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Erlwanger A, Rocroi I, Kirtley S, Hemelaar J. Perinatal outcomes associated with pre-exposure prophylaxis for HIV prevention during pregnancy: a systematic review and meta-analysis. EClinicalMedicine 2024; 70:102532. [PMID: 38685925 PMCID: PMC11056414 DOI: 10.1016/j.eclinm.2024.102532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 05/02/2024] Open
Abstract
Background The World Health Organization (WHO) recommends tenofovir disoproxil fumarate (TDF)-based oral pre-exposure prophylaxis (PrEP), the dapivirine vaginal ring, and long-acting intramuscular injectable cabotegravir (CAB-LA) for HIV prevention in populations at substantial risk of HIV infection. Pregnancy is a period of elevated risk of maternal HIV infection and transmission to the infant. This systematic review and meta-analysis assessed the risk of adverse perinatal outcomes among HIV-negative pregnant women with exposure to any PrEP modality. Methods We conducted a systematic review by searching Medline, EMBASE, CINAHL, Global Health, the Cochrane Library, WHO ICTR, ISRCTN, PACTR, and ClinicalTrials.gov for studies published between 1 January 2000 and 29 August 2023. We included studies reporting on the association of antenatal exposure to any PrEP modality with 13 perinatal outcomes: preterm birth (PTB), very PTB, spontaneous PTB, spontaneous very PTB, low birthweight (LBW), very LBW, term LBW, preterm LBW, small for gestational age (SGA), very SGA, miscarriage, stillbirth, or neonatal death (NND). Quality assessments of included studies were performed. Fixed-effect meta-analyses were conducted to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs). The protocol is registered with PROSPERO, CRD42022339825. Findings Of 18,598 citations identified, 13 studies (eight randomised controlled trials (RCTs) and five cohort studies), assessing 8712 pregnant women in Africa, were included. Oral PrEP, compared to no PrEP, was not associated with PTB in meta-analyses of six RCTs (OR 0.73, 95% CI 0.43-1.26; I2 = 0.0%) or five unadjusted cohort studies (OR 0.84, 95% CI 0.69-1.03; I2 = 0.0%), but was associated with a reduced risk of PTB in three adjusted cohort studies (aOR 0.67; 95% CI 0.52-0.88, I2 = 0.0%). There was no association of oral PrEP with LBW, vLBW, SGA, or NND, compared to no PrEP. There was no association with PTB when oral TDF/emtricitabine (FTC) PrEP, oral TDF PrEP, and tenofovir vaginal gel were compared to each other. There was no association of the dapivirine vaginal ring with PTB or NND, compared to placebo or oral TDF/FTC PrEP. We found no data on CAB-LA. Interpretation We found no evidence of adverse perinatal outcomes associated with PrEP exposure during pregnancy. Our findings support the WHO recommendation to provide oral PrEP to women of reproductive age and pregnant women. More data is needed to assess the safety of all PrEP modalities in pregnancy. Funding None.
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Affiliation(s)
- Alison Erlwanger
- National Perinatal Epidemiology Unit, Infectious Disease Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle Rocroi
- National Perinatal Epidemiology Unit, Infectious Disease Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Infectious Disease Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Goulding AN, Meeks K, Shay L, Casey S, Applegarth C, McKinney J. Antiretroviral Therapy in Pregnancy: A 2023 Review of the Literature. Curr HIV/AIDS Rep 2024; 21:1-10. [PMID: 38277098 PMCID: PMC11095844 DOI: 10.1007/s11904-024-00688-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE OF REVIEW Selection of antiretroviral therapy during pregnancy must consider maternal physiology and resulting pharmacokinetic changes in pregnancy, resistance and efficacy profiles, tolerability and frequency of adverse effects, teratogenicity, and maternal, neonatal, and pregnancy outcomes. The objective of this review is to summarize the underlying data that informs the current clinical perinatal guidelines in the USA. RECENT FINDINGS Data now supports the use of dolutegravir at all stages of pregnancy with no significant increase in neural tube defects. Safety and pharmacokinetic data on newer antiretroviral medications in pregnancy continue to lag behind the general population. While there are multiple safety and tolerability concerns with older regimens, there are now multiple options of regimens that are highly efficacious and have good safety data in pregnancy. Most pregnant patients who are virally suppressed on a well-tolerated regimen are able to safely continue those medications during pregnancy.
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Affiliation(s)
- Alison N Goulding
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Kasey Meeks
- School of Medicine, Saint Louis University, Saint Louis, MO, USA
| | - Lena Shay
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Sarah Casey
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Colton Applegarth
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jennifer McKinney
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA.
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Modjadji P, Mokgalaboni K, Nonterah EA, Lebelo SL, Mchiza ZJR, Madiba S, Kengne AP. A Systematic Review on Cardiometabolic Risks and Perinatal Outcomes among Pregnant Women Living with HIV in the Era of Antiretroviral Therapy. Viruses 2023; 15:1441. [PMID: 37515129 PMCID: PMC10385451 DOI: 10.3390/v15071441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/23/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023] Open
Abstract
Antiretroviral therapy (ART) regimens have been shown to cause metabolic changes in people living with HIV (PLWH), predisposing them to cardiometabolic disease (CVMD). However, such evidence is less established in pregnant women living with HIV (pWLWH) on ART. Pregnancy-induced cardiometabolic risks (CMR) can predispose to unfavourable pregnancy outcomes and further persist in the postpartum period, resolve, and recur in subsequent pregnancies, or emerge as newly diagnosed chronic diseases of ageing. Therefore, this systematic review aimed at synthesizing evidence on CMR and perinatal outcomes among pWLWH in the era of ART. We considered prospective and retrospective cohorts, case-control, cross-sectional, and interventional studies published in English. Specific keywords were used to conduct a thorough literature search on PubMed-Medline and Scopus following the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline. Two investigators independently screened the search outputs and reviewed full texts of potentially eligible articles. Data extraction was conducted by one investigator and verified by the second investigator. Thirty-one relevant studies conducted on 20,904 pWLWH on ART across Africa, Asia, Europe, and America were included. Studies demonstrate inconclusive findings, especially on perinatal outcomes, but significant risks of gestational hypertension and dyslipidemia were reported in pWLWH on ART compared to the control group. Therefore, future studies should focus more on these perinatal outcomes, and their impact on postpartum maternal health and growth trajectories of uninfected infants born from pWLWH who are either on ART or ART-naïve in comparison to infants born of HIV-negative mothers over the life course, especially in HIV-burdened African countries.
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Affiliation(s)
- Perpetua Modjadji
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Tygerberg, Cape Town 7505, South Africa
| | - Kabelo Mokgalaboni
- Department of Life and Consumer Sciences, College of Agriculture and Environmental Sciences, University of South Africa, Florida Campus, Johannesburg 1709, South Africa
| | - Engelbert A Nonterah
- Navrongo Health Research Centre, Ghana Health Service, Navrongo P.O. Box 114, Ghana
| | - Sogolo Lucky Lebelo
- Department of Life and Consumer Sciences, College of Agriculture and Environmental Sciences, University of South Africa, Florida Campus, Johannesburg 1709, South Africa
| | - Zandile June-Rose Mchiza
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Tygerberg, Cape Town 7505, South Africa
| | - Sphiwe Madiba
- Faculty of Health Sciences, University of Limpopo, Polokwane 0700, South Africa
| | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Tygerberg, Cape Town 7505, South Africa
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Ugwu EO, Eleje GU, Ugwu AO, Nwagha UI, Ikechebelu JI, Umeh UA, Okafor HU. Antivirals for prevention of hepatitis B virus mother-to-child transmission in human immunodeficiency virus positive pregnant women co-infected with hepatitis B virus. Cochrane Database Syst Rev 2023; 6:CD013653. [PMID: 37306558 PMCID: PMC10259198 DOI: 10.1002/14651858.cd013653.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Hepatitis B virus (HBV)-human Immunodeficiency virus (HIV) co-infection promotes an aggressive disease course of HBV infection. In the only available non-Cochrane systematic review on antiviral therapy during pregnancy for prevention of mother-to-child transmission of HBV, none of the women studied had HBV-HIV co-infection but were either HBV- or HIV-seropositive. Treatment of HBV alone may develop HIV-strains that are resistant to non-nucleoside reverse transcriptase inhibitors. Accordingly, co-treatment of the HIV infection is recommended. OBJECTIVES To evaluate the benefits and harms of tenofovir-based antiviral combination regimens versus placebo, tenofovir alone, or non-tenofovir-based antiviral regimen either alone or in combination with HBV for the prevention of mother-to-child transmission of HBV in HIV-positive pregnant women co-infected with HBV. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase Ovid, LILACS (Bireme), Science Citation Index Expanded (Web of Science), and Conference Proceedings Citation Index-Science (Web of Science) on 30 January 2023. We manually searched the reference lists of included trials, searched on-line trial registries, and contacted experts in the field and pharmaceutical companies for any further potential trials. SELECTION CRITERIA We aimed to include randomised clinical trials comparing tenofovir-based antiviral combination regimens (anti-HIV regimen with lopinavir-ritonavir therapy, or any other antiviral therapy, and two drugs with activity against HBV, specifically, tenofovir alafenamide (TAF) or tenofovir disoproxil fumarate (TDF), plus lamivudine or emtricitabine) with placebo alone, or tenofovir alone, or non-tenofovir-based antiviral regimen (zidovudine, lamivudine, telbivudine, emtricitabine, entecavir, lopinavir-ritonavir, or any other antiviral therapy) either alone or in combination with at least two other antivirals. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Primary outcomes included all-cause infant mortality, proportion of infants with serious adverse events, proportion of infants with HBV mother-to-child transmission, all-cause maternal mortality, and proportion of mothers with serious adverse events. Secondary outcomes included proportion of infants with adverse events not considered serious, proportion of mothers with detectable HBV DNA (deoxyribonucleic acid) (before delivery), maternal hepatitis B e antigen (HBeAg) to HBe-antibody seroconversion (before delivery) and maternal adverse events not considered serious. We used RevMan Web to carry out analyses and presented results, where feasible, using a random-effects model and risk ratios (RR) with 95% confidence intervals (CIs). We performed sensitivity analysis. We assessed risk of bias using predefined domains, assessed the certainty of the evidence using GRADE, controlled risk of random errors with Trial Sequential Analysis, and presented outcome results in a summary of findings table. MAIN RESULTS Five completed trials were included, of which four trials contributed data to one or more of the outcomes. They included a total of 533 participants randomised to tenofovir-based antiviral combination regimens (196 participants) versus control (337 participants). The control groups received non-tenofovir-based antiviral regimens either as zidovudine alone (three trials) or as a combination of zidovudine, lamivudine and lopinavir-ritonavir (five trials). None of the trials used placebo or tenofovir alone. All trials were at unclear risk of bias. Four trials used intention-to-treat analyses. In the remaining trial, two participants in the intervention group and two in the control group were lost to follow-up. However, the outcomes of these four participants were not described. Tenofovir-based antiviral combination regimen versus control We are very uncertain about the effect of a tenofovir-based antiviral combination regimen versus control on all-cause infant mortality (RR 2.24, 95% CI 0.72 to 6.96; participants = 132; trials = 1; very low-certainty evidence); proportion of infants with serious adverse events (RR 1.76, 95% CI 1.27 to 2.43; participants = 132; trials = 1; very low-certainty evidence), and proportion of mothers with serious adverse events (RR 0.90, 95% CI 0.62 to 1.32; participants = 262; trials = 2; very low-certainty evidence). No trial reported data on the proportion of infants with HBV mother-to-child transmission and all-cause maternal mortality. We are also very uncertain about the effect of tenofovir-based antiviral combination regimens versus control on the proportion of infants with adverse events not considered serious (RR 0.94, 95% CI 0.06 to 13.68; participants = 31; trials = 1; very low-certainty evidence), and proportion of mothers with detectable HBV DNA (before delivery) (RR 0.66, 95% CI 0.42 to 1.02; participants = 169; trials = 2; very low-certainty evidence). No trial reported data on maternal hepatitis B e antigen (HBeAg) to HBe-antibody seroconversion (before delivery) and maternal adverse events not considered serious. All trials received support from industry. AUTHORS' CONCLUSIONS We do not know what the effects of tenofovir-based antiviral combination regimens are on all-cause infant mortality, proportion of infants with serious adverse events and proportion of mothers with serious adverse events, proportion of infants with adverse events not considered serious, and proportion of mothers with detectable HBV DNA before delivery because the certainty of evidence was very low. Only one or two trials, with insufficient power, contributed data for analyses. We lack randomised clinical trials at low risk of systematic and random errors, and fully reporting all-cause infant mortality, serious adverse events and reporting on clinical and laboratory outcomes, such as infants with HBV mother-to-child transmission, all-cause maternal mortality, maternal hepatitis B e antigen (HBeAg) to HBe-antibody seroconversion before delivery and maternal adverse events not considered serious.
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Affiliation(s)
- Emmanuel O Ugwu
- Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, College of Medicine, University of Nigeria Nsukka/University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu State, Enugu, Nigeria
| | - George U Eleje
- Effective Care Research Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, PMB 5001, Nnewi, Nigeria
| | - Angela O Ugwu
- Department of Haematology and Immunolology, College of Medicine, University of Nigeria Nsukka/University of Nigeria Teaching Hospital Ituku Ozalla, Enugu State, Enugu, Nigeria
| | - Uchenna I Nwagha
- Department of Haematology and Immunology, Faculty of Medical Sciences, College of Medicine, University of Nigeria Nsukka/University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu State, Enugu, Nigeria
| | - Joseph I Ikechebelu
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Uchenna A Umeh
- Department of Obstetrics and Gynaecology, Faculty of Medical Science, College of Medicine, University of Nigeria Enugu Campus/University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu State, Enugu, Nigeria
| | - Henrietta U Okafor
- Department of Paediatrics, Faculty of Medical Sciences, College of Medicine, University of Nigeria Enugu Campus/University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu State, Enugu, Nigeria
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Moseholm E, Katzenstein TL, Pedersen G, Johansen IS, Wienecke LS, Storgaard M, Obel N, Weis N. Use of antiretroviral therapy in pregnancy and association with birth outcome among women living with HIV in Denmark: A nationwide, population-based cohort study. HIV Med 2022; 23:1007-1018. [PMID: 35388607 PMCID: PMC9545374 DOI: 10.1111/hiv.13304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/25/2022] [Accepted: 03/12/2022] [Indexed: 11/28/2022]
Abstract
Objective To describe antiretroviral therapy (ART) regimens during pregnancy among women living with HIV (WLWH) in Denmark and to examine the association between ART use in pregnancy and adverse birth outcomes. Methods A population‐based cohort study including all pregnancies among WLWH in Denmark between 2000 and 2019. Data were collected through national registries. Temporal trends of ART use in pregnancy were evaluated. Logistic regression models were used to examine the association of ART use in pregnancy and other risk factors with adverse birth outcomes. Results In total, 589 pregnancies were included. Combination treatment with a nucleoside reverse transcriptase inhibitor (NRTI) and a protease inhibitor (PI) was the most common ART regimen (96%). ART regimen, PI use in pregnancy and timing of ART initiation were not significantly associated with increased odds of preterm birth, small for gestational age or low birth weight. First‐trimester initiation of ART was significantly associated with increased odds of intrauterine growth restriction in the multivariate analysis [adjusted odds ratio (aOR) = 3.78, 95% confidence interval (CI): 1.23–11.59], while first trimester PI use was associated with increased odds of IUGR in the univariate analysis only [OR = 3.24, 95% CI: 1.13–9.30]. Smoking, comorbidity, and maternal HIV RNA ≥ 50 copies/mL were independently associated with increased odds of adverse birth outcomes. Conclusions Pregnant WLWH living in Denmark are generally well treated with HIV RNA < 50 copies/mL at delivery and NRTI + PI as the most common ART regimen used in pregnancy. Initiation of ART in the first trimester may be associated with poor fetal growth. The association between ART use in pregnancy and adverse birth outcomes may partly be explained by maternal risk factors.
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Affiliation(s)
- Ellen Moseholm
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark.,Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Terese Lea Katzenstein
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Gitte Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nina Weis
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Dapar MP, Joseph BN, Okunlola RC, Mutihir J, Chingle MP, Banwat ME. Pregnancy and Birth Outcomes Among Women on Antiretroviral Therapy: A Long-term Retrospective Analysis of Data from a Major Tertiary Hospital in North Central Nigeria. Int J MCH AIDS 2021; 10:183-190. [PMID: 34754614 PMCID: PMC8564061 DOI: 10.21106/ijma.511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Antiretroviral therapy (ART) has transformed human immune deficiency virus (HIV) infection from a death sentence to a chronic syndrome, allowing infected individuals to lead near-normal lives, including achieving pregnancy and bearing children. Notwithstanding, concerns remain about the effects of ART in pregnancy. Previous studies suggested contradictory associations between ART and pregnancy. This study determined birth outcomes in pregnant women who accessed ART between 2004 and 2017 at a major tertiary hospital in North Central Nigeria. METHODS This was a retrospective study of 5,080 participants. Ethical clearance was obtained from the Institutional Review Board of the Harvard T. H. Chan School of Public Health Boston. A pro forma for data abstraction was designed and used to collect data. Abstracted data were sorted and managed using SPSS® version 22. The Chi-square test was used to calculate the proportions of pregnancy outcomes. One-way analysis of variance was used to test the effect of antiretroviral drug regimens on mean birth weight and gestational age at delivery. All levels of significance were set at p 0.05. RESULTS Pregnancy outcomes were recorded as live birth (99.8%), stillbirth (0.2%), preterm delivery (6.6%), and low birth weight (23%). There was a statistically significant association between ART in pregnancy and low birth weight {χ2 [(5, n = 3439) = 11.99, p = 0.04]}. The highest mean birth weights were recorded in participants who received drug combinations with protease inhibitors or efavirenz, in contrast to participants who received Nevirapine, stavudine and Emtricitabine/Tenofovirbased regimens. However, there was no significant difference in the gestational age of babies at birth for the six ART regimens in the study. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS Findings support the benefits of ART in pregnancy, which is in line with the testing and treatment policies of the 90-90-90 targets for ending HIV by the year 2030.
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Affiliation(s)
- Maxwell P. Dapar
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, University of Jos, Nigeria
| | - Benjamin N. Joseph
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, University of Jos, Nigeria
| | - Rotkangmwa C. Okunlola
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, University of Jos, Nigeria
| | - Josiah Mutihir
- Department of Obstetrics and Gynecology, College of Health Sciences, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - Moses P. Chingle
- Department of Community Medicine, College of Health Sciences, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - Mathilda E. Banwat
- Department of Community Medicine, College of Health Sciences, University of Jos and Jos University Teaching Hospital, Jos Nigeria
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Tukei VJ, Hoffman HJ, Greenberg L, Thabelo R, Nchephe M, Mots’oane T, Masitha M, Chabela M, Mokone M, Mofenson L, Guay L, Tiam A. Adverse Pregnancy Outcomes Among HIV-positive Women in the Era of Universal Antiretroviral Therapy Remain Elevated Compared With HIV-negative Women. Pediatr Infect Dis J 2021; 40:821-826. [PMID: 33990522 PMCID: PMC8357042 DOI: 10.1097/inf.0000000000003174] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Without treatment, HIV infection in pregnant women is associated with adverse pregnancy outcomes. We compared adverse pregnancy outcomes among HIV-positive women on antiretroviral therapy (ART) and HIV-negative women who enrolled for antenatal care in selected health facilities in Maseru district, Lesotho. METHODS We enrolled a cohort of HIV-positive and HIV-negative women at their first antenatal visit and followed them through delivery. Study data on miscarriage, stillbirth, preterm birth, low birth weight and birth defects were collected through participant interviews and medical record abstraction. We used the Rao-Scott χ2 test and the t test to assess differences in characteristics and outcomes between HIV-positive and HIV-negative women and generalized estimating equations for multivariable analysis. RESULTS A total of 614 HIV-positive and 390 HIV-negative pregnant women were enrolled in the study with delivery information on 571 (93.1%) and 352 (90.3%) respectively. In the delivery cohort, the median age at enrolment was 28 years for HIV-positive women and 23 years for HIV-negative women with median gestational ages of 20 and 21 weeks, respectively. A total of 149 singleton pregnancies had documented adverse pregnancy outcomes; 33 (9.6%) HIV-negative pregnancies and 116 (20.6%) HIV-positive pregnancies. Compared with their HIV-negative counterparts, HIV-positive women were more likely to experience an adverse pregnancy outcome, adjusted odds ratio (AOR) 2.6 [95% confidence interval (CI): 1.71-3.97]; an intrauterine death (miscarriage or stillbirth), AOR 2.64 [95% CI: 1.25-5.49]; or a low birth weight delivery, AOR 1.89 [95% CI: 1.16-3.09]. CONCLUSION Adverse pregnancy outcomes remained 2-3 times higher among HIV-positive women compared with HIV-negative women despite universal ART.
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Affiliation(s)
- Vincent J. Tukei
- From the Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Heather J. Hoffman
- Department of Biostatistics and Bioinformatics, George Washington University Milken Institute School of Public Health, Washington, District of Columbia
| | - Lauren Greenberg
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
| | | | | | | | - Matseliso Masitha
- From the Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Mammatli Chabela
- From the Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Majoalane Mokone
- From the Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
| | - Laura Guay
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
- Department of Epidemiology, George Washington University Milken Institute School of Public Health, Washington, District of Columbia
| | - Appolinaire Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
- Department of global public health and primary care, Center for International Health, University of Bergen, Bergen, Norway
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Efficacy and safety of antiviral prophylaxis during pregnancy to prevent mother-to-child transmission of hepatitis B virus: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2020; 21:70-84. [PMID: 32805200 DOI: 10.1016/s1473-3099(20)30586-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/10/2020] [Accepted: 07/10/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND To eliminate mother-to-child transmission (MTCT) of hepatitis B virus (HBV), peripartum antiviral prophylaxis might be required for pregnant women infected with HBV who have a high risk of MTCT despite infant immunoprophylaxis. We aimed to determine the efficacy and safety of peripartum antiviral prophylaxis to inform the 2020 WHO guidelines. METHODS In this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, CENTRAL, CNKI, and Wanfang for randomised controlled trials and non-randomised studies of peripartum antiviral prophylaxis versus placebo or no prophylaxis, with no language restriction, published from database inception until March 28, 2019. We used search terms covering HBV, antiviral therapy, and pregnancy. We included studies that enrolled pregnant women with chronic infection with HBV who received antiviral prophylaxis anytime during pregnancy; that included any of the following antivirals: adefovir, emtricitabine, entecavir, lamivudine, telbivudine, tenofovir alafenamide fumarate, and tenofovir disoproxil fumarate; and that reported the following outcomes: MTCT, indicated by infant HBsAg positivity or HBV DNA positivity, or both, at age 6-12 months, and any infant or maternal adverse events. Two reviewers independently extracted data. Our primary endpoint was MTCT based on infant HBsAg positivity. We assessed pooled odds ratios (ORs) of the efficacy of peripartum antiviral prophylaxis to reduce the risk of MTCT. We assessed safety of prophylaxis by pooling risk differences. The protocol for the systematic review was pre-registered in PROSPERO, CRD42019134614. FINDINGS Of 7463 articles identified, 595 articles were eligible for full-text review and 129 studies (in 157 articles) were included. The following antivirals were assessed in the meta-analysis: tenofovir disoproxil fumarate 300 mg (19 studies, with 1092 mothers and 1072 infants), lamivudine 100-150 mg (40 studies, with 2080 mothers and 2007 infants), and telbivudine 600 mg (83 studies, with 6036 mothers and 5971 infants). The pooled ORs for randomised controlled trials were similar, at 0·10 (95% CI 0·03-0·35) for tenofovir disoproxil fumarate, 0·16 (0·10-0·26) for lamivudine, and 0·14 (0·09-0·21) for telbivudine. The pooled ORs in non-randomised studies were 0·17 (0·10-0·29) for tenofovir disoproxil fumarate, 0·17 (0·12-0·24) for lamivudine, and 0·09 (0·06-0·12) for telbivudine. We found no increased risk of any infant or maternal safety outcomes after peripartum antiviral prophylaxis. INTERPRETATION Peripartum antiviral prophylaxis is highly effective at reducing the risk of HBV MTCT. Our findings support the 2020 WHO recommendation of administering antivirals during pregnancy, specifically tenofovir disoproxil fumarate, for the prevention of HBV MTCT. FUNDING World Health Organization.
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Ugwu EO, Eleje GU, Ugwu AO, Nwagha UI, Ikechebelu JI, Umeh UA, Okafor HU. Antivirals for prevention of hepatitis B virus mother-to-child transmission in human immunodeficiency virus positive pregnant women co-infected with hepatitis B virus. Hippokratia 2020. [DOI: 10.1002/14651858.cd013653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Emmanuel O Ugwu
- Obstetrics and Gynaecology; University of Nigeria Enugu Campus/University of Nigeria Teaching Hospital Ituko-Ozalla; Enugu Nigeria
| | - George U Eleje
- Effective Care Research Unit, Department of Obstetrics and Gynaecology; Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus; PMB 5001, Nnewi Nigeria
| | - Angela O Ugwu
- Haematology and Immunolology; University of Nigeria Nsukka/University of Nigeria Teaching Hospital Ituku Ozalla; Enugu Nigeria
| | - Uchenna I Nwagha
- Department of Obstetrics and Gynaecology, Faculty of Medicine; University of Nigeria Enugu Campus/University of Nigeria Teaching Hospital Ituko-Ozalla; Enugu Nigeria
| | - Joseph I Ikechebelu
- Department of Obstetrics/Gynaecology; Nnamdi Azikiwe University Teaching Hospital; Nnewi Nigeria
| | - Uchenna A Umeh
- Department of Obstetrics and Gynaecology, Faculty of Medical Science; College of Medicine, University of Nigeria Enugu Campus/University of Nigeria Teaching Hospital Ituku-Ozalla; Enugu Nigeria
| | - Henrietta U Okafor
- Department of Paediatrics; Faculty of Medical Sciences, College of Medicine, University of Nigeria Enugu Campus/University of Nigeria Teaching Hospital Ituku-Ozalla; Enugu Nigeria
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10
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Gilleece DY, Tariq DS, Bamford DA, Bhagani DS, Byrne DL, Clarke DE, Clayden MP, Lyall DH, Metcalfe DR, Palfreeman DA, Rubinstein DL, Sonecha MS, Thorley DL, Tookey DP, Tosswill MJ, Utting MD, Welch DS, Wright MA. British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018. HIV Med 2020; 20 Suppl 3:s2-s85. [PMID: 30869192 DOI: 10.1111/hiv.12720] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Dr Yvonne Gilleece
- Honorary Clinical Senior Lecturer and Consultant Physician in HIV and Genitourinary Medicine, Brighton and Sussex University Hospitals NHS Trust
| | - Dr Shema Tariq
- Postdoctoral Clinical Research Fellow, University College London, and Honorary Consultant Physician in HIV, Central and North West London NHS Foundation Trust
| | - Dr Alasdair Bamford
- Consultant in Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Dr Sanjay Bhagani
- Consultant Physician in Infectious Diseases, Royal Free Hospital NHS Trust, London
| | - Dr Laura Byrne
- Locum Consultant in HIV Medicine, St George's University Hospitals NHS Foundation Trust, London
| | - Dr Emily Clarke
- Consultant in Genitourinary Medicine, Royal Liverpool and Broadgreen University Hospitals NHS Trust
| | - Ms Polly Clayden
- UK Community Advisory Board representative/HIV treatment advocates network
| | - Dr Hermione Lyall
- Clinical Director for Children's Services and Consultant Paediatrician in Infectious Diseases, Imperial College Healthcare NHS Trust, London
| | | | - Dr Adrian Palfreeman
- Consultant in Genitourinary Medicine, University Hospitals of Leicester NHS Trust
| | - Dr Luciana Rubinstein
- Consultant in Genitourinary Medicine, London North West Healthcare University NHS Trust, London
| | - Ms Sonali Sonecha
- Lead Directorate Pharmacist HIV/GUM, Chelsea and Westminster Healthcare NHS Foundation Trust, London
| | | | - Dr Pat Tookey
- Honorary Senior Lecturer and Co-Investigator National Study of HIV in Pregnancy and Childhood, UCL Great Ormond Street Institute of Child Health, London
| | | | - Mr David Utting
- Consultant Obstetrician and Gynaecologist, Brighton and Sussex University Hospitals NHS Trust
| | - Dr Steven Welch
- Consultant in Paediatric Infectious Diseases, Heart of England NHS Foundation Trust, Birmingham
| | - Ms Alison Wright
- Consultant Obstetrician and Gynaecologist, Royal Free Hospitals NHS Foundation Trust, London
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11
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Neary M, Owen A, Olagunju A. Pharmacokinetics of HIV therapies in pregnant patients: an update. Expert Opin Drug Metab Toxicol 2020; 16:449-461. [PMID: 32271621 DOI: 10.1080/17425255.2020.1754792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Mother-to-child transmission (MTCT) of HIV is thought to account for over 90% of new pediatric infections, and is associated with poor maternal and fetal outcomes. As such ensuring further reduction in MTCT is a priority in HIV treatment and prevention programs. AREAS COVERED This review aims to provide a comprehensive update on the pharmacokinetics of recently approved antiretroviral drugs and novel drug formulations and delivery systems. Alongside recent recommendations for dose adjustments, and an overview of the implications of co-infections on the pharmacokinetics of antiretrovirals relevant to pregnant HIV positive patients. Additionally, potential opportunities to progress pharmacokinetic research of new treatments in this population are highlighted. EXPERT OPINION In order to improve our understanding of how to provide safe and effective treatment to HIV positive pregnant women, further work is required to enable their inclusion in early stages of clinical trials. Incentives must be created for this research, in the form of additional investment by key stakeholders and regulatory agencies. Furthermore, as the incidence of MTCT is reduced globally there is a need to conduct long-term pharmacovigilance studies in uninfected children exposed to HIV and antiretrovirals in utero, in order to determine the safest and most effective antiretroviral therapies.
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Affiliation(s)
- Megan Neary
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool , Liverpool, UK
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool , Liverpool, UK
| | - Adeniyi Olagunju
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool , Liverpool, UK.,Faculty of Pharmacy, Obafemi Awolowo University , Ile-Ife, Nigeria
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12
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Venkatesh KK, Farhad M, Fenton T, Moodley D, Naik S, Nakabiito C, Fairlie L, Fowler MG, Stringer JSA, Chi BH. Association between HIV antiretroviral therapy and preterm birth based on antenatal ultrasound gestational age determination: a comparative analysis. AIDS 2019; 33:2403-2413. [PMID: 31764105 PMCID: PMC7293898 DOI: 10.1097/qad.0000000000002367] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the association between HIV antiretroviral therapy (ART) and preterm birth (PTB), when defined by gold standard antenatal ultrasound versus newborn exam. DESIGN A secondary analysis of the PROMISE 1077BF/1077FF randomized controlled trial, which compared antiretroviral strategies to reduce perinatal HIV transmission and improve maternal health. The trial used newborn exam (i.e. New Ballard Score, NBS) to assess gestational age. This analysis included liveborn singleton pregnancies with both newborn exam and ultrasound data. The primary exposure was the trial's antiretroviral strategies: zidovudine with intrapartum nevirapine ('ZDV alone'); zidovudine/lamivudine/lopinavir-ritonavir ('ZDV-based ART'); or tenofovir/emtricitabine/lopinavir-ritonavir ('TDF-based ART'). The primary outcome was PTB less than 37 and less than 34 weeks based on the gold standard of ultrasound dating. We evaluated the association between antiretroviral strategy and PTB. We fit multivariable logistic regression models, adjusting for maternal characteristics, obstetric history, and HIV disease severity. RESULTS Among 720 assessed pregnant women, PTB less than 37 weeks was 15.4% by NBS and 18.3% by ultrasound. The NBS was specific but not sensitive for PTB less than 37 weeks (92.0% and 48.5%). Women receiving ZDV-based and TDF-based ART had significantly higher odds of PTB less than 37 by ultrasound compared with ZDV alone (adjusted odds ratios: 1.68; 95% confidence interval 1.10-2.57, and 2.71; 95% confidence interval 1.39-5.29), as well as for PTB less than 34 weeks. These results held for ultrasounds performed less than 24 weeks, and were generally consistent with prior analyses from the PROMISE trial using the NBS. CONCLUSION Women starting HIV ART in pregnancy remained at higher risk of PTB when determined by ultrasound, consistent with prior data using newborn exam. However, newborn exam misclassified cases of PTB compared with gold standard ultrasound.
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Affiliation(s)
- Kartik Kailas Venkatesh
- aDivision of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina bHarvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, Massachusetts, USA cCentre for AIDS Research in South Africa and Department of Obstetrics and Gynecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa dByramiee Jeejeebhoy Government Medical College, Pune, India eMakerere University, Kampala, Uganda fWits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa gDepartment of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland hDivision of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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13
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Mehta UC, van Schalkwyk C, Naidoo P, Ramkissoon A, Mhlongo O, Maharaj NR, Naidoo N, Fieggen K, Urban MF, Krog S, Welte A, Dheda M, Pillay Y, Moran NF. Birth outcomes following antiretroviral exposure during pregnancy: Initial results from a pregnancy exposure registry in South Africa. South Afr J HIV Med 2019; 20:971. [PMID: 31616571 PMCID: PMC6779987 DOI: 10.4102/sajhivmed.v20i1.971] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/04/2019] [Indexed: 11/29/2022] Open
Abstract
Background In 2013, a pregnancy exposure registry and birth defects surveillance (PER/BDS) system was initiated in eThekwini District, KwaZulu-Natal (KZN), to assess the impact of antiretroviral treatment (ART) on birth outcomes. Objectives At the end of the first year, we assessed the risk of major congenital malformations (CM) and other adverse birth outcomes (ABOs) detected at birth, in children born to women exposed to ART during pregnancy. Method Data were collected from women who delivered at Prince Mshiyeni Memorial Hospital, Durban, from 07 October 2013 to 06 October 2014, using medicine exposure histories and birth outcomes from maternal interviews, clinical records and neonatal surface examination. Singleton births exposed to only one ART regimen were included in bivariable analysis for CM risk and multivariate risk analysis for ABO risk. Results Data were collected from 10 417 women with 10 517 birth outcomes (4013 [38.5%] HIV-infected). Congenital malformations rates in births exposed to Efavirenz during the first trimester (T1) (RR 0.87 [95% CI 0.12–6.4; p = 0.895]) were similar to births not exposed to ART during T1. However, T1 exposure to Nevirapine was associated with the increased risk of CM (RR 9.28 [95% CI 2.3–37.9; p = 0.002]) when compared to the same group. Other ABOs were more frequent in the combination of HIV/ART-exposed births compared to HIV-unexposed births (29.9% vs. 26.0%, adjusted RR 1.23 [1.14–1.31; p < 0.001]). Conclusion No association between T1 use of EFV-based ART regimens and CM was observed. Associations between T1 NVP-based ART regimen and CM need further investigation. HIV- and ART-exposed infants had more ABOs compared to HIV-unexposed infants.
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Affiliation(s)
- Ushma C Mehta
- Centre for Infectious Disease Epidemiology and Research (CIDER), School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Cari van Schalkwyk
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch, South Africa
| | - Prineetha Naidoo
- Maternal and Adolescent Child Health Systems (MatCH), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Arthi Ramkissoon
- Maternal and Adolescent Child Health Systems (MatCH), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Otty Mhlongo
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | | | - Niree Naidoo
- Prince Mshiyeni Memorial Hospital, Durban, South Africa
| | - Karen Fieggen
- Division of Human Genetics, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael F Urban
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Shaun Krog
- VP Health Systems, KwaZulu-Natal, Durban, South Africa
| | - Alex Welte
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch, South Africa
| | - Mukesh Dheda
- Programmatic Pharmacovigilance Unit, National Department of Health, Pretoria, South Africa
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | - Neil F Moran
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
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14
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Abstract
To evaluate the efficacy and safety of telbivudine (LdT) and tenofovir (TDF) for preventing hepatitis B virus (HBV) vertical transmission for HBV-positive pregnant women.Pregnant women (n = 145) from January 2013 to June 2017 were enrolled when they met inclusion criteria, which included HBV DNA ≥1.0 × 10 copies/mL and increased alanine aminotransferase (ALT) levels. Groups A (n = 58) and B (n = 51) were treated with LdT and TDF, respectively. Group C (n = 36) received no antiviral treatment. All infants were vaccinated with hepatitis B immunoglobulin and HBV vaccine. Vertical transmission of HBV was indicated by the presence of hepatitis B surface antigen (HBsAg) in infants 6 months and 12 months after birth.There is no difference of clinical characteristics of patients among the 3 groups. Serum HBV DNA levels of the 3 groups were similar at baseline (Group A vs. Group B vs. Group C, 7.88 ± 0.65 vs. 7.91 ± 0.75 vs. 7.69 ± 0.53 P = .25). In addition, the after anti-HBV treatment in Groups A and B were significantly decreased. Also, the serum HBV DNA levels in both Groups A and B were lower than that of Group C (P < .01, both). The HBV infection rate in Group A treated with LdT was not different from Group B treated with TDF. The dynamic changes of serum ALT level were similar. ALT levels were similar among the 3 Groups (P = .171), while there is statistically significant difference between A and C, and between B and C before delivery (P < .01). For the infants, there were no significant differences among body weight, height, head circumference, or Apgar score. However, the HBsAg positivity rates of infants in Groups A, B, C at postpartum 24 weeks and 48 weeks was 0%, 0%, and 11.1%, respectively (P < .001).Administration of LdT or TDF to HBV-infected mothers are effective and safe to block mother-to-infant HBV transmission.
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Affiliation(s)
| | | | - Hua Li
- Department of Gastroenterology, First Affiliated Hospital of Xiamen University, Fujian Province, China
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15
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Maraolo AE, Gentile I, Buonomo AR, Pinchera B, Borgia G. Current evidence on the management of hepatitis B in pregnancy. World J Hepatol 2018; 10:585-594. [PMID: 30310536 PMCID: PMC6177570 DOI: 10.4254/wjh.v10.i9.585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/26/2018] [Accepted: 06/09/2018] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B virus (HBV) infection is one of the main public health problems across the globe, since almost one third of the world population presents serological markers of contact with the virus. A profound impact on the epidemiology has been exerted by universal vaccination programmes in many countries, nevertheless the infection is still widespread also in its active form. In the areas of high endemicity (prevalence of hepatitis B surface antigen positivity > 7%), mother-to-child transmission represents the main modality of infection spread. That makes the correct management of HBV in pregnancy a matter of utmost importance. Furthermore, the infection in pregnancy needs to be carefully assessed and handled not only with respect to the risk of vertical transmission but also with respect to gravid women health. Each therapeutic or preventive choice deserves to be weighed upon attentively. On many aspects evidence is scarce or controversial. This review will highlight the latest insights into the paramount steps in managing HBV in pregnancy, with particular attention to recommendations from recent guidelines and data from up-do-date research syntheses.
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Affiliation(s)
- Alberto Enrico Maraolo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Ivan Gentile
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Antonio Riccardo Buonomo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Biagio Pinchera
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Guglielmo Borgia
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
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16
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Siemieniuk RAC, Lytvyn L, Mah Ming J, Mullen RM, Anam F, Otieno T, Guyatt GH, Taylor GP, Beltrán-Arroyave C, Okwen PM, Nduati R, Kinuthia J, Luma HN, Kirpalani H, Merglen A, Lesi OA, Vandvik PO, Agoritsas T, Bewley S. Antiretroviral therapy in pregnant women living with HIV: a clinical practice guideline. BMJ 2017; 358:j3961. [PMID: 28893728 PMCID: PMC5590100 DOI: 10.1136/bmj.j3961] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Approximately 1.4 million women living with HIV become pregnant every year. Most women use antiretroviral therapy, to reduce the risk of vertical transmission or for personal health reasons. Using the GRADE framework according to the BMJ Rapid Recommendation process, we make recommendations for optimal choice of combination antiretroviral regimen considering patient values and preferences, the balance of desirable and undesirable outcomes, their uncertainty, and practical issues. We suggest a zidovudine and lamivudine-based regimen over one that includes tenofovir or emtricitabine (weak recommendation). We recommend alternatives over the combination of tenofovir, emtricitabine, and lopinavir/ritonavir (strong recommendation).
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Affiliation(s)
- Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Lyubov Lytvyn
- Oslo University Hospital, Forskningsveien 2b, Blindern 0317 Oslo, Norway
| | | | | | - Florence Anam
- International Community of Women living with HIV (ICW-Global), Nairobi, Kenya
| | | | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | | | | | | | | | | | | | | | | | - Olufunmilayo A Lesi
- Lagos University Teaching Hospital, Lagos, Nigeria; College of Medicine, University of Lagos, Nigeria
| | - Per Olav Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway; Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
| | - Susan Bewley
- Women's Health Academic Centre, King's College London, London, UK
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17
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Lytvyn L, Siemieniuk RA, Dilmitis S, Ion A, Chang Y, Bala MM, Manja V, Mirza R, Rodriguez-Gutierrez R, Mir H, El Dib R, Banfield L, Vandvik PO, Bewley S. Values and preferences of women living with HIV who are pregnant, postpartum or considering pregnancy on choice of antiretroviral therapy during pregnancy. BMJ Open 2017; 7:e019023. [PMID: 28893759 PMCID: PMC5988094 DOI: 10.1136/bmjopen-2017-019023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 08/17/2017] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To investigate women's values and preferences regarding antiretroviral therapy (ART) during pregnancy to inform a BMJ Rapid Recommendation. SETTING Primary studies reporting patient-reported outcomes relevant to decision-making regarding ART in any clinical and geographical setting. PARTICIPANTS Women living with HIV who are pregnant, postpartum or considering pregnancy. OUTCOME MEASURES Quantitative measurements and qualitative descriptions of values and preferences in relation to ART during pregnancy. We also included studies on women's reported barriers and facilitators to adherence. We excluded studies correlating objective measures (eg, CD4 count) with adherence, or reporting only outcomes which are not expected to differ between ART alternatives (eg, access to services, knowledge about ART). RESULTS We included 15 qualitative studies reporting values and preferences about ART in the peripartum period; no study directly studied choice of ART therapy during pregnancy. Six themes emerged: a desire to reduce vertical transmission (nine studies), desire for child to be healthy (five studies), concern about side effects to the child (eight studies), desire for oneself to be healthy (five studies), distress about side effect to oneself (10 studies) and pill burden (two studies). None of the studies weighed the relative importance of these outcomes directly, but pill burden/medication complexity appears to be a lower priority for most women compared with other factors. Overall, the body of evidence was at low risk of bias, with minor limitations. CONCLUSIONS Women who are or may become pregnant and who are considering ART appear to place a high value on both their own and their children's health. Evidence on the relative importance between these values when choosing between ART regimens is uncertain. There is variability in individual values and preferences among women. This highlights the importance of an individualised women-centred approach, such as shared decision-making when choosing between ART alternatives. TRIAL REGISTRATION NUMBER International Prospective Register of Systematic Reviews:CRD42017057157.
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Affiliation(s)
- Lyubov Lytvyn
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Reed A Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | | | - Allyson Ion
- School of Social Work, McMaster University, Hamilton, Canada
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Malgorzata M Bala
- Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Veena Manja
- Department of Medicine, Division of Cardiology, VA Western New York Health Care System, Buffalo, New York, USA
| | - Reza Mirza
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Rene Rodriguez-Gutierrez
- Internal Medicine, University Hospital 'Dr. José E. González', Monterrey, Mexico
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hassan Mir
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Regina El Dib
- Institute of Science and Technology, UNESP—Universidade Estadual Paulista, São José dos Campos, São Paulo, Brazil
| | - Laura Banfield
- Health Sciences Library, McMaster University, Hamilton, Canada
| | - Per Olav Vandvik
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Susan Bewley
- Women's Health Academic Centre, King's College London, London, UK
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