significant difference in MTCT at 12 months between breastfeeding women who initiated AZT/3TC/LPV-r starting between 28 and 36 weeks and those receiving a short course regimen (RR 0.58, 95% CI: 0.34-0.97) (deVincenzi, 2009). MTCT also decreased significantly when AZT/3TC/NVP was compared with a short-course regimen at seven months in a feeding intervention study (RR 0.15, 95% CI: 0.04-0.62) (Bae, 2008) and 12 months in a population where either exclusive breastfeeding or replacement feeding was encouraged (RR 0.14, CI: 0.04-0.47) (Ekouevi, 2008).In the Mma Bana study, there was increased risk of prematurity among infants born to women receiving AZT/3TC/LPV-r (RR 1.52, CI: 1.07- 2.17) compared with AZT/3TC/ABC (Shapiro, 2009). Ekouevi 2008 showed higher rates of infant low birth weight on AZT/3TC/NVP started at 24 weeks compared to a short course regimen started between 32 and 36 weeks (RR 1.81, 95% CI: 1.09- 3.0). Tonwe-Gold 2007 showed an increase in maternal severe adverse events among the women receiving AZT/3TC/NVP compared with a short-course regimen (RR 25.33, CI 1.49- 340.51).

AUTHORS' CONCLUSIONS

In ART-eligible pregnant women with HIV infection, ART is a safe and effective means of providing maternal virologic suppression, decreasing infant mortality, and reducing MTCT. Specifically, AZT/3TC/NVP, AZT/3TC/LPV-r, and AZT/3TC/ABC have been shown to decrease MTCT. More research is needed regarding the use of specific regimens and their maternal and infant side-effect profiles.

Antiretroviral therapy in pregnancy: balancing the risk of preterm delivery with prevention of mother-to-child HIV transmission

BACKGROUND

Highly active antiretroviral therapy (HAART) for pregnant HIV-positive women reduces the risk of mother-to-child transmission, but is associated with an increased risk of preterm delivery (<37 weeks gestation). We aimed to quantify the incremental risk-benefit ratio for HAART compared with zidovudine monotherapy with respect to these outcomes.

METHODS

Two-stage Monte Carlo simulation methods were used to estimate the risk-benefit ratio for HAART in pregnancy. Estimates of mother-to-child transmission and preterm delivery rates were obtained from UK and Ireland surveillance data collected through the National Study of HIV in Pregnancy and Childhood.

RESULTS

At a population level, HAART was associated with a more than sevenfold reduction in mother-to-child transmission compared with zidovudine monotherapy (adjusted odds ratio [AOR] 0.13, 95% confidence interval [CI] 0.06-0.27), but with a 1.4-fold increased odds of preterm delivery (AOR 1.43, 95% CI 1.10-1.86) and twofold increased odds of severe preterm delivery (<32 weeks; AOR 2.06, 95% CI 1.09-3.88). The incremental risk-benefit ratio for HAART in pregnancy compared with monotherapy was 0.63 (95% simulation interval 0.06-1.96) additional preterm births and 0.23 (95% simulation interval -0.02-0.88) severe preterm births for each infection prevented.

CONCLUSIONS

It is estimated that for every 100 HIV transmissions prevented through the use of HAART (rather than monotherapy), 63 additional preterm deliveries would occur, including 23 at <32 weeks gestation. Interpretation of these ratios is context-dependent and requires additional information about morbidity, mortality and costs associated with the outcomes.

Antiretroviral medications during pregnancy for therapy or prophylaxis

The use of combination antiretroviral therapy during pregnancy has enabled us to decrease perinatal HIV transmission to less than 1%, in areas with adequate resources. Questions remain regarding the safety of these medications for the mother, fetus, and child. Recent publications present conflicting data about associations between antiretrovirals and prematurity and other adverse pregnancy outcomes, and if highly active antiretroviral therapy (HAART) is necessary for all pregnant women. The pharmacokinetics of some antiretroviral medications are altered significantly during pregnancy; placental transfer to the fetus is variable. The well-documented benefit of HAART for preventing mother-to-child transmission generally outweighs the potential risks to the fetus, infant, and mother. However, potential adverse effects are of concern, and questions remain as to the optimal treatment strategy. More data on the effects of antiretrovirals during pregnancy are needed.