Small for gestational age birth outcomes in pregnant women with perinatally acquired HIV

HIV and Pregnancy: Navigating Complex Decision Making and Preventing Perinatal Transmission

PURPOSE OF REVIEW

The objective of this review is to examine the intersection of pregnancy and HIV, focusing on birthing person and fetal health outcomes, prevention of perinatal HIV transmission, and the latest advancements in treatment and care in the United States. It highlights current guidelines, challenges in management, and future directions for improving outcomes.

RECENT FINDINGS

HIV treatment guidelines continue to highlight key principles for the choice of antiretroviral therapy in pregnancy, challenges, and strategies for adherence support. Guidelines have been updated to reflect patient-centered counseling to support shared decision making about infant feeding. Counseling should begin prior to pregnancy, and be reviewed throughout pregnancy, again at delivery, and throughout the periods when breast/chestfeeding occurs. ART use during pregnancy has significantly reduced perinatal HIV transmission. Ongoing research and collaboration are vital to addressing remaining challenges. Prioritizing maternal and infant health ensures that ART not only prevents transmission but also improves future health for families affected by HIV.

Pregnancy Outcomes and All-Cause Mortality After Pregnancy Among US-Born Women With Perinatally Acquired HIV

BACKGROUND

Maternal and pregnancy outcomes among women with perinatally acquired HIV (PHIV) versus women with HIV acquired through other routes (NPHIV) are not fully understood.

SETTING

US-born women during 2005-2015 in New York City.

METHODS

We used data from the New York City HIV surveillance registry, Expanded Perinatal Surveillance database, and Vital Statistics, to compare pregnancy and all-cause mortality outcomes among women with PHIV versus NPHIV delivering infants during 2005-2015.

RESULTS

There were 186 deliveries among 137 women with PHIV and 1188 deliveries among 910 women with NPHIV. Women with PHIV were younger at delivery, more likely to be aware of their HIV status, and less likely to use substances or be incarcerated. At the time of delivery, women with PHIV were more likely to have HIV RNA >1000 copies/mL (34% vs. 19%), CD4 <200 cells/µL (18% vs. 7%; median CD4 300 cells/µL vs. 435 cells/µL), to have adequate prenatal care (43% vs. 35%), and to deliver by elective C-section (63% vs. 49%). There were no differences in intrapartum and neonatal antiretroviral therapy use, perinatal transmission, gestational age, and birth weight of the infants, nor infant mortality. Women with NPHIV had higher survival than women with PHIV (RR = 2.29, P = 0.004; age-adjusted risk ratio = 3.23, P < 0.001; age and CD4 adjusted risk ratio = 2.09, P = 0.046).

CONCLUSIONS

Women with PHIV had lower long-term survival after delivery likely because of limited HIV treatment options in childhood and a longer duration of HIV infection, underscoring the importance of close follow-up and tailored support services beyond the postpartum period.

Routine Vaccination During Pregnancy Among People Living With HIV in the United States

Importance

Pregnancy represents a window of opportunity for vaccination due to established maternal and fetal benefits of vaccination. Little is known about receipt of routinely recommended vaccines in pregnancy, specifically tetanus, diphtheria, plus acellular pertussis (Tdap) and influenza, among pregnant people living with HIV (PLHIV).

Objective

To estimate prevalence of vaccination receipt among pregnant people with HIV (PLHIV) and identify demographic and clinical characteristics associated with vaccination.

Design, Setting, and Participants

This multicenter cohort study included women participating in Women's Health Study (WHS) of the Surveillance Monitoring for ART Toxicities (SMARTT) Study of the Pediatric HIV/AIDS Cohort Study. The network has been enrolling pregnant PLHIV at 22 US sites since 2007. Participants for this study enrolled between December 2017 and July 2019. Data analysis was conducted from October 2021 to March 2022.

Exposure

Data on vaccination in pregnancy were collected through medical record abstraction.

Main Outcomes and Measures

Vaccination receipt was defined as Tdap vaccination received at less than 36 weeks' gestation and influenza vaccination at any gestational age, based on current guidelines. Log-binomial and modified Poisson regression models with generalized estimating equations were fit to identify factors associated with successful receipt of (1) Tdap, (2) influenza, and (3) both vaccinations.

Results

A total of 310 pregnancies among 278 people participating in the WHS were included (mean [SD] age, 29.5 [6.1] years; 220 [71%] Black, 77 [25%] Hispanic, and 77 [25%] race and ethnicity other than Black; 64 [21%] with perinatally acquired HIV). Less than one-third of pregnancies were vaccinated as recommended (Tdap, 32.6% [95% CI, 27.4%-38.1%]; influenza, 31.6% [95% CI, 26.5%-37.1%]; both, 22.6% [95% CI, 18.0%-27.6%]). People living with perinatally acquired HIV, those who did not identify as Black, or those who were multiparous had adjusted risk ratios (aRRs) less than 1, while older PLHIV had aRRs greater than 1, but these differences did not reach statistical significance (perinatally acquired HIV: adjusted risk ratio [aRR], 0.46; 95% CI, 0.21-1.02; race other than Black: aRR, 0.53; 95% CI, 0.26-1.08; multiparous: aRR, 0.59; 95% CI, 0.35-1.00; age 24-29 years: aRR, 2.03; 95% CI, 0.92-4.48).

Conclusions and Relevance

In this diverse, multicenter cohort of pregnant PLHIV, receipt of recommended vaccinations was low. Identifying and addressing barriers to vaccination receipt is urgently needed for pregnant people with HIV.

Understanding clinical outcome measures reported in HIV pregnancy studies involving antiretroviral-naive and antiretroviral-experienced women

HIV infection is a clinically significant public health disease and contributes to increased risk of maternal and fetal morbidity and mortality. HIV pregnancy studies use outcome measures as metrics to show how people with HIV feel, function, or survive. These endpoints are crucial for tracking the evolution of HIV illness over time, assessing the effectiveness of antiretroviral therapy (ART), and comparing outcomes across studies. Although the need for ideal outcome measures is widely acknowledged, selecting acceptable outcome measures for these HIV pregnancy studies can be challenging. We discuss the many outcome measures that have been implemented over time to assess HIV in pregnancy studies, their benefits, and drawbacks. Finally, we offer suggestions for improving the reporting of outcome measures in HIV in pregnancy studies. Medical professionals can best care for pregnant women living with HIV receiving ART by having a thorough understanding of these outcome metrics.

Pregnancy in women living with perinatally acquired HIV: Perinatal outcomes and drug resistance profile

OBJECTIVES

To analyze the perinatal outcomes of Perinatally acquired HIV Infection (PHIV) in pregnant women.

METHOD

This retrospective cohort study included singleton pregnancies in Women Living with HIV (WLH) between 2006 and 2019. Patient charts were revised, and maternal characteristics, type of HIV infection (perinatal vs. behavioral), Antiretroviral Therapy (ART) exposure, and obstetric and neonatal outcomes were assessed. The HIV-related aspects considered were: Viral Load (VL), CD4+ cell count, opportunistic infections, and genotype testing. Laboratory analyses were performed at baseline (first appointment) and 34 weeks of gestation.

RESULTS

There were 186 WLH pregnancies, and 54 (29%) patients had PHIV. Patients with PHIV were younger (p < 0.001), had less frequently stable partnerships (p < 0.001), had more commonly serodiscordant partners (p < 0.001), had a longer time on ART (p < 0.001), and had lower rates of undetectable VL at baseline (p = 0.046) and at 34 weeks of gestation (p < 0.001). No association was observed between PHIV and adverse perinatal outcomes. Among patients with PHIV, third trimester anemia was associated with preterm birth (p = 0.039). Genotype testing was available only for 11 patients with PHIV, who presented multiple mutations related to ART resistance.

CONCLUSIONS

PHIV did not seem to increase the risk of adverse perinatal outcomes. However, PHIV pregnancies have a higher risk of viral suppression failure and exposure to complex ARTs.

Growth patterns of uninfected children born to women living with perinatally versus nonperinatally acquired HIV

OBJECTIVE

The aim of this study was to compare long-term growth between HIV-exposed uninfected children (CHEU) born to women with perinatally acquired HIV (CHEU-PHIV) and CHEU born to women with nonperinatally acquired HIV (CHEU-NPHIV).

DESIGN

A longitudinal analysis of anthropometric measurements from a U.S.-based multisite prospective cohort study enrolling CHEU and their mothers since April 2007.

METHODS

CHEU were evaluated for growth annually from birth through age 5 and again at age 7 years. Z-scores were calculated using U.S. growth references for weight (WTZ), height (HTZ), and weight-for-length or BMI-for-age (WLZ/BMIZ). Mid-upper arm circumference (MUACZ) and triceps skinfold thickness (TSFZ) Z-scores were obtained from ages 1 and 2, respectively, through age 7 years. Piecewise mixed-effects models, overall and stratified by race and sex, were fit to assess differential growth patterns across age by maternal PHIV status.

RESULTS

One thousand four hundred fifty-four singleton infants (286 CHEU-PHIV and 1168 CHEU-NPHIV) were included. CHEU-PHIV had slower growth rates than CHEU-NPHIV for WTZ and WLZ/BMIZ at earlier ages and continued to have lower mean WTZ [-0.27, 95% confidence interval (95% CI): -0.50, -0.04] and WLZ/BMIZ (-0.39, 95% CI: -0.67, -0.11) through age 7. Among non-Black boys, CHEU-PHIV had slightly lower WTZ and WLZ/BMIZ at birth than CHEU-NPHIV and these growth deficits persisted through age 7 years.

CONCLUSION

Compared with CHEU-NPHIV, CHEU-PHIV had diminished growth in early childhood with differences most pronounced among non-Black male children. Further longitudinal follow-up of CHEU-PHIV into young adulthood is needed to understand whether these early effects of maternal PHIV status on growth persist and have other health consequences.

Performance of a local reference curve for predicting small for gestational age fetuses in pregnant women with HIV/AIDS

PURPOSE

To compare the performance of a local estimated fetal weight curve with curves established for other populations to predict small for gestational age (SGA) fetuses.

METHODS

A retrospective and cross-sectional study involving 231 fetuses in which the performance of a local curve (proposed model) was compared with the Hadlock and Intergrowth-21st curves in the prediction of SGA fetuses, by applying them to a population of high-risk pregnant woman with HIV/AIDS. For each model, a receiver operating characteristic curve was adjusted, considering the SGA classification by the neonatal Intergrowth method as the gold standard, and the area under the curve (AUC) was calculated.

RESULTS

The models presented linear correlations with each other. The agreement of the proposed model with Hadlock was very good (kappa = 0.83), whereas the proposed model and Intergrowth-21st had moderate agreement (kappa = 0.44). The SGA fetus detection sensitivities of the proposed model and Hadlock were 61.9% and 57.1%, with specificity of 84.1% and 86.2% and accuracy of 80.1% and 81%, respectively, without statistical difference. The sensitivity of the Intergrowth-21st model was 33.3%, while the accuracy was 85.7% and the specificity was 97.4%. The AUC estimated values for the Hadlock, proposed, and Intergrowth-21st models were 0.834, 0.832, and 0.835, respectively.

CONCLUSION

The proposed model and Hadlock were interchangeable in the prediction of SGA fetuses and superior to the Intergrowth-21st model.

The next generation: Pregnancy in adolescents and women living with perinatally acquired HIV in South Africa

BACKGROUND

An increasing number of girls living with perinatally acquired HIV (PHIV) are reaching adolescence and adulthood and becoming pregnant. Youth living with PHIV (YLPHIV) may have HIV-associated infections/complications, long-term exposure to antiretroviral treatment (ART), drug resistance and increased psychosocial challenges, which may adversely affect pregnancy outcomes. There is a lack of published studies on pregnancy in YLPHIV in sub-Saharan Africa. Objectives. To describe characteristics of pregnant South African (SA) YLPHIV and their pregnancy outcomes.

METHODS

We retrospectively identified pregnancies in YLPHIV, who were diagnosed with HIV when they were <12 years old and before their first pregnancy (as a proxy for perinatal route of infection), from routinely collected data in Western Cape Province, SA (2007 - 2018). We combined these with pregnancies from a Johannesburg cohort of YLPHIV. Results. We identified 258 pregnancies among 232 females living with likely PHIV; 38.8% of pregnancies occurred in YLPHIV ≤16 years old, 39.1% at age 17 - 19 years and 22.1% at age ≥20 years. In recent years, a steady increase in the number of pregnancies in YLPHIV was noted; more than two-thirds occurred during 2016 - 2018. ART was commenced prior to pregnancy in 84.9% of YLPHIV, during pregnancy in 6.6% and was not commenced by pregnancy end date in 8.5%. Of the pregnancies in young women with documented outcomes (88.8%; n=229), 80.3% were live births, 14.4% terminations, 3.1% miscarriages and 2.2% stillbirths. Mother-to-child transmission of HIV occurred in 2.2% of infants, 75.3% were uninfected when last tested and 22.6% had unknown HIV status. Among YLPHIV with CD4 counts available within 12 months of pregnancy end date (n=202), 20.3% had a CD4 count <200 cells/μL, 43.1% CD4 count 200 - 499 cells/μL and 36.6% CD4 count ≥500 cells/μL. Among those with a viral load (VL) available within 12 months of pregnancy end date (n=219), 66.7% had a VL <400 copies/mL, 5.0% VL 400 - 999 copies/mL and 28.3% VL ≥1 000 copies/mL. Of 186 neonates, 20.4% were preterm deliveries (<37 weeks' gestation). Among neonates with known birthweight (n=176), the mean birthweight was 2 900 g (95% confidence interval (CI) 2 747 - 2 935 g) and 20.5% had a low birthweight (<2 500 g). One congenital malformation (musculoskeletal) and 2 neonatal deaths were recorded.

CONCLUSIONS

In recent years, the number of pregnancies in YLPHIV has increased. A considerable proportion of pregnancies occurred in YLPHIV ≤16 years old. A high proportion of pregnancies was electively terminated. The prevalence of elevated VL and poor immunological status among pregnant YLPHIV is concerning.

Impact of maternal HIV-HBV coinfection on pregnancy outcomes in an underdeveloped rural area of southwest China

OBJECTIVES

Our objective was to determine the impact of maternal HIV-hepatitis B virus (HBV) coinfection on pregnancy outcomes.

METHODS

The current study was conducted in a county of Yi Autonomous Prefecture in southwest China. Data were abstracted from hospitalisation records, including maternal and infant information. The seroprevalences of HIV and HBV infections and HIV-HBV coinfection were determined and the impact of maternal HIV-HBV coinfection on adverse pregnancy outcomes was assessed using logistic regression analysis. A treatment effects linear regression model was also applied to examine the effect of HBV, HIV or coinfection to quantify the absolute difference in birth weight from a reference of HBV-HIV negative participants.

RESULTS

A total of 13 198 pregnant women were included in our study, and among them, 99.1% were Yi people and 90.8% lived in rural area. The seroprevalences of HIV and HBV infections and HIV-HBV coinfection were 3.6% (95% CI: 3.2% to 3.9%), 3.2% (95% CI: 2.9% to 3.5%) and 0.2% (95% CI: 0.1% to 0.2%) among the pregnant women, respectively. Maternal HIV-HBV coinfection was a risk factor for low birth weight (adjusted OR (aOR)=5.52, 95% CI: 1.97 to 15.40). Compared with the HIV mono-infection group, the risk of low birth weight was significantly higher in the HIV-HBV coinfection group (aOR=3.62, 95% CI: 1.24 to 10.56). Maternal HIV infection was associated with an increased risk of low birth weight (aOR=1.90, 95% CI: 1.38 to 2.60) and preterm delivery (aOR=2.84, 95% CI: 1.81 to 4.47). Perinatal death was more common when mothers were infected with HBV (aOR=2.85, 95% CI: 1.54 to 5.26).

CONCLUSIONS

The prevalence of HIV infection was high among pregnant women of the Yi region. Both HIV and HBV infections might have adverse effects on pregnancy outcomes. Maternal HIV-HBV coinfection might be a risk factor for low birth weight in the Yi region, which needs to be confirmed.

Timing is everything: assessing the impact of maternal HIV infection diagnosis timing on infant outcomes in a ten-year retrospective cohort study in South Carolina

The aims were to evaluate the impact of maternal HIV infection diagnosis timing on infant outcomes. The outcomes of interest included preterm delivery (PTD) and confirmed infant HIV infection. Data for all HIV-exposed infants from 2004-14 were obtained. Maternal HIV infection diagnosis timing was categorized as: perinatal (PHIV), adult infection before conception, and after conception. Infant outcomes were compared according to timing of maternal HIV diagnosis. Bivariate outcomes were compared using χ ² tests. Continuous variables were compared using Kruskal-Wallis tests. Logistic regression was used to determine predictors of PTD and infant HIV infection. Most women were diagnosed with HIV before conception: PHIV (21, 3%), before conception (431, 69%), and post-conception (176, 28%). Women diagnosed with HIV as an adult before conception were more likely to deliver preterm (P = 0.007). Prenatal care was associated with lower risk of PTD (aOR 0.1, 95% CI 0.04-0.5). Six infants contracted HIV. Infant HIV infection was more likely in women who did not take antiretroviral therapy (aOR 13.5, 95% CI 2.5-72.1) or delivered preterm (aOR 5.3, 95% 1.1-25.1). Women with PHIV were more likely to deliver at term, and there were no HIV infections among PHIV-exposed infants. These findings are reassuring to PHIV women who desire pregnancy.

Simulation Modeling and Metamodeling to Inform National and International HIV Policies for Children and Adolescents

Objective and Approach:

Computer-based simulation models serve an important purpose in informing HIV care for children and adolescents. We review current model-based approaches to informing pediatric and adolescent HIV estimates and guidelines.

Findings:

Clinical disease simulation models and epidemiologic models are used to inform global and regional estimates of numbers of children and adolescents living with HIV and in need of antiretroviral therapy, to develop normative guidelines addressing strategies for diagnosis and treatment of HIV in children, and to forecast future need for pediatric and adolescent antiretroviral therapy formulations and commodities. To improve current model-generated estimates and policy recommendations, better country-level and regional-level data are needed about children living with HIV, as are improved data about survival and treatment outcomes for children with perinatal HIV infection as they age into adolescence and adulthood. In addition, novel metamodeling and value of information methods are being developed to improve the transparency of model methods and results, as well as to allow users to more easily tailor model-based analyses to their own settings.

Conclusions:

Substantial progress has been made in using models to estimate the size of the pediatric and adolescent HIV epidemic, to inform the development of guidelines for children and adolescents affected by HIV, and to support targeted implementation of policy recommendations to maximize impact. Ongoing work will address key limitations and further improve these model-based projections.

The Reproductive Years of Women with Perinatally Acquired HIV: From Gynecologic Care to Obstetric Outcomes

Women with PHIV have distinct medical and social concerns in the context of lifelong immunosuppression, complex HIV care, and stigma because of with HIV from an early age. This article reviews the gynecologic and obstetric concerns experienced by women with PHIV. Cervical cancer screening is suboptimal, and data suggest higher rates of unintended pregnancy. Pregnant women with PHIV are younger and exposed to more antiretroviral therapy regimens compared with women with NPHIV. Although obstetric outcomes are similar between women with PHIV and NPHIV, there are concerns that infant morbidity may be increased in infants of women with PHIV.

Maternal Perinatal HIV Infection Is Associated With Increased Infectious Morbidity in HIV-exposed Uninfected Infants

BACKGROUND

The aging population of females with perinatally-acquired HIV (PHIV) are having their own children. HIV-exposed uninfected infants (HEU-N) born to women living with non-perinatally-acquired HIV (NPHIV) experience higher infectious morbidity compared with HIV-unexposed infants (HUU). Little is known about the infectious morbidity risk of HIV-exposed uninfected infants (HEU-P) born to PHIV women.

METHODS

We evaluated prevalence of infectious cause hospitalizations (ICH) during the first year of life among HEU-P, HEU-N and HUU infants in a United States (U.S) tertiary care center. Maternal HIV status was categorized as PHIV vs. NPHIV vs. HIV-uninfected. Generalized Estimating Equation models were fit to evaluate the association between maternal HIV status and infant ICH.

RESULTS

ICH was evaluated among 205 infants, 28 HEU-P infants, 112 HEU-N infants, and 65 HUU infants. PHIV women were younger compared with NPHIV and HIV-uninfected women (median age 22 years vs. 29 and 23 respectively, p<0.01). Overall, 21% of HEU-P, 4% of HEU-N and 12% of HUU infants experienced at least one ICH event (p<0.01) in the first year of life. After adjusting for confounders, HEU-P infants were at increased ICH risk compared with HEU-N infants [adjusted odds ratio (aOR)=7.45, 95% Confidence Interval (CI):1.58-35.04]. In sub-group analysis of HEU infants, excluding HUU infants, this relationship persisted after adjustment for maternal CD4 and HIV RNA level (aOR=10.24, 95% CI:1.66-63.31) CONCLUSIONS:: In a small U.S. cohort, HEU-P infants experienced increased ICH risk. Differences in intrauterine environments, social factors, or access to care may be important factors to assess in future larger studies.

Pregnancy outcomes in young mothers with perinatally and behaviorally acquired HIV infections in Rio de Janeiro

BACKGROUND

Perinatally HIV-infected children are surviving into adulthood, and getting pregnant. There is a scarcity of information on health and pregnancy outcomes in these women.

AIM

To evaluate characteristics related to HIV disease and pregnancy outcomes in perinatally infected women, and to compare these women with a group of youth with behaviorally acquired HIV-infection, at a reference hospital in Rio de Janeiro, Brazil.

METHODS

A cohort study. Epidemiological, clinical, and laboratory data were compared between perinatally (PHIV) and behaviorally HIV-infected (BHIV) pregnant youth with the primary aim to study pregnancy outcomes in the PHIV group and compare with outcomes to BHIV group.

RESULTS

Thirty-two pregnancies occurred in PHIV group, and 595 in BHIV group. A total of seven (22%) PHIV women and 64 (11%) BHIV women had a premature delivery (p=0.04), however, when adjusting for younger age at pregnancy, and antiretroviral therapy initiation in 1st trimester of pregnancy (OR=18.66, 95%CI=5.52-63.14), the difference was no longer significant. No cases of mother-to-child HIV transmission (MTCT) were observed in the PHIV group while there was a 2% MTCT rate in BHIV group.

CONCLUSION

Pregnancy among PHIV was as safe as among BHIV. The differences between those groups were probably related to treatment and prolonged care in the first group.

Birth Weight and Preterm Delivery Outcomes of Perinatally vs Nonperinatally Human Immunodeficiency Virus-Infected Pregnant Women in the United States: Results From the PHACS SMARTT Study and IMPAACT P1025 Protocol

Background

Pregnancy outcomes of perinatally human immunodeficiency virus-infected women (PHIV) are poorly defined.

Methods

We compared preterm delivery and birth weight (BW) outcomes (low BW [LBW], <2500 g), small-for-gestational-age [SGA], and BW z scores [BWZ]) in HIV-exposed uninfected infants of PHIV vs nonperinatally HIV-infected (NPHIV) pregnant women in the Pediatric HIV/AIDS Cohort Study Surveillance Monitoring of ART Toxicities or International Maternal Pediatric Adolescent AIDS Clinical Trials P1025 studies. Mixed effects models and log binomial models were used to assess the association of maternal PHIV status with infant outcomes. Age-stratified analyses were performed.

Results

From 1998 to 2013, 2270 HIV-infected pregnant women delivered 2692 newborns (270 born to PHIV and 2422 to NPHIV women). PHIV women were younger, (mean age 21 vs 25 years, P < .01) and more likely to have a pregnancy CD4 count <200 cells/mm3 (19% vs 11%, P = .01). No associations between maternal PHIV status and preterm delivery, SGA, or LBW were observed. After adjustment, BWZ was 0.12 lower in infants of PHIV vs NPHIV women (adjusted mean, -0.45 vs -0.33; P = .04). Among women aged 23-30 years (n = 1770), maternal PHIV was associated with LBW (aRR = 1.74; 95% confidence interval, 1.18, 2.58; P < .01).

Conclusion

The overall lack of association between maternal PHIV status and preterm delivery or infant BW outcomes is reassuring. The higher rates of LBW observed in PHIV women aged 23-30 years warrants further mechanism-based investigations as this is a rapidly growing and aging population worldwide.

Clinical Trials Registration

PHACS SMARTT study, NCT01310023.

Clinical Trials Registration

IMPAACT 1025, NCT00028145.

Long term engagement in HIV care among postpartum women with perinatal HIV infection in the United States

Despite growing literature on pregnancy in women with perinatally-acquired HIV infection (PHIV), little is known regarding HIV and reproductive health outcomes postpartum. We describe pregnancy, reproductive, and HIV care outcomes for 2 years postpartum among pregnant women with PHIV who delivered in a large urban health system in Atlanta, Georgia, USA from 2011-2016. We reviewed medical records of women with PHIV to estimate retention in HIV care (two HIV care visits or viral load measurements >90 days apart) and viral suppression (<200 copies/mL) at 12 and 24 months postpartum. Among 22 pregnant women with PHIV, 13 (59%) had a CD4 count of less than 300 cells/mm³ at the time of antenatal care entry; most (n = 13, 59%) women achieved viral suppression at time of delivery. Three quarters of women attended a postpartum HIV primary care visit, within an average of 193 (range 17-727) days. Only 4 (20%) women were retained and 3 (15%) virally suppressed at 12 postpartum, and 2 (12%) were retained and none virally suppressed at 24 months. Despite the unique challenges they face, multidisciplinary efforts are needed to engage women with PHIV during pregnancy and facilitate the transition to sustained HIV primary care in the postpartum period.

Pregnancy outcomes in perinatally HIV-infected young women in Madrid, Spain: 2000-2015

Background

An increasing number of perinatally HIV-infected women (PHIV) are reaching adulthood and becoming pregnant. Most PHIV women have been exposed to a high number of antiretroviral regimens, and they may have difficulties to achieve viral suppression. Psychosocial problems are not uncommon and could be an important barrier for treatment adherence. The effects of chronic HIV infection and long-term exposure to antiretroviral treatment of PHIV women cause concerns on the developing fetus. The aims of this study were to describe the prevention of mother-to-child transmission strategies in PHIV women and the infant outcomes in the Madrid Cohort of HIV-infected mother-infant pairs.

Methods

All PHIV pregnant women registered in the Cohort that gave birth from 2000 to 2015 were included in the study.

Results

Twenty-eight pregnancies in twenty-two perinatally infected women were registered. Most women were Caucasian and heavily treatment-experienced. Nine cases (32.1%) were at high risk of HIV mother-to-child transmission. Maternal HIV-1 viral load was detectable close to delivery in four women (14.3%). The management of these cases was described, and the treatment strategies were discussed. None of the newborns acquired HIV infection. Eight infants (28.6%) were small for gestational age.

Conclusions

This study included a large series of pregnancies among PHIV women attended according to a youth-centered care model. The challenges in the management of this population by health-care providers were described. Specific strategies to minimize perinatal transmission risks should be addressed in future collaborative studies.

Pregnancy incidence and outcomes in women with perinatal HIV infection

Objectives:

To estimate the incidence of first pregnancy in women living with perinatally acquired HIV (PHIV) in the United Kingdom and to compare pregnancy management and outcomes with age-matched women with behaviourally acquired HIV (BHIV).

Design:

The National Study of HIV in Pregnancy and Childhood is a comprehensive, population-based surveillance study that collects demographic and clinical data on all pregnant women living with HIV, their children, and all HIV-infected children in the United Kingdom and Ireland.

Methods:

The incident rate ratio of first pregnancy was calculated for all women of reproductive age who had been reported to the National Study of HIV in Pregnancy and Childhood as vertically infected children. These women and their pregnancies were compared to age-matched pregnant women with BHIV.

Results:

Of the 630 women with PHIV reported in the United Kingdom as children, 7% (45) went on to have at least one pregnancy, with 70 pregnancies reported. The incident rate ratio of first pregnancy was 13/1000 woman-years. The BHIV comparison group comprised 118 women (184 pregnancies). Women with PHIV were more likely to be on combined antiretroviral therapy at conception and have a lower baseline CD4⁺ cell count (P < 0.01 for both). In adjusted analysis, PHIV and a low baseline CD4⁺ cell count were risk factors for detectable viral load near delivery; older age at conception and being on combined antiretroviral therapy at conception reduced this risk.

Conclusion:

Women with PHIV in the United Kingdom have a low pregnancy incidence, but those who become pregnant are at risk of detectable viral load near delivery, reflecting their often complex clinical history, adherence, and drug resistance issues.

Antiretroviral Resistance and Pregnancy Characteristics of Women with Perinatal and Nonperinatal HIV Infection

Objective. To compare HIV drug resistance in pregnant women with perinatal HIV (PHIV) and those with nonperinatal HIV (NPHIV) infection. Methods. We conducted a multisite cohort study of PHIV and NPHIV women from 2000 to 2014. Sample size was calculated to identify a fourfold increase in antiretroviral (ARV) drug resistance in PHIV women. Continuous variables were compared using Student's t-test and Wilcoxon rank-sum tests. Categorical variables were compared using χ² and Fisher's exact tests. Univariate analysis was used to determine factors associated with antiretroviral drug resistance. Results. Forty-one PHIV and 41 NPHIV participants were included. Women with PHIV were more likely to have drug resistance than those with NPHIV ((55% versus 17%, p = 0.03), OR 6.0 (95% CI 1.0–34.8), p = 0.05), including multiclass resistance (15% versus 0, p = 0.03), and they were more likely to receive nonstandard ARVs during pregnancy (27% versus 5%, p = 0.01). PHIV and NPHIV women had similar rates of preterm birth (11% versus 28%, p = 0.08) and cesarean delivery (47% versus 46%, p = 0.9). Two infants born to a single NPHIV woman acquired HIV infection. Conclusions. PHIV women have a high frequency of HIV drug resistance mutations, leading to nonstandard ARVs use during pregnancy. Despite nonstandard ARV use during pregnancy, PHIV women did not experience increased rates of adverse pregnancy outcomes.

Viral Suppression and Resistance in a Cohort of Perinatally-HIV Infected (PHIV+) Pregnant Women

Our objective was to describe viral suppression and antiretroviral (ARV) resistance mutations in an ongoing cohort of perinatally-infected HIV+ (PHIV+) pregnant women. Descriptive analysis was performed using SPSS 18.0. From 2011 to 2014, we followed 22 PHIV+ pregnant women. Median age at prenatal entry was 19 years (Interquartile range (IQR) 17.6–21.0); 86% had an AIDS diagnosis; 81% had disclosed their HIV status to partner 11. The median age at HIV diagnosis was 8.3 y (IQR 4.0–13.6), the median age at sexual debut was 16 years (IQR 14–18). At the time of prenatal care initiation, four (18%) were on their first antiretroviral treatment (ART), eight (36%) in their second regimen and nine (41%) in their third regimen or beyond, and one had no data. Seventeen of 22 (77%) had HIV-viral load (VL) > 50 copies/mL at prenatal care entry, 16 had a genotyping exam performed. Seventeen of 22 PHIV+ had VL results near delivery: 7/17 (41%) had VL < 50 copies/mL. Among those who had genotyping at prenatal entry, 11/16 (69%) had mutations associated with ARV resistance. The most frequent major mutations were K103N, M184V, T215, M41L, D67N at reverse transcriptase gene and M46, I54V and V82A at protease gene. No vertical transmissions occurred. Management of pregnancy among PHIV+ is challenging. Individualized ART are needed to achieve viral suppression in a highly ART-exposed subpopulation.

Growth patterns in the first year of life differ in infants born to perinatally vs. nonperinatally HIV-infected women

OBJECTIVE

To compare the growth patterns in the first year of life between children born to perinatally HIV-infected (PHIV) vs. nonperinatally HIV-infected (NPHIV) women in the United States.

DESIGN

Retrospective cohort study of HIV-infected pregnant women who received care and delivered a live-born at two urban tertiary centers from January 2004 to March 2012.

METHODS

We collected data via chart review on demographics, behavioral risk factors, HIV clinical markers, combination antiretroviral therapy (cART), mode of HIV acquisition, pregnancy outcomes, and infant anthropometrics on study participants. Mixed-effects models were used to assess the association between maternal mode of HIV acquisition and weight-for-age z-score (WAZ), length-for-age z-score (LAZ), and weight-for-length z-score (WLZ).

RESULTS

Of the 152 pregnancies evaluated, 32 and 120 infants were born to 25 PHIV and 99 NPHIV women, respectively. Infants of PHIV women exhibited lower mean WAZ and LAZ throughout the first year of life in unadjusted analyses. After adjusting for potential confounders, the relationship between PHIV women and LAZ persisted (β = -0.54, P = 0.026). Small-for-gestational age for each birth anthropometric parameter (birth length, birth weight, and both birth length and weight) was associated with decreased LAZ (β = -0.48, P = 0.007), WAZ (β = -0.99, P < 0.001), and WLZ (β = -0.36, P = 0.027), respectively. A delivery HIV RNA level below 400 copies/ml was associated with increased WAZ and WLZ (β = 0.43, P = 0.015 and β = 0.38, P = 0.021, respectively).

CONCLUSIONS

Infants of PHIV women may remain at persistently decreased lengths throughout the first year of life. Further studies aimed at understanding intrauterine and environmental factors in PHIV women are warranted.

Risk of intrauterine growth restriction among HIV-infected pregnant women: a cohort study

The purpose of this investigation was to study the risk of intrauterine growth restriction in human immunodeficiency virus (HIV)-infected women and to describe the associated risk factors. A cohort study was performed among HIV-infected women who delivered in a single tertiary centre in Barcelona, Spain, from January 2006 to December 2011. Consecutive singleton pregnancies delivered beyond 22 weeks of pregnancy were included. Intrauterine growth restriction (IUGR) was defined as a birth weight below the 10th customised centile for gestational age and IUGR babies were compared to non-IUGR newborns. Intrauterine Doppler findings were described among IUGR foetuses. Baseline characteristics, HIV infection data and perinatal outcome were compared between groups. The results were adjusted for potential confounders. A total of 156 singleton pregnancies were included. IUGR occurred in 23.4 % of cases (38/156). In two-thirds of the cases detected before birth, Doppler abnormalities compatible with placental insufficiency were observed. IUGR pregnancies presented a worse perinatal outcome, mainly due to a higher risk of iatrogenic preterm delivery [adjusted odds ratio 6.9, 95 % confidence interval (CI) 1.4-33.5]. IUGR foetuses also had a higher risk of emergent Caesarean section and neonatal intensive care unit admission. No cases of intrauterine foetal death occurred. A high rate of IUGR was observed among HIV pregnancies, and it was associated with adverse perinatal outcomes, mainly iatrogenic preterm and very preterm birth due to placental insufficiency. Our results support that ultrasound detection and follow-up of IUGR foetuses should be part of routine antenatal care in this high-risk population to improve antenatal management.