Prophylaxis and treatment of HIV-1 infection in pregnancy: Swedish Recommendations 2010

The Role of PXR Genotype and Transporter Expression in the Placental Transport of Lopinavir in Mice

Lopinavir (LPV), an antiretroviral protease inhibitor frequently prescribed in HIV-positive pregnancies, is a substrate of Abcb1 and Abcc2. As differences in placental expression of these transporters were seen in Pregnane X Receptor (PXR) −/− mice, we examined the impact of placental transporter expression and fetal PXR genotype on the fetal accumulation of LPV. PXR +/− dams bearing PXR +/+, PXR +/−, and PXR −/− fetuses were generated by mating PXR +/− female mice with PXR +/− males. On gestational day 17, dams were administered 10 mg/kg LPV (i.v.) and sacrificed 30 min post injection. Concentrations of LPV in maternal plasma and fetal tissue were measured by LC-MS/MS, and transporter expression was determined by quantitative RT-PCR. As compared to the PXR +/+ fetal units, placental expression of Abcb1a, Abcc2, and Abcg2 mRNA were two- to three-fold higher in PXR −/− fetuses (p < 0.05). Two-fold higher fetal:maternal LPV concentration ratios were also seen in the PXR +/+ as compared to the PXR −/− fetuses (p < 0.05), and this significantly correlated to the placental expression of Abcb1a (r = 0.495; p < 0.005). Individual differences in the expression of placental transporters due to genetic or environmental factors can impact fetal exposure to their substrates.

HIV drug therapy duration; a Swedish real world nationwide cohort study on InfCareHIV 2009-2014

Background

As HIV infection needs a lifelong treatment, studying drug therapy duration and factors influencing treatment durability is crucial. The Swedish database InfCareHIV includes high quality data from more than 99% of all patients diagnosed with HIV infection in Sweden and provides a unique opportunity to examine outcomes in a nationwide real world cohort.

Methods

Adult patients who started a new therapy defined as a new 3^rd agent (all antiretrovirals that are not N[t]RTIs) 2009–2014 with more than 100 observations in treatment-naive or treatment-experienced patients were included. Dolutegravir was excluded due to short follow up period. Multivariate Cox proportional hazards models were used to estimate hazard ratios for treatment discontinuation.

Results

In treatment-naïve 2541 patients started 2583 episodes of treatments with a 3^rd agent. Efavirenz was most commonly used (n = 1096) followed by darunavir (n = 504), atazanavir (n = 386), lopinavir (n = 292), rilpivirine (n = 156) and raltegravir (n = 149). In comparison with efavirenz, patients on rilpivirine were least likely to discontinue treatment (adjusted HR 0.33; 95% CI 0.20–0.54, p<0.001), while patients on lopinavir were most likely to discontinue treatment (adjusted HR 2.80; 95% CI 2.30–3.40, p<0.001). Also raltegravir was associated with early treatment discontinuation (adjusted HR 1.47; 95% CI 1.12–1.92, p = 0.005). The adjusted HR for atazanavir and darunavir were not significantly different from efavirenz. In treatment-experienced 2991 patients started 4552 episodes of treatments with a 3^rd agent. Darunavir was most commonly used (n = 1285), followed by atazanavir (n = 806), efavirenz (n = 694), raltegravir (n = 622), rilpivirine (n = 592), lopinavir (n = 291) and etravirine (n = 262). Compared to darunavir all other drugs except for rilpivirine (HR 0.66; 95% CI 0.52–0.83, p<0.001) had higher risk for discontinuation in the multivariate adjusted analyses; atazanavir (HR 1.71; 95% CI 1.48–1.97, p<0.001), efavirenz (HR 1.86; 95% CI 1.59–2.17, p<0.001), raltegravir (HR 1.35; 95% CI 1.15–1.58, p<0.001), lopinavir (HR 3.58; 95% CI 3.02–4.25, p<0.001) and etravirine (HR 1.61; 95% CI 1.31–1.98, p<0.001).Besides the 3^rd agent chosen also certain baseline characteristics of patients were independently associated with differences in treatment duration. In naive patients, presence of an AIDS-defining diagnosis and the use of other backbone than TDF/FTC or ABC/3TC increased the risk for early treatment discontinuation. In treatment-experienced patients, detectable plasma viral load at the time of switch or being highly treatment experienced increased the risk for early treatment discontinuation.

Conclusions

Treatment durability is dependent on several factors among others patient characteristics and ART guidelines. The choice of 3^rd agent has a strong impact and significant differences between different drugs on treatment duration exist.

Strategies for the prevention of mother to child transmission in Western countries: an update

BACKGROUND

During the last decades remarkable scientific advances have been made toward the prevention of HIV mother-to-child transmission, in particular in developed nations. The aim of this review was to analyze the latest findings and available international recommendations on the prevention of HIV mother-to-child transmission in high-income countries.

METHODS

We performed a literature search of the Cochrane Library, MEDLINE by PubMed and EMBASE from database inception through June 2014, using the following terms: HIV, mother-to-child transmission and mother-to-child-transmission prevention. All types of articles in the English language were included. US and available European guidelines were searched and included in the analysis.

RESULTS

One hundred fifty articles were selected for inclusion in this review.

CONCLUSIONS

Global epidemiology of HIV infection is rapidly evolving, in particular in high-resource countries. The interpretation of clinical and epidemiological studies is crucial for the development of evidence-based recommendations to guide the management of HIV mother-to-child transmission. Although significant progress has been made, heterogeneity between countries in specific interventions still exists, which may address future research.

Adverse drug reactions associated with antiretroviral therapy during pregnancy

INTRODUCTION

Antiretroviral (ARV) drug use during pregnancy significantly reduces mother-to-child HIV transmission, delays disease progression in the women and reduces the risk of HIV transmission to HIV-serodiscordant partners. Pregnant women are susceptible to the same adverse reactions to ARVs as nonpregnant adults as well as to specific pregnancy-related reactions. In addition, we should consider adverse pregnancy outcomes and adverse reactions in children exposed to ARVs during intrauterine life. However, studies designed to assess the safety of ARV in pregnant women are rare, usually with few participants and short follow-up periods.

AREAS COVERED

In this review, we discuss studies reporting adverse reactions to ARV drugs, including maternal toxicity, adverse pregnancy outcomes and the consequences of exposure to ARV in infants. We included results of observational studies, both prospective and retrospective, as well as randomized clinical trials, systematic reviews and meta-analyses.

EXPERT OPINION

The benefits of ARV use during pregnancy outweigh the risks of adverse reactions identified to date. More studies are needed to assess the adverse effects in the medium- and long term in children exposed to ARVs during pregnancy, as well as pregnant women using lifelong antiretroviral therapy and more recently available drugs.

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.

[Consensus statement on monitoring of HIV: pregnancy, birth, and prevention of mother-to-child transmission]

OBJECTIVE

The main objective in the management of HIV-infected pregnant women is prevention of mother-to-child transmission; therefore, it is essential to provide universal antiretroviral treatment, regardless of CD4 count. All pregnant women must receive adequate information and undergo HIV serology testing at the first visit.

METHODS

We assembled a panel of experts appointed by the Secretariat of the National AIDS Plan (SPNS) and the other participating Scientific Societies, which included internal medicine physicians with expertise in the field of HIV infection, gynecologists, pediatricians and psychologists. Four panel members acted as coordinators. Scientific information was reviewed in publications and conference reports up to November 2012. In keeping with the criteria of the Infectious Diseases Society of America, 2levels of evidence were applied to support the proposed recommendations: the strength of the recommendation according to expert opinion (A, B, C), and the level of empirical evidence (I, II, III). This approach has already been used in previous documents from SPNS.

RESULTS AND CONCLUSIONS

The aim of this paper was to review current scientific knowledge, and, accordingly, develop a set of recommendations regarding antiretroviral therapy (ART), regarding the health of the mother, and from the perspective of minimizing mother-to-child transmission (MTCT), also taking into account the rest of the health care of pregnant women with HIV infection. We also discuss and evaluate other strategies to reduce the MTCT (elective Cesarean, child's treatment…), and different aspects of the topic (ARV regimens, their toxicity, monitoring during pregnancy and postpartum, etc.).

How does HIV affect the reproductive choices of women of childbearing age?

The majority of women living with HIV are of childbearing age and many of these women wish to have a family. As a result of advances in the treatment and management of HIV, more reproductive opportunities are now available to this group. However, women living with HIV may still require education and guidance in a range of reproductive situations, including avoiding pregnancy, seeking fertility treatment or having a child. HIV physicians should be aware of recent data and guidance on these situations--including areas where more data are required--and consider them when deciding on appropriate management for their patients.

What do we know about antiretroviral treatment of HIV in women?

As the number of women living with HIV continues to increase, the lack of sex-specific data on responses to antiretroviral therapy (ART) becomes increasingly problematic. Establishing the specific needs of women has been hampered by a strong male bias of study populations in clinical trials resulting in a lack of female-specific data for ART. The limited data currently available make it difficult to draw conclusions about the pharmacokinetic profile and clinical efficacy of ART in women. Data relating to the safety and tolerability profiles of ART in women are more plentiful, with indications that women may experience adverse event profiles distinct from those experienced by men. This, in turn, may be a factor in the generally higher rates of discontinuation of ART observed in women. Psychological and social aspects of HIV infection are particularly pertinent for women and girls, presenting potential barriers to diagnosis, access and adherence to therapy. Understanding these factors, in conjunction with an increase in clinical trial and real-world data specific to women with HIV is required to provide clearer guidance on optimum ART options for women.

Rapid decline in HIV viral load when introducing raltegravir-containing antiretroviral treatment late in pregnancy

Antenatal screening program for HIV has been in use in Sweden since 1987 with a 95-98% acceptance rate. Screening is performed during gestational week 10-12 and antiretroviral treatment (ART) to prevent mother-to-child transmission (MTCT) is initiated at gestational week 14-18. However, some women present with HIV in late pregnancy and additional treatment are wanted to achieve viral suppression before delivery. The integrase inhibitor raltegravir has a favorable pharmacokinetic profile and a capacity to rapidly decrease the viral load (VL). We describe four women presenting as HIV positive late in pregnancy, their ART, and outcome for the mother and child. Four women were discovered as HIV positive late in pregnancy, of 7 discovered in the antenatal screening programme in Stockholm County Council during 2011. Raltegravir was added to standard ART. The mean VL at presentation was 217,000 copies per milliliter (range, 65,000-637,000). A rapid decline of HIV RNA was observed in all cases, one woman treated with ART for only 8 days prior to delivery. The mean VL decline per week was 1.12 log (range, 0.94-1.22), which is estimated to occur (based on literature) after 1-2 months with standard ART. No side effects due to raltegravir were observed in mothers or infants. Caesarean section was performed in all cases, and the women did not breastfeed. No infant was infected. This report suggests that raltegravir added to standard antiretroviral treatment would be an option for women presenting with HIV in late pregnancy.