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Portwood C, Sexton H, Kumarendran M, Brandon Z, Johnson B, Kirtley S, Hemelaar J. Perinatal outcomes associated with combination antiretroviral therapy compared with monotherapy. AIDS 2023; 37:489-501. [PMID: 36695359 DOI: 10.1097/qad.0000000000003432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Increasing numbers of women living with HIV (WLHIV) worldwide receive combination antiretroviral therapy (cART) during pregnancy. We aimed to assess the risk of adverse perinatal outcomes in pregnant WLHIV receiving cART compared with pregnant WLHIV receiving zidovudine monotherapy. DESIGN Systematic review and meta-analysis. METHODS We searched four electronic literature databases (PubMed, CINAHL, Global Health, EMBASE) for studies published between 1 January 1980 and 20 April 2020 using a comprehensive search strategy. Studies reporting data on WLHIV receiving cART compared with WLHIV receiving monotherapy for 11 adverse perinatal outcomes were sought: preterm birth (PTB), very PTB, spontaneous PTB, low birthweight (LBW), very LBW, preterm and term LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Random-effects meta-analyses were conducted to calculate relative risk (RR) and 95% confidence intervals (95% CI). RESULTS We included 30 studies reporting on 317 101 pregnant women in 27 countries. WLHIV receiving cART were at increased risk of PTB (RR 1.32, 95% CI 1.18-1.46), LBW (1.35, 1.19-1.53), SGA (1.32, 1.13-1.53), VSGA (1.64, 1.34-2.02), and stillbirth (2.41, 1.83-3.17) compared to WLHIV receiving monotherapy. The significance of these results was maintained in subgroup analyses for studies conducted in low and middle-income countries and average quality studies. Additionally, WLHIV receiving nonnucleoside reverse transcriptase inhibitor-based cART were associated with increased risk of PTB, LBW, and stillbirth, while WLHIV receiving protease inhibitor-based cART were associated with increased risk of PTB, compared with WLHIV receiving monotherapy. CONCLUSION Pregnant WLHIV receiving cART are associated with increased risk of adverse perinatal outcomes, compared with WLHIV receiving monotherapy.
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Affiliation(s)
- Clara Portwood
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Harriet Sexton
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Bradley Johnson
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - 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, Nuffield Department of Population Health
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D'arminio Monforte A, Tavelli A, Sala M, Mondi A, Rusconi S, Antinori S, Puoti M, Celesia BM, Taramasso L, Saracino A, Antinori A, Cozzi-Lepri A. Long-term outcome of dolutegravir-containing regimens according to sex: data from the ICONA study. J Antimicrob Chemother 2023; 78:933-945. [PMID: 36775983 DOI: 10.1093/jac/dkad026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/18/2023] [Indexed: 02/14/2023] Open
Abstract
OBJECTIVES To compare the long-term risk of treatment failure of dolutegravir-based ART in men and women in a real-life setting. PATIENTS AND METHODS Persons living with HIV (PLWH) from the ICONA cohort were included if they had started dolutegravir in a two- or three-drug regimen as ART-naive or as virologically controlled ART-experienced. The primary endpoint was time to treatment failure (virological/clinical failure or dolutegravir discontinuation). Secondary endpoints were: time to dolutegravir discontinuation due to toxicity and to neuropsychiatric adverse events; and time to virological failure. Cox regression analyses focused on differences in outcomes by sex. RESULTS A total of 2304 PLWH (15% women) initiated dolutegravir-based therapy from ART-naive, and 1916 (19.8% women) while experienced. After a median follow-up of 2.2 (IQR: 0.9-3.9) years in ART-naive and 2.4 (IQR: 1.1-4.3) years in experienced, the 4-year cumulative probability of treatment failure was 33% (95% CI 30.5-35.1) and 20% (95% CI 17.8-22.3), respectively. In the multivariable analyses, in ART-naive the risk of treatment failure was higher for women, but not different after excluding women discontinuing dolutegravir for pregnancy concerns. We also observed a higher risk of discontinuation for toxicity in women (ART-naives: Adjusted Hazard Ratio (AHR): 1.56%; 95% CI: 1.03-2.37; ART-experienced: AHR: 1.53%; 95% CI: 1.01-2.32), although the absolute 4-year probability was low: 7.7% (95% CI 6.5-9.2) in ART-naive and 8.3% (95% CI 6.9-9.9) in experienced. CONCLUSIONS In our cohort of PLWH treated with dolutegravir-based regimens and followed up for up to 4 years, we observed a low risk of treatment failure and no evidence for a difference by sex, after excluding discontinuation due to pregnancy concerns. However, we observed a higher risk of dolutegravir discontinuation for toxicity in women.
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Affiliation(s)
- Antonella D'arminio Monforte
- Unit of Infectious Diseases ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, ASST Santi Paolo e Carlo, via A. di Rudinì 8, 20142, Milan, Italy
| | | | - Matteo Sala
- Unit of Infectious Diseases ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, ASST Santi Paolo e Carlo, via A. di Rudinì 8, 20142, Milan, Italy
| | - Annalisa Mondi
- Clinical and Research Infectious Diseases Department, National Institute of Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Stefano Rusconi
- Infectious Diseases Unit, Ospedale Civile di Legnano, ASST Ovest Milanese, and DIBIC Luigi Sacco, Università degli Studi di Milano, Legnano, Italy
| | - Spinello Antinori
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, and DIBIC Luigi Sacco, Università degli Studi di Milano, Milan, Italy
| | - Massimo Puoti
- Infectious Diseases Division, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Lucia Taramasso
- Clinic of Infectious Diseases, Policlinico San Martino Hospital IRCCS, Genova, Italy
| | - Annalisa Saracino
- Clinic of Infectious Diseases, University of Bari, University Hospital Policlinico, Bari, Italy
| | - Andrea Antinori
- Clinical and Research Infectious Diseases Department, National Institute of Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Alessandro Cozzi-Lepri
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, University College London, London, UK
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Portwood C, Sexton H, Kumarendran M, Brandon Z, Kirtley S, Hemelaar J. Adverse perinatal outcomes associated with antiretroviral therapy in women living with HIV: A systematic review and meta-analysis. Front Med (Lausanne) 2023; 9:924593. [PMID: 36816720 PMCID: PMC9935588 DOI: 10.3389/fmed.2022.924593] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 12/20/2022] [Indexed: 02/05/2023] Open
Abstract
Background Maternal HIV infection is associated with an increased risk of adverse perinatal outcomes. The World Health Organization (WHO) recommends immediate initiation of lifelong antiretroviral therapy (ART) for all people living with HIV, including pregnant women living with HIV (WLHIV). We aimed to assess the risk of adverse perinatal outcomes in WLHIV receiving ART compared to ART-naïve WLHIV and HIV-negative women. Materials and methods We conducted a systematic literature review by searching PubMed, CINAHL, Global Health, and EMBASE for studies published between Jan 1, 1980, and April 20, 2020. Two investigators independently selected relevant studies and extracted data from studies reporting on the association of pregnant WLHIV receiving ART with adverse perinatal outcomes. Perinatal outcomes examined were preterm birth (PTB), very PTB, spontaneous PTB (sPTB), low birth weight (LBW), very LBW (VLBW), term LBW, preterm LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Random-effects meta-analyses examined the risk of adverse perinatal outcomes in WLHIV receiving ART compared to ART-naïve WLHIV and HIV-negative women. Subgroup and sensitivity analyses were performed based on country income status and study quality, and adjustment for confounding factors assessed. Results Of 94,594 studies identified, 73 cohort studies, including 424,277 pregnant women, met the inclusion criteria. We found that WLHIV receiving ART are associated with a significantly decreased risk of PTB (relative risk 0.79, 95% CI 0.67-0.93), sPTB (0.46, 0.32-0.66), LBW (0.86, 0.79-0.93), and VLBW (0.62, 0.39-0.97) compared to ART-naïve WLHIV. However, WLHIV receiving ART are associated with a significantly increased risk of PTB (1.42, 1.28-1.57), sPTB (2.20, 1.32-3.67), LBW (1.58, 1.36-1.84), term LBW (1.88, 1.23-2.85), SGA (1.69, 1.32-2.17), and VSGA (1.22, 1.10-1.34) compared to HIV-negative women. Conclusion ART reduces the risk of adverse perinatal outcomes in pregnant WLHIV, but the risk remains higher than in HIV-negative women. Our findings support the WHO recommendation of immediate initiation of lifelong ART for all people living with HIV, including pregnant WLHIV. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42021248987.
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Affiliation(s)
- Clara Portwood
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Harriet Sexton
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom,*Correspondence: Joris Hemelaar,
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Poliektov NE, Badell ML. Antiretroviral Options and Treatment Decisions During Pregnancy. Paediatr Drugs 2023; 25:267-282. [PMID: 36729360 DOI: 10.1007/s40272-023-00559-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/03/2023]
Abstract
The majority of pediatric human immunodeficiency virus (HIV) infections are the result of vertical transmissions that occur during pregnancy, childbirth, and breastfeeding. The treatment of all pregnant persons living with HIV remains a global health initiative. Early and consistent use of antiretroviral therapy throughout pregnancy and childbirth drastically reduces the risk of perinatal transmission of HIV, resulting in fewer children living with the disease worldwide. Given that the maternal HIV viral load is the strongest predictor of perinatal transmission, suppressive antiretroviral treatment during pregnancy is the principal means to eliminate transmission of HIV from mother to child. With the use of combined antiretroviral therapy, typically with dual-nucleoside reverse transcriptase inhibitors plus an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, HIV-infected mothers can now achieve virologic suppression to undetectable levels and yield a perinatal transmission rate of less than 2%. Important considerations of HIV treatment in pregnancy include the safety and efficacy of antiretroviral drugs, altered pregnancy-related pharmacokinetics, potential for birth defects or adverse neonatal outcomes, and individualized delivery planning based on maternal viral load. This practical review article summarizes the options, considerations, and recommendations for antiretroviral treatment in pregnancy to reduce perinatal HIV transmission and optimize health outcomes for mothers and infants worldwide.
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Affiliation(s)
- Natalie E Poliektov
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Martina L Badell
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA.
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Abstract
Prior to widespread availability of antiretroviral therapy (ART) in sub-Saharan Africa, children who were HIV-exposed but uninfected (HEU) had increased mortality, morbidity and undernutrition compared with children who were HIV-unexposed. Scale-up of ART has led to impressive declines in vertical HIV transmission, but over 15 million children are now HEU, 90% of whom live in sub-Saharan Africa. There are ongoing health disparities among children who are HEU, with higher mortality, morbidity and stunting and modest impairments in early child development, which collectively hamper health and human capital in high prevalence countries. The underlying causes are multifactorial and include exposure to HIV, co-infections and a skewed antenatal inflammatory milieu, particularly if mothers start ART once they have advanced disease, as well as socioeconomic risk factors, which may cluster in HIV-affected households. Improving maternal health through early and sustained ART, ensuring optimal breastfeeding, and implementing evidence-based priority interventions for all children in areas of high HIV prevalence, will likely improve outcomes. A more comprehensive intervention package based on the Nurturing Care Framework may have particular benefits for children who are HEU, to close health gaps and ensure that the next generation of HIV-free children survive and thrive, and lead healthy and productive lives.
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Sexton H, Kumarendran M, Brandon Z, Shi C, Kirtley S, Hemelaar J. Adverse perinatal outcomes associated with timing of initiation of antiretroviral therapy: Systematic review and meta-analysis. HIV Med 2023; 24:111-129. [PMID: 35665582 DOI: 10.1111/hiv.13326] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 05/05/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The World Health Organization (WHO) recommends immediate initiation of lifelong antiretroviral therapy (ART) for all people living with HIV, including pregnant women. As a result, an increasing number of women living with HIV conceive while taking ART, the vast majority of whom reside in low- and middle-income countries (LMICs). We aimed to assess the association between timing of ART initiation and perinatal outcomes. METHODS We conducted a systematic literature review by searching PubMed, CINAHL (EBSCOhost), Global Health (Ovid), EMBASE (Ovid), and the Cochrane Central Register of Controlled Trials and four clinical trial databases (WHO International Clinical Trials Registry Platform, the Pan African Clinical Trials Registry, the ClinicalTrials.gov database, and the ISRCTN Registry) from 1 January 1980 to 28 April 2018. We identified studies reporting specific perinatal outcomes among pregnant women living with HIV according to timing of ART initiation and extracted data. Perinatal outcomes assessed were preterm birth (<37 weeks), very preterm birth (<32 weeks), low birthweight (<2500 g), very low birthweight (<1500 g), small for gestational age (<10th centile), very small for gestational age (<3rd centile) and neonatal death (<29 days). Random-effects meta-analyses examined perinatal outcomes associated with preconception and antenatal ART initiation as well as according to trimesters of antenatal initiation. We performed quality assessments and subgroup and sensitivity analyses, and assessed the effect of adjustment for confounders. This systematic review and meta-analyses is registered with PROSPERO, number CRD42021248987. RESULTS Of 51 874 unique citations, 25 studies (eight prospective and 17 retrospective cohort studies) were eligible for analysis, including 40 920 women living with HIV. Preconception ART initiation was associated with a significantly increased risk of preterm birth (relative risk 1.16; 95% confidence interval [CI] 1.03-1.31) compared with antenatal ART initiation. Preconception ART initiation was not significantly associated with very preterm birth, low birthweight, very low birthweight, small for gestational age, very small for gestational age, or neonatal death. First trimester exposure (i.e. preconception or first trimester initiation) was not significantly associated with any increased risk of adverse perinatal outcomes. No significant association between timing of ART initiation and adverse perinatal outcomes was found in the studies of higher quality and those conducted in LMICs. CONCLUSION Preconception ART initiation is associated with preterm birth but no other adverse perinatal outcomes. In LMICs, where most pregnant women living with HIV reside, the timing of ART initiation was not associated with any adverse perinatal outcomes.
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Affiliation(s)
- Harriet Sexton
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christine Shi
- National Perinatal Epidemiology Unit, 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, Botnar Research Centre, Oxford, UK
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Eke AC, Mirochnick M, Lockman S. Antiretroviral Therapy and Adverse Pregnancy Outcomes in People Living with HIV. N Engl J Med 2023; 388:344-356. [PMID: 36720135 PMCID: PMC10400304 DOI: 10.1056/nejmra2212877] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Ahizechukwu C Eke
- From the Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, and the Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore (A.C.E.); the Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine (M.M.), the Division of Infectious Diseases, Brigham and Women's Hospital (S.L.), and the Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health (S.L.) - all in Boston; and the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana (S.L.)
| | - Mark Mirochnick
- From the Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, and the Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore (A.C.E.); the Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine (M.M.), the Division of Infectious Diseases, Brigham and Women's Hospital (S.L.), and the Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health (S.L.) - all in Boston; and the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana (S.L.)
| | - Shahin Lockman
- From the Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, and the Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore (A.C.E.); the Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine (M.M.), the Division of Infectious Diseases, Brigham and Women's Hospital (S.L.), and the Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health (S.L.) - all in Boston; and the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana (S.L.)
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Chi BH, Sebikari D, Brummel SS, DeMarrais P, Chamanga R, Owor M, Dadabhai S, Price JT, Taha T, Stringer J, Fowler MG. Progesterone and prolactin levels in pregnant women living with HIV who delivered preterm and low birthweight infants: A nested case-control study. PLoS One 2023; 18:e0280730. [PMID: 36689442 PMCID: PMC9870101 DOI: 10.1371/journal.pone.0280730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/20/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) is associated with high rates of adverse birth outcomes, including preterm birth and low birthweight. Studies suggest that progesterone and prolactin may play important intermediary roles. METHODS We analyzed data from the Antenatal Component of the PROMISE trial, a multi-center study of pregnant women taking antiretroviral regimens (lopinavir/ritonavir-containing ART or zidovudine alone) to prevent mother-to-child HIV transmission. In a nested case-control study, we compared data from women who gave birth to preterm (<37 weeks gestation) and/or low birthweight (<2500 g) infants to matched individuals who did not. We measured serum progesterone and prolactin at 24-34 weeks gestation. We used conditional logistic regression to describe relationships between hormone levels, birth outcomes, and antiretroviral regimens. RESULTS 299 women and their newborns were included (146 cases, 153 controls). When compared to women receiving zidovudine alone, those on ART had higher odds of progesterone levels under the 10th percentile (adjusted odds ratio [AOR]:2.34, 95%CI:1.41-3.89) and 25th percentile (AOR:2.07, 95%CI:1.46-2.94). However, higher levels of progesterone-rather than lower levels-were associated with our composite case outcome at the 10th percentile (AOR:1.88, 95%CI:0.77-4.59) and 25th percentile (AOR:1.96, 95%CI:1.06-3.61). Associations were not observed between prolactin, antiretroviral regimen, and birth outcomes. CONCLUSION We observed lower progesterone levels among women allocated to ART regimens; however, higher progesterone levels were associated with preterm birth and/or low birthweight. While features of the study design may have contributed to these findings, they nevertheless highlight the potentially complex mechanisms underpinning adverse birth outcomes and HIV.
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Affiliation(s)
- Benjamin H. Chi
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Dorothy Sebikari
- Makerere University–Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Sean S. Brummel
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Patricia DeMarrais
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Rachel Chamanga
- College of Medicine-Johns Hopkins Research Project, Blantyre, Malawi
| | - Maxensia Owor
- Makerere University–Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Sufia Dadabhai
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Joan T. Price
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Taha Taha
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jeffrey Stringer
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Mary Glenn Fowler
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Gandhi RT, Bedimo R, Hoy JF, Landovitz RJ, Smith DM, Eaton EF, Lehmann C, Springer SA, Sax PE, Thompson MA, Benson CA, Buchbinder SP, Del Rio C, Eron JJ, Günthard HF, Molina JM, Jacobsen DM, Saag MS. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2022 Recommendations of the International Antiviral Society-USA Panel. JAMA 2023; 329:63-84. [PMID: 36454551 DOI: 10.1001/jama.2022.22246] [Citation(s) in RCA: 208] [Impact Index Per Article: 208.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Importance Recent advances in treatment and prevention of HIV warrant updated recommendations to guide optimal practice. Objective Based on a critical evaluation of new data, to provide clinicians with recommendations on use of antiretroviral drugs for the treatment and prevention of HIV, laboratory monitoring, care of people aging with HIV, substance use disorder and HIV, and new challenges in people with HIV, including COVID-19 and monkeypox virus infection. Evidence Review A panel of volunteer expert physician scientists were appointed to update the 2020 consensus recommendations. Relevant evidence in the literature (PubMed and Embase searches, which initially yielded 7891 unique citations, of which 834 were considered relevant) and studies presented at peer-reviewed scientific conferences between January 2020 and October 2022 were considered. Findings Initiation of antiretroviral therapy (ART) is recommended as soon as possible after diagnosis of HIV. Barriers to care should be addressed, including ensuring access to ART and adherence support. Integrase strand transfer inhibitor-containing regimens remain the mainstay of initial therapy. For people who have achieved viral suppression with a daily oral regimen, long-acting injectable therapy with cabotegravir plus rilpivirine given as infrequently as every 2 months is now an option. Weight gain and metabolic complications have been linked to certain antiretroviral medications; novel strategies to ameliorate these complications are needed. Management of comorbidities throughout the life span is increasingly important, because people with HIV are living longer and confronting the health challenges of aging. In addition, management of substance use disorder in people with HIV requires an evidence-based, integrated approach. Options for preexposure prophylaxis include oral medications (tenofovir disoproxil fumarate or tenofovir alafenamide plus emtricitabine) and, for the first time, a long-acting injectable agent, cabotegravir. Recent global health emergencies, like the SARS-CoV-2 pandemic and monkeypox virus outbreak, continue to have a major effect on people with HIV and the delivery of services. To address these and other challenges, an equity-based approach is essential. Conclusions and Relevance Advances in treatment and prevention of HIV continue to improve outcomes, but challenges and opportunities remain.
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Affiliation(s)
- Rajesh T Gandhi
- Massachusetts General Hospital and Harvard Medical School, Boston
| | - Roger Bedimo
- University of Texas Southwestern Medical Center, Dallas
| | - Jennifer F Hoy
- The Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Davey M Smith
- University of California San Diego School of Medicine
| | | | - Clara Lehmann
- University of Cologne and German Center for Infection Research (DZIF), Bonn-Cologne
| | - Sandra A Springer
- Yale University School of Medicine, New Haven, Connecticut
- The Veterans Administration Connecticut Healthcare System, West Haven
| | - Paul E Sax
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Carlos Del Rio
- Emory University School of Medicine and Grady Health System, Atlanta, Georgia
| | - Joseph J Eron
- The University of North Carolina School of Medicine at Chapel Hill
| | - Huldrych F Günthard
- University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Jean-Michel Molina
- University of Paris Cité, Saint-Louis and Lariboisière Hospitals, Assistance Publique Hopitaux de Paris, France
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Zeng QL, Zhang HX, Zhang JY, Huang S, Li WZ, Li GM, Pan YJ, Feng YH, Li ZQ, Zhang GF, Xu JH, Lin WB, Xu GH, Liu N, Zhang GQ, Li GT, Li W, Zeng YL, Song N, Wang M, Zhang DW, Chen ZM, Cui GL, Li J, Lv J, Liu YM, Liang HX, Sun CY, Zhou YH, Yu ZJ, Wang FS. Tenofovir Alafenamide for Pregnant Chinese Women With Active Chronic Hepatitis B: A Multicenter Prospective Study. Clin Gastroenterol Hepatol 2022; 20:2826-2837.e9. [PMID: 34902570 DOI: 10.1016/j.cgh.2021.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/10/2021] [Accepted: 12/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Data on long-term tenofovir alafenamide (TAF) therapy for pregnant women with active chronic hepatitis B (CHB) (immune clearance and reactivation phases, currently and previously diagnosed) and their infants are lacking. METHODS Pregnant women with active CHB treated with TAF and tenofovir disoproxil fumarate (TDF) were enrolled in this multicenter prospective study, and infants received immunoprophylaxis. The primary outcomes were rates of adverse (safety) events in pregnant women and defects in infants and fetuses. The secondary outcomes were virologic responses in pregnant women, infants' safety, hepatitis B surface antigen (HBsAg) status, and growth conditions. RESULTS One hundred three and 104 pregnant women were enrolled and 102 and 104 infants were born in the TAF and TDF groups, respectively. In the TAF group, the mean age, gestational age, alanine aminotransferase level, and viral loads at treatment initiation were 29.3 years, 1.3 weeks, 122.2 U/L, and 5.1 log10 IU/mL, respectively. TAF was well-tolerated, and the most common adverse event was nausea (29.1%) during a mean of 2 years of treatment. Notably, 1 (1.0%) TAF-treated pregnant woman underwent induced abortion due to noncausal fetal cleft lip and palate. No infants in either group had birth defects. In the TAF group, the hepatitis B e antigen seroconversion rate was 20.7% at postpartum month 6, infants had normal growth parameters, and no infants were positive for HBsAg at 7 months. The TDF group had comparable safety and effectiveness profiles. CONCLUSIONS TAF administered throughout or beginning in early pregnancy is generally safe and effective for pregnant women with active CHB and their infants.
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Affiliation(s)
- Qing-Lei Zeng
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province.
| | - Hong-Xu Zhang
- Department of Infectious Diseases, Luohe Central Hospital, Luohe, Henan Province
| | - Ji-Yuan Zhang
- Treatment and Research Center for Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing
| | - Shuo Huang
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Wei-Zhe Li
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Guang-Ming Li
- Department of Hepatology, The Sixth People's Hospital of Zhengzhou City, Zhengzhou, Henan Province
| | - Ya-Jie Pan
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Ying-Hua Feng
- Department of Hepatology, The Sixth People's Hospital of Kaifeng City, Kaifeng, Henan Province
| | - Zhi-Qin Li
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Guo-Fan Zhang
- Department of Infectious Diseases, The First Affiliated Hospital of Nanyang Medical College, Nanyang, Henan Province
| | - Jiang-Hai Xu
- Department of Hepatology, The Fifth People's Hospital of Anyang City, Anyang, Henan Province
| | - Wan-Bao Lin
- Department of Infectious Diseases, Xinyang Central Hospital, Xinyang, Henan Province
| | - Guang-Hua Xu
- Department of Infectious Diseases, The Affiliated Hospital of Yan'an University, Yan'an, Shaanxi Province
| | - Na Liu
- Department of Infectious Diseases, The Affiliated Hospital of Yan'an University, Yan'an, Shaanxi Province
| | - Guo-Qiang Zhang
- Department of Infectious Diseases, Luoyang Central Hospital, Luoyang, Henan Province
| | - Guo-Tao Li
- Department of Infectious Diseases, Luoyang Central Hospital, Luoyang, Henan Province
| | - Wei Li
- Department of Infectious Diseases, Henan Provincial People's Hospital, Zhengzhou, Henan Province
| | - Yan-Li Zeng
- Department of Infectious Diseases, Henan Provincial People's Hospital, Zhengzhou, Henan Province
| | - Ning Song
- Center for Reproductive Medicine, Henan Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Meng Wang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Da-Wei Zhang
- Treatment and Research Center for Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing
| | - Zhi-Min Chen
- Department of Obstetrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Guang-Lin Cui
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Juan Li
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Jun Lv
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Yan-Min Liu
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Hong-Xia Liang
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Chang-Yu Sun
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Yi-Hua Zhou
- Department of Experimental Medicine and Jiangsu Key Laboratory for Molecular Medicine, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Zu-Jiang Yu
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province.
| | - Fu-Sheng Wang
- Treatment and Research Center for Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing.
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Saidi F, Chi BH. Human Immunodeficiency Virus Treatment and Prevention for Pregnant and Postpartum Women in Global Settings. Obstet Gynecol Clin North Am 2022; 49:693-712. [DOI: 10.1016/j.ogc.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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62
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Coutinho CM, Warshaw MG, Duarte G, Stek A, Violari A, Hofer CB, Deville JG, Ngocho JS, Pilotto JH, Correa MD, Shapiro DE, Fuller TL, Chakhtoura N, Mirochnick M, João EC. Effects of Initiating Raltegravir-Based Versus Efavirenz-Based Antiretroviral Regimens During Pregnancy on Weight Changes and Perinatal Outcomes: NICHD P1081. J Acquir Immune Defic Syndr 2022; 91:403-409. [PMID: 36049477 PMCID: PMC9613542 DOI: 10.1097/qai.0000000000003081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/16/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Integrase inhibitors have been associated with excess gestational weight gain that may lead to adverse pregnancy outcomes (APOs). This post hoc analysis of NICHD P1081 compared antepartum changes in weight and body mass index (BMI) in pregnant women initiating raltegravir- or efavirenz-based combined antiretroviral therapy (cART) and examined associations between rates of weight gain and APOs. SETTING NICHD P1081 enrolled antiretroviral-naive pregnant women living with HIV in the second and third trimester in Brazil, Tanzania, South Africa, Thailand, Argentina, and the United States. METHODS Two hundred eighty-one women enrolled between 20 and 31 gestational weeks were randomized to raltegravir- or efavirenz-based cART and followed for ≥4 weeks. A low rate of weight gain was defined as <0.18 kg/wk and high as >0.59 kg/wk. We compared weight gain and BMI increase between treatment arms using Kruskal-Wallis tests. Logistic regression was used to investigate the association between weight gain and APOs. RESULTS Raltegravir-based cART was associated with significantly higher antepartum weight gain (median 0.36 kg/wk versus 0.29 kg/wk, P = 0.01) and BMI increase (median 0.14 kg/m 2 /wk versus 0.11 kg/m 2 /wk, P = 0.01) compared with efavirenz-based treatment. Women on raltegravir had less low weight gain (18% versus 36%) and more high weight gain (21% versus 12%) ( P = 0.001). Women with low weight gain were more likely than those with normal weight gain to have small for gestational age infants or a composite of APOs. CONCLUSIONS A raltegravir-based antiretroviral regimen was associated with significantly higher antepartum rate of weight gain and BMI increase compared with efavirenz-based treatment in antiretroviral-naive pregnant women.
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Affiliation(s)
- Conrado Milani Coutinho
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Meredith G Warshaw
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Geraldo Duarte
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Alice Stek
- Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, CA
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Cristina B Hofer
- Infectious Diseases Department, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jaime G Deville
- Department of Pediatrics, University of California, Los Angeles, CA
| | - James Samwel Ngocho
- Department of Epidemiology and Applied Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - José Henrique Pilotto
- Infectious Diseases Department, Hospital Geral de Nova Iguaçu & Laboratório de AIDS e Imunologia Molecular/IOC/Fiocruz, Rio de Janeiro, Brazil
| | - Mario Dias Correa
- Department of Gynecology and Obstetrics, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - David E Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Trevon L Fuller
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
- University of California, Los Angeles, CA
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch at the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD; and
| | - Mark Mirochnick
- Department of Pediatrics, Boston University School of Medicine, Boston, MA
| | - Esaú C João
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
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Smith MSR, Mohan H, Ajaykumar A, Hsieh AYY, Martineau L, Patel R, Gadawska I, Sherwood C, Serghides L, Piret JM, Côté HCF. Second-Generation Human Immunodeficiency Virus Integrase Inhibitors Induce Differentiation Dysregulation and Exert Toxic Effects in Human Embryonic Stem Cell and Mouse Models. J Infect Dis 2022; 226:1992-2001. [PMID: 36124861 DOI: 10.1093/infdis/jiac386] [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: 07/19/2022] [Accepted: 09/16/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Each year, approximately 1.1 million children are exposed in utero to human immunodeficiency virus antiretrovirals, yet their safety is often not well characterized during pregnancy. The Tsepamo study reported a neural tube defect signal in infants exposed to the integrase strand transfer inhibitor (InSTI) dolutegravir from conception, suggesting that exposure during early fetal development may be detrimental. METHODS The effects of InSTIs on 2 human embryonic stem cell (hESC) lines were characterized with respect to markers of pluripotency, early differentiation, and cellular health. In addition, fetal resorptions after exposure to InSTIs from conception were analyzed in pregnant mice. RESULTS At subtherapeutic concentrations, second-generation InSTIs bictegravir, cabotegravir, and dolutegravir decreased hESC counts and pluripotency and induced dysregulation of genes involved in early differentiation. At therapeutic concentrations, bictegravir induced substantial hESC death and fetal resorptions. It is notable that first-generation InSTI raltegravir did not induce any hESC toxicity or differentiation, at any concentration tested. CONCLUSIONS Exposure to some InSTIs, even at subtherapeutic concentrations, can induce adverse effects in hESCs and pregnant mice. Given the increasingly prevalent use of second-generation InSTIs, including in women of reproductive age, it is imperative to further elucidate the effect of InSTIs on embryonic development, as well as their long-term safety after in utero exposure.
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Affiliation(s)
- Marie-Soleil R Smith
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, Canada
| | - Haneesha Mohan
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | - Abhinav Ajaykumar
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, Canada
| | - Anthony Y Y Hsieh
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, Canada
| | - Lou Martineau
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Ronil Patel
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Izabella Gadawska
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, Canada
| | | | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada.,Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada.,Women's College Research Institute, Toronto, Canada
| | - James M Piret
- Michael Smith Laboratories, University of British Columbia, Vancouver, Canada.,Department of Chemical and Biological Engineering, University of British Columbia, Vancouver, Canada.,School of Biomedical Engineering, The University of British Columbia, Vancouver, Canada
| | - Hélène C F Côté
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, Canada.,Women's Health Research Institute, Vancouver, Canada
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64
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Chen ZR, Lv QL, Peng HW, Liu XY, Hu WL, Hu JF. Drug screening against F13 protein, the target of tecovirimat, as potential therapies for monkeypox virus. J Infect 2022; 86:154-225. [PMID: 36442658 PMCID: PMC9694522 DOI: 10.1016/j.jinf.2022.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/16/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Zhang-Ren Chen
- Department of pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China.
| | - Qiao-Li Lv
- Jiangxi Key Laboratory of Translational Cancer Research, Department of Head and Neck Surgery, Jiangxi Cancer Hospital of Nanchang University, Nanchang, China
| | - Hong-Wei Peng
- Department of pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiao-Yi Liu
- Department of pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wen-Lei Hu
- Department of pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jin-Fang Hu
- Department of pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China.
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Yang L, Cambou MC, Segura ER, De Melo MG, Santos BR, Dos Santos Varella IR, Nielsen-Saines K. Patterns of pregnancy loss among women living with and without HIV in Brazil, 2008-2018. AJOG GLOBAL REPORTS 2022; 2:100121. [PMID: 36387295 PMCID: PMC9643582 DOI: 10.1016/j.xagr.2022.100121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Pregnancy loss is poorly understood, but infection may be a risk factor. Few studies have evaluated pregnancy loss among women living with HIV in the era of potent combination antiretroviral therapy. OBJECTIVE We hypothesize that maternal HIV and syphilis infection lead to increased risk of pregnancy loss, including both miscarriage and stillbirth. This study aimed to assess trends and possible predictors of spontaneous miscarriage and stillbirth among women living with HIV in a cohort of nearly 56,000 deliveries at a major referral institution in a city with the highest prevalence of HIV in Brazil. STUDY DESIGN Data from hospital records for women delivering from January 1, 2008 to December 31, 2018 were reviewed. Rates of stillbirth, miscarriage, and any pregnancy loss were compared using the Pearson chi-square test. Predictors of pregnancy loss were evaluated by robust univariate log-linear Poisson regression using a generalized estimating equations approach. RESULTS A total of 55,844 pregnancies were included in the analysis, with 54,308 pregnancies from 43,502 women without HIV and 1536 pregnancies from 1186 women living with HIV (seroprevalence of maternal HIV: 2.7%). Overall, 1130 stillbirths (2.0%) and 6558 miscarriages (11.7%) occurred. Any pregnancy loss was similar in both groups (13.8% in women without and 14.1% in women with HIV; P=.733). Stillbirth was higher among women living with HIV (3.4%) than among women without HIV (2.0%; P<.001), but there was no difference in overall miscarriage rates (10.7% in women with vs. 11.8% in women without HIV; P=.188). Women living with HIV had higher miscarriage rates between 12 and 20 weeks than women without HIV (34.8% vs 23.7%; P=.001), likely because of syphilis coinfection. Stillbirth rates were higher for women living with HIV from 2008 to 2014; however, a steady plateau was reached from 2014 to 2018, mirroring stillbirth rates in women without HIV. Maternal HIV infection did not increase the risk of miscarriage (relative risk, 0.90; 95% confidence interval, 0.77-1.05) or any pregnancy loss (relative risk, 1.00; 95% confidence interval, 0.88-1.15), but was associated with stillbirth (relative risk, 1.65; 95% confidence interval, 1.23-2.21). Maternal syphilis was associated with any pregnancy loss (relative risk, 1.24; 95% confidence interval, 1.11-1.38) and stillbirth (relative risk, 3.39; 95% confidence interval, 2.77-4.14), but not miscarriage (relative risk, 0.91; 95% confidence interval, 0.80-1.04). CONCLUSION In the era of combination antiretroviral therapy, there was no difference in miscarriage rates between women with and without HIV. HIV was associated with stillbirth risk but improved over time. Maternal syphilis was significantly associated with any pregnancy loss and stillbirth in all women. Syphilis is likely the main driver of pregnancy loss in women living with HIV in Brazil.
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Affiliation(s)
- Lanbo Yang
- From the Warren Alpert Medical School, Brown University, Providence, RI (Dr Lanbo Yang)
| | - Mary Catherine Cambou
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA (Drs Mary Catherine Cambou, and Eddy R. Segura)
| | - Eddy R. Segura
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA (Drs Mary Catherine Cambou, and Eddy R. Segura)
- Facultad de Ciencas de la Salud, Universidad de Huánuco, Huánuco, Péru (Dr Eddy R. Segura)
| | - Marineide Gonçalves De Melo
- Hospital Nossa Senhora da Conceição, Sistéma Único de Saúde, Porto Alegre, Brazil (Drs Marineide Gonçalves De Melo, Breno Riegel Santos, and Ivana Rosngela Dos Santos Varella)
| | - Breno Riegel Santos
- Hospital Nossa Senhora da Conceição, Sistéma Único de Saúde, Porto Alegre, Brazil (Drs Marineide Gonçalves De Melo, Breno Riegel Santos, and Ivana Rosngela Dos Santos Varella)
| | - Ivana Rosângela Dos Santos Varella
- Hospital Nossa Senhora da Conceição, Sistéma Único de Saúde, Porto Alegre, Brazil (Drs Marineide Gonçalves De Melo, Breno Riegel Santos, and Ivana Rosngela Dos Santos Varella)
| | - Karin Nielsen-Saines
- Division of Pediatric Infectious Diseases, Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA (Dr Karin Nielsen-Saines)
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Brandon O, Chakravarti S, Hemelaar J. Trends in management and outcomes of pregnant women living with HIV between 2008–2013 and 2014–2019: A retrospective cohort study. Front Med (Lausanne) 2022; 9:970175. [DOI: 10.3389/fmed.2022.970175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDespite major advances in the care of pregnant women living with HIV (WLHIV), they remain at increased risk of adverse pregnancy outcomes. This study assesses recent developments in management and outcomes of pregnant WLHIV at a tertiary obstetric unit in the United Kingdom.MethodsWe conducted a retrospective cohort study of WLHIV delivering at the John Radcliffe Hospital, Oxford, during 2008–2019. Detailed data was collected for maternal, virological, obstetric, and perinatal characteristics. To determine changes over time, data from the periods 2008–13 and 2014–19 were compared.ResultsWe identified 116 pregnancies in 94 WLHIV. Between 2008–2013 and 2014–2019, the rate of preconception HIV diagnosis increased from 73 to 90% (p = 0.021) and the proportion of WLHIV on combination ART (cART) at conception increased from 54 to 84% (p = 0.001). The median gestation at which cART was initiated antenatally decreased from 22+1 to 17+1 weeks (p = 0.003). In 2014-2019, 41% of WLHIV received non-nucleoside reverse transcriptase inhibitor-based cART, 37% protease inhibitor-based cART, and 22% of cART regimens contained an integrase inhibitor. The proportion of WLHIV with a viral load <50 copies/mL at delivery rose from 87 to 94% (p = 0.235). Sixty-six percent of WLHIV delivered by Cesarean section, with a significant decrease over time in the rate of both planned (62–39%, p = 0.016) and actual (49–31%, p = 0.044) elective Cesarean. Perinatal outcomes included one case of perinatal HIV transmission (0.86%), 11% preterm birth, 15% small-for-gestational-age, and 2% stillbirth. There was an association between a viral load >50 copies/mL at delivery and preterm delivery (p = 0.0004).ConclusionVirological, obstetric, and perinatal outcomes of WLHIV improved during the study period. Implementation of national guidance has led to an increase in preconception diagnosis and treatment, earlier initiation of antenatal treatment, a reduction in the number of women with a detectable viral load at delivery, and an increase in vaginal deliveries.
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67
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Boyce CL, Beck IA, Styrchak SM, Hardy SR, Wallner JJ, Milne RS, Morrison RL, Shapiro DE, João EC, Mirochnick MH, Frenkel LM. Assessment of minority frequency pretreatment HIV drug-resistant variants in pregnant women and associations with virologic non-suppression at term. PLoS One 2022; 17:e0275254. [PMID: 36166463 PMCID: PMC9514603 DOI: 10.1371/journal.pone.0275254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/13/2022] [Indexed: 11/19/2022] Open
Abstract
Objective
To assess in ART-naïve pregnant women randomized to efavirenz- versus raltegravir-based ART (IMPAACT P1081) whether pretreatment drug resistance (PDR) with minority frequency variants (<20% of individual’s viral quasispecies) affects antiretroviral treatment (ART)-suppression at term.
Design
A case-control study design compared PDR minority variants in cases with virologic non-suppression (plasma HIV RNA >200 copies/mL) at delivery to randomly selected ART-suppressed controls.
Methods
HIV pol genotypes were derived from pretreatment plasma specimens by Illumina sequencing. Resistance mutations were assessed using the HIV Stanford Database, and the proportion of cases versus controls with PDR to their ART regimens was compared.
Results
PDR was observed in 7 participants (11.3%; 95% CI 4.7, 21.9) and did not differ between 21 cases and 41 controls (4.8% vs 14.6%, p = 0.4061). PDR detected only as minority variants was less common (3.2%; 95% CI 0.2, 11.7) and also did not differ between groups (0% vs. 4.9%; p = 0.5447). Cases’ median plasma HIV RNA at delivery was 347c/mL, with most (n = 19/22) showing progressive diminution of viral load but not ≤200c/mL. Among cases with viral rebound (n = 3/22), none had PDR detected. Virologic non-suppression at term was associated with higher plasma HIV RNA at study entry (p<0.0001), a shorter duration of ART prior to delivery (p<0.0001), and randomization to efavirenz- (versus raltegravir-) based ART (p = 0.0085).
Conclusions
We observed a moderate frequency of PDR that did not significantly contribute to virologic non-suppression at term. Rather, higher pretreatment plasma HIV RNA, randomization to efavirenz-based ART, and shorter duration of ART were associated with non-suppression. These findings support early prenatal care engagement of pregnant women and initiation of integrase inhibitor-based ART due to its association with more rapid suppression of plasma RNA levels. Furthermore, because minority variants appeared infrequent in ART-naïve pregnant women and inconsequential to ART-suppression, testing for minority variants may be unwarranted.
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Affiliation(s)
- Ceejay L. Boyce
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Ingrid A. Beck
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Sheila M. Styrchak
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Samantha R. Hardy
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Jackson J. Wallner
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Ross S. Milne
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - R. Leavitt Morrison
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Esaú C. João
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | - Mark H. Mirochnick
- Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Lisa M. Frenkel
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Departments of Pediatrics, Laboratory Medicine and Pathology and Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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Nabhan A, Stringer E. Contemporary issues in women's health. Int J Gynaecol Obstet 2022; 159:341-342. [PMID: 36148778 DOI: 10.1002/ijgo.14454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Ashraf Nabhan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Elizabeth Stringer
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
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Ryom L, De Miguel R, Cotter AG, Podlekareva D, Beguelin C, Waalewijn H, Arribas JR, Mallon PWG, Marzolini C, Kirk O, Bamford A, Rauch A, Molina JM, Kowalska JD, Guaraldi G, Winston A, Boesecke C, Cinque P, Welch S, Collins S, Behrens GMN. Major revision version 11.0 of the European AIDS Clinical Society Guidelines 2021. HIV Med 2022; 23:849-858. [PMID: 35338549 PMCID: PMC9545286 DOI: 10.1111/hiv.13268] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The European AIDS Clinical Society (EACS) Guidelines were revised in 2021 for the 17th time with updates on all aspects of HIV care. KEY POINTS OF THE GUIDELINES UPDATE Version 11.0 of the Guidelines recommend six first-line treatment options for antiretroviral treatment (ART)-naïve adults: tenofovir-based backbone plus an unboosted integrase inhibitor or plus doravirine; abacavir/lamivudine plus dolutegravir; or dual therapy with lamivudine or emtricitabine plus dolutegravir. Recommendations on preferred and alternative first-line combinations from birth to adolescence were included in the new paediatric section made with Penta. Long-acting cabotegravir plus rilpivirine was included as a switch option and, along with fostemsavir, was added to all drug-drug interaction (DDI) tables. Four new DDI tables for anti-tuberculosis drugs, anxiolytics, hormone replacement therapy and COVID-19 therapies were introduced, as well as guidance on screening and management of anxiety disorders, transgender health, sexual health for women and menopause. The sections on frailty, obesity and cancer were expanded, and recommendations for the management of people with diabetes and cardiovascular disease risk were revised extensively. Treatment of recently acquired hepatitis C is recommended with ongoing risk behaviour to reduce transmission. Bulevirtide was included as a treatment option for the hepatitis Delta virus. Drug-resistant tuberculosis guidance was adjusted in accordance with the 2020 World Health Organization recommendations. Finally, there is new guidance on COVID-19 management with a focus on continuance of HIV care. CONCLUSIONS In 2021, the EACS Guidelines were updated extensively and broadened to include new sections. The recommendations are available as a free app, in interactive web format and as an online pdf.
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Affiliation(s)
- Lene Ryom
- CHIPCenter of Excellence for Health, Immunity and InfectionsSection 2100, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
- Department of Infectious Diseases 144Hvidovre University HospitalCopenhagenDenmark
| | - Rosa De Miguel
- HIV/Infectious Disease UnitInternal MedicineUniversity Hospital La PazMadridSpain
| | - Aoife Grace Cotter
- Mater Misericordiae University Hospital DublinDublinIreland
- Centre for Experimental Pathogen Host ResearchUniversity College DublinDublinIreland
| | - Daria Podlekareva
- CHIPCenter of Excellence for Health, Immunity and InfectionsSection 2100, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
- Department of Respiratory MedicineBispebjerg HospitalCopenhagenDenmark
| | - Charles Beguelin
- Department of Infectious Diseases, InselspitalBern University HospitalBernSwitzerland
| | - Hylke Waalewijn
- Department of PharmacyRadboud Institute for Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | - Josè R Arribas
- HIV/Infectious Disease UnitInternal MedicineUniversity Hospital La PazMadridSpain
| | - Patrick W. G. Mallon
- Mater Misericordiae University Hospital DublinDublinIreland
- Centre for Experimental Pathogen Host ResearchUniversity College DublinDublinIreland
| | - Catia Marzolini
- Departments of Medicine and Clinical ResearchUniversity Hospital Basel and University of BaselBaselSwitzerland
- Department of Molecular and Clinical PharmacologyInstitute of Translational MedicineUniversity of LiverpoolLiverpoolUK
| | - Ole Kirk
- CHIPCenter of Excellence for Health, Immunity and InfectionsSection 2100, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
- Department of Infectious Diseases, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | - Alasdair Bamford
- Great Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Andri Rauch
- Department of Infectious Diseases, InselspitalBern University HospitalBernSwitzerland
| | - Jean Michel Molina
- Department of Infectious DiseasesSt‐Louis and Lariboisière HospitalsAPHPUniversity of ParisParisFrance
| | | | - Giovanni Guaraldi
- Department of SurgicalMedical, Dental and Morphological SciencesUniversity of Modena and Reggio EmiliaModenaItaly
| | - Alan Winston
- Section of VirologyDepartment of Infectious DiseaseImperial College LondonLondonUK
| | | | - Paola Cinque
- Unit of Infectious DiseasesSan Raffaele Scientific InstituteMilanoItaly
| | - Steven Welch
- Department of PaediatricsUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | | | - Georg M. N. Behrens
- Department for Rheumatology and ImmunologyHannover Medical SchoolHannoverGermany
- German Center for Infection Research (DZIF)Partner Site Hannover‐BraunschweigHannoverGermany
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70
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Patel K, Huo Y, Jao J, Powis KM, Williams PL, Kacanek D, Yee LM, Chadwick EG, Shiau S, Jacobson DL, Brummel SS, Sultan-Beyer L, Kahlert CR, Zash R, Seage GR. Dolutegravir in Pregnancy as Compared with Current HIV Regimens in the United States. N Engl J Med 2022; 387:799-809. [PMID: 36053505 PMCID: PMC9744124 DOI: 10.1056/nejmoa2200600] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data on the effectiveness and safety of dolutegravir-based antiretroviral therapy (ART) for human immunodeficiency virus type 1 (HIV-1) infection in pregnancy as compared with other ART regimens commonly used in the United States and Europe, particularly when initiated before conception, are limited. METHODS We conducted a study involving pregnancies in persons with HIV-1 infection in the Pediatric HIV/AIDS Cohort Study whose initial ART in pregnancy included dolutegravir, atazanavir-ritonavir, darunavir-ritonavir, oral rilpivirine, raltegravir, or elvitegravir-cobicistat. Viral suppression at delivery and the risks of infants being born preterm, having low birth weight, and being small for gestational age were compared between each non-dolutegravir-based ART regimen and dolutegravir-based ART. Supplementary analyses that included participants in the Swiss Mother and Child HIV Cohort Study were conducted to improve the precision of our results. RESULTS Of the pregnancies in the study, 120 were in participants who received dolutegravir, 464 in those who received atazanavir-ritonavir, 185 in those who received darunavir-ritonavir, 243 in those who received rilpivirine, 86 in those who received raltegravir, and 159 in those who received elvitegravir-cobicistat. The median age at conception was 29 years; 51% of the pregnancies were in participants who started ART before conception. Viral suppression was present at delivery in 96.7% of the pregnancies in participants who received dolutegravir; corresponding percentages were 84.0% for atazanavir-ritonavir, 89.2% for raltegravir, and 89.8% for elvitegravir-cobicistat (adjusted risk differences vs. dolutegravir, -13.0 percentage points [95% confidence interval {CI}, -17.0 to -6.1], -17.0 percentage points [95% CI, -27.0 to -2.4], and -7.0 percentage points [95% CI, -13.3 to -0.0], respectively). The observed risks of preterm birth were 13.6 to 17.6%. Adjusted risks of infants being born preterm, having low birth weight, or being small for gestational age did not differ substantially between non-dolutegravir-based ART and dolutegravir. Results of supplementary analyses were similar. CONCLUSIONS Atazanavir-ritonavir and raltegravir were associated with less frequent viral suppression at delivery than dolutegravir. No clear differences in adverse birth outcomes were observed with dolutegravir-based ART as compared with non-dolutegravir-based ART, although samples were small. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others.).
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Affiliation(s)
- Kunjal Patel
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Yanling Huo
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Jennifer Jao
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Kathleen M Powis
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Paige L Williams
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Deborah Kacanek
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Lynn M Yee
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Ellen G Chadwick
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Stephanie Shiau
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Denise L Jacobson
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Sean S Brummel
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Leila Sultan-Beyer
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Christian R Kahlert
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - Rebecca Zash
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
| | - George R Seage
- From the Department of Epidemiology (K.P., P.L.W., G.R.S.), the Center for Biostatistics in AIDS Research (K.P., Y.H., P.L.W., D.K., D.L.J., S.S.B., G.R.S.), and the Department of Immunology and Infectious Diseases (K.M.P.), Harvard T.H. Chan School of Public Health, the Departments of Pediatrics and Medicine, Massachusetts General Hospital (K.M.P.), and the Department of Medicine, Beth Israel Deaconess Medical Center (R.Z.) - all in Boston; the Departments of Pediatrics (J.J., E.G.C.) and Obstetrics and Gynecology (L.M.Y.), Northwestern University Feinberg School of Medicine, Chicago; the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ (S.S.); and the Department of Gynecology, University Hospital Zurich, Zurich (L.S.-B.), and Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen (C.R.K.) - both in Switzerland
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Malaba TR, Nakatudde I, Kintu K, Colbers A, Chen T, Reynolds H, Read L, Read J, Stemmet LA, Mrubata M, Byrne K, Seden K, Twimukye A, Theunissen H, Hodel EM, Chiong J, Hu NC, Burger D, Wang D, Byamugisha J, Alhassan Y, Bokako S, Waitt C, Taegtmeyer M, Orrell C, Lamorde M, Myer L, Khoo S. 72 weeks post-partum follow-up of dolutegravir versus efavirenz initiated in late pregnancy (DolPHIN-2): an open-label, randomised controlled study. Lancet HIV 2022; 9:e534-e543. [PMID: 35905752 DOI: 10.1016/s2352-3018(22)00173-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/12/2022] [Accepted: 06/08/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Late initiation of antiretrovirals in pregnancy is associated with increased risk of perinatal transmission and higher infant mortality. We report the final 72-week postpartum results for efficacy and safety of dolutegravir-based compared with efavirenz-based regimens in mothers and infants. METHODS DolPHIN-2 was a randomised, open-label trial. Pregnant women in South Africa and Uganda aged at least 18 years, with untreated but confirmed HIV infection and an estimated gestation of at least 28 weeks, initiating antiretroviral therapy in third trimester were eligible for inclusion. Eligible women were randomly assigned (1:1) to receive either dolutegravir-based (50 mg dolutegravir, 300 mg tenofovir disoproxil fumarate, and either 200 mg emtricitabine in South Africa or 300 mg lamivudine in Uganda) or efavirenz-based (fixed dose combination 600 mg tenofovir disoproxil fumarate plus either emtricitabine in South Africa or lamivudine in Uganda) therapy. The primary efficacy outcome was the time to a viral load of less than 50 copies per mL measured at 6, 12, 24, 48, and 72 weeks postpartum with a Cox model adjusting for viral load and CD4 cell count. Safety endpoints were summarised by the number of women and infants with events. This trial is registered with ClinicalTrials.gov, NCT03249181. FINDINGS Between Jan 23 and Aug 15, 2018, 280 women were screened for inclusion, of whom 268 (96%) women were randomly assigned: 133 (50%) to the efavirenz group and 135 (50%) to the dolutegravir group. 250 (93%; 125 [50%] in the efavirenz group and 125 [50%] in the dolutegravir group) women were included in the intention-to-treat analysis of efficacy. Median time to viral load of less than 50 copies per mL was 4·1 weeks (IQR 4·0-5·1) in the dolutegravir group compared with 12·1 weeks (10·7-13·3) in the efavirenz group (adjusted hazard ratio [HR] 1·93 [95% CI 1·5-2·5]). At 72 weeks postpartum, 116 (93%) mothers in the dolutegravir group and 114 (91%) in the efavirenz group had a viral load of less than 50 copies per mL. Of 57 (21%) mothers with a severe adverse event, three (2%) in the dolutegravir group and five (4%) in the efavirenz group were related to the drug (dolutegravir drug-related events were one woman each with suicidal ideation, suicide attempt, herpes zoster meningitis; efavirenz drug-related events were one woman each with suicide attempt and liver cirrhosis, and three people with drug-induced liver injury). Of 136 (56%) infants in whom severe adverse events were recorded, none were related to the study drugs. In addition to the three infant HIV infections detected at birth in the dolutegravir group that have been previously reported, an additional transmission in the efavirenz group occurred during breastfeeding despite optimal maternal viral suppression and serial negative infant tests in the first year of life. INTERPRETATION Dolutegravir was safe and well tolerated, supporting updated WHO treatment recommendations in pregnant and breastfeeding women. Infant HIV transmissions can occur during breastfeeding despite persistently undetectable maternal viral load highlighting the need for continued infant testing. FUNDING Unitaid.
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Affiliation(s)
- Thokozile R Malaba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Irene Nakatudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kenneth Kintu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Tao Chen
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Reynolds
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Lucy Read
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jim Read
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Lee-Ann Stemmet
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Megan Mrubata
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly Byrne
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kay Seden
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Adelline Twimukye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Helene Theunissen
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Eva Maria Hodel
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Justin Chiong
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Nai-Chung Hu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - David Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Duolao Wang
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Josaphat Byamugisha
- Department of Gynaecology and Obstetrics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yussif Alhassan
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sharon Bokako
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK; Tropical Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Catherine Orrell
- Desmond Tutu Health Foundation, Department of Medicine, Institute of Infectious Diseases & Molecular Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Centre for Infectious Diseases Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Saye Khoo
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK; Tropical Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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72
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Brummel SS, Stringer J, Mills E, Tierney C, Caniglia EC, Colbers A, Chi BH, Best BM, Gaaloul ME, Hillier S, Jourdain G, Khoo SH, Mofenson LM, Myer L, Nachman S, Stranix‐Chibanda L, Clayden P, Sachikonye M, Lockman S. Clinical and population-based study design considerations to accelerate the investigation of new antiretrovirals during pregnancy. J Int AIDS Soc 2022; 25 Suppl 2:e25917. [PMID: 35851758 PMCID: PMC9294861 DOI: 10.1002/jia2.25917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 04/28/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Pregnant women are routinely excluded from clinical trials, leading to the absence or delay in even the most basic pharmacokinetic (PK) information needed for dosing in pregnancy. When available, pregnancy PK studies use a small sample size, resulting in limited safety information. We discuss key study design elements that may enhance the timely availability of pregnancy data, including the role and timing of randomized controlled trials (RCTs) to evaluate pregnancy safety; efficacy and safety outcome measures; stand-alone protocols, platform trials, single arm studies, sample size and the effect that follow-up time during gestation has on analysis interpretations; and observational studies. DISCUSSION Pregnancy PK should be studied during drug development, after dosing in non-pregnant persons is established (unless non-clinical or other data raise pregnancy concerns). RCTs should evaluate the safety during pregnancy of priority new HIV agents that are likely to be used by large numbers of females of childbearing age. Key endpoints for pregnancy safety studies include birth outcomes (prematurity, small for gestational age and stillbirth) and neonatal death, with traditional adverse events and infant growth also measured (congenital anomalies are best studied through surveillance). We recommend that viral efficacy be studied as a secondary endpoint of pregnancy RCTs, once PK studies confirm adequate drug exposure in pregnancy. RCTs typically use a stand-alone protocol for new agents. In contrast, master protocols using a platform design can add agents over time, possibly speeding safety data ascertainment. To speed accrual, stand-alone pregnancy trial protocols can include pre-specified starting rules based upon adequate PK levels in pregnancy; and seamless master protocols or platform trials can include a pregnancy PK and safety component. When RCTs are unethical or cost-prohibitive, observational studies should be conducted, preferably using target trial emulation to avoid bias. CONCLUSIONS Pregnancy PK needs to be obtained earlier in drug evaluation. Timely RCTs are needed to understand safety in pregnancy for high-priority new HIV agents. RCTs that enrol pregnant women should focus on outcomes unique to pregnancy, and observational studies should focus on questions that RCTs are not equipped to answer.
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Affiliation(s)
- Sean S. Brummel
- Department of BiostatisticsCenter for Biostatistics in AIDS ResearchBostonMassachusettsUSA
- Harvard T.H. Chan School of Public HeathBostonMassachusettsUSA
| | - Jeff Stringer
- School of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Ed Mills
- MTEK SciencesVancouverBritish ColumbiaCanada
- MTEK SciencesKigaliRwanda
| | - Camlin Tierney
- Department of BiostatisticsCenter for Biostatistics in AIDS ResearchBostonMassachusettsUSA
- Harvard T.H. Chan School of Public HeathBostonMassachusettsUSA
| | - Ellen C. Caniglia
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Angela Colbers
- Department of PharmacyRadboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Benjamin H. Chi
- Department of Obstetrics and GynecologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical SciencesSan DiegoCaliforniaUSA
- Pediatrics Department – Rady Children's Hospital San DiegoUniversity of California San DiegoLa JollaCaliforniaUSA
| | | | - Sharon Hillier
- Department of ObstetricsGynecology and Reproductive SciencesUniversity of Pittsburgh and the Magee‐Womens Research InstitutePittsburghPennsylvaniaUSA
| | | | - Saye H. Khoo
- Department of PharmacologyUniversity of LiverpoolLiverpoolUK
| | - Lynne M. Mofenson
- Research DepartmentElizabeth Glaser Pediatric AIDS FoundationWashingtonDCUSA
| | - Landon Myer
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Sharon Nachman
- Department of PediatricsThe State University of New York (SUNY)Stony BrookNew YorkUSA
| | - Lynda Stranix‐Chibanda
- Child and Adolescent Health UnitFaculty of Medicine and Health Sciences, University of ZimbabweHarareZimbabwe
| | | | | | - Shahin Lockman
- Harvard T.H. Chan School of Public HeathBostonMassachusettsUSA
- Brigham and Women's HospitalBostonMassachusettsUSA
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Brooks KM, Pinilla M, Stek AM, Shapiro DE, Barr E, Febo IL, Paul ME, Deville JG, George K, Knowles K, Rungruengthanakit K, Browning R, Chakhtoura N, Capparelli EV, Mirochnick M, Best BM. Pharmacokinetics of Tenofovir Alafenamide With Boosted Protease Inhibitors in Pregnant and Postpartum Women Living With HIV: Results From IMPAACT P1026s. J Acquir Immune Defic Syndr 2022; 90:343-350. [PMID: 35195573 PMCID: PMC9203910 DOI: 10.1097/qai.0000000000002944] [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] [Received: 11/03/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tenofovir alafenamide (TAF) is a key component of HIV treatment, but pharmacokinetic data supporting the use of TAF during pregnancy are limited. In this study, we report pharmacokinetic, safety, and birth outcomes for TAF 25 mg with a boosted protease inhibitor in pregnant women living with HIV. METHODS IMPAACT P1026s was a multicenter, nonrandomized, open-label, phase IV prospective study. Pregnant women living with HIV receiving TAF 25 mg with a boosted protease inhibitor were eligible. Intensive pharmacokinetic assessments were performed during the second and third trimesters and 6-12 weeks postpartum. Maternal and cord blood samples were collected at delivery. Infant washout samples were collected through 5-9 days postbirth. Comparisons of paired pharmacokinetic data between pregnancy and postpartum were made using geometric mean ratios (GMR) [90% confidence intervals (CIs)] and Wilcoxon signed-rank tests with P < 0.10 considered significant. RESULTS Twenty-nine women were enrolled from the United States (median age 31 years and weight 84.5 kg during the third trimester; 48% Black, 45% Hispanic/Latina). TAF AUCtau did not significantly differ in the second [GMR 0.62 (90% CI: 0.29 to 1.34); P = 0.46] or third trimester [GMR 0.94 (90% CI: 0.63 to 1.39); P = 0.50] vs. postpartum and were comparable with historical data in nonpregnant adults. TAF was only quantifiable in 2/25 maternal delivery samples and below the limit of quantification in all cord blood and infant washout samples, likely because of the short half-life of TAF. CONCLUSION TAF AUCtau did not significantly differ between pregnancy and postpartum. These findings provide reassurance as TAF use during pregnancy continues to expand.
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Affiliation(s)
- Kristina M. Brooks
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mauricio Pinilla
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alice M. Stek
- Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, CA, USA
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Emily Barr
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Irma L. Febo
- Department of Pediatrics, School of Medicine, University of Puerto Rico, San Juan, PR, USA
| | - Mary E. Paul
- Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Jaime G. Deville
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | | | | | | | - Renee Browning
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA
| | - Edmund V. Capparelli
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
- Pediatrics Department, University of California San Diego – Rady Children’s Hospital San Diego, San Diego, CA, USA
| | | | - Brookie M. Best
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
- Pediatrics Department, University of California San Diego – Rady Children’s Hospital San Diego, San Diego, CA, USA
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Quinn MK, Williams PL, Muhihi A, Duggan CP, Ulenga N, Alwy Al-Beity FM, Perumal N, Aboud S, Fawzi WW, Manji KP, Sudfeld CR. Timing of Antiretroviral Therapy: Initiation and Birth Outcomes Among Pregnant Women With Human Immunodeficiency Virus in Tanzania. J Infect Dis 2022; 226:687-695. [PMID: 35678698 PMCID: PMC9890905 DOI: 10.1093/infdis/jiac224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/06/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Combination antiretroviral therapy (cART) initiation during pregnancy reduces the risk of perinatal human immunodeficiency virus (HIV) transmission; however, studies have suggested that there may be unintended adverse consequences on birth outcomes for selected cART regimens. METHODS We analyzed adverse birth outcomes among a prospective cohort of 1307 pregnant women with HIV in Dar es Salaam who initiated cART during the first or second trimester of a singleton pregnancy. Our primary analysis compared birth outcomes by gestational age at cART initiation among these women initiating cART in pregnancy. RESULTS Among women who initiated cART in pregnancy, there was no relationship of gestational age at cART initiation with the risk of fetal death or stillbirth. However, women who initiated cART before 20 weeks of gestation compared with after 20 weeks had increased risk of preterm birth (risk ratio [RR], 1.30; 95% confidence interval [CI], 1.03-1.67) but decreased risk of small-for-gestational age birth (RR, 0.71; 95% CI, .55-.93). CONCLUSIONS With increasing use of cART preconception and early in pregnancy, clinicians should be aware of the benefits and potential risks of cART regimens to optimize birth outcomes.
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Affiliation(s)
- M K Quinn
- Correspondence: M. K. Quinn, PhD, Department of Pediatrics, Stanford University School of Medicine, Center for Academic Medicine, Neonatology - MC 5660, 453 Quarry Road, Palo Alto, CA, USA ()
| | - Paige L Williams
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Alfa Muhihi
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Christopher P Duggan
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Fadhlun M Alwy Al-Beity
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nandita Perumal
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wafaie W Fawzi
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher R Sudfeld
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Zhao Y, Hohlfeld A, Namale P, Meintjes G, Maartens G, Engel ME. Risk of Immune Reconstitution Inflammatory Syndrome With Integrase Inhibitors Versus Other Classes of Antiretrovirals: A Systematic Review and Meta-analysis of Randomized Trials. J Acquir Immune Defic Syndr 2022; 90:232-239. [PMID: 35175970 PMCID: PMC7612870 DOI: 10.1097/qai.0000000000002937] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/02/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Integrase strand transfer inhibitors (InSTIs) decrease HIV plasma viral load faster than other antiretroviral classes. More rapid viral load decline has been associated with higher risk of immune reconstitution inflammatory syndrome (IRIS). There are conflicting reports on the association between InSTI and IRIS. We performed a systematic review and meta-analysis to compare the risk of IRIS among treatment-naive HIV-positive patients starting InSTI versus non-InSTI regimens. METHODS We searched PubMed, Scopus, Web of Science, Africa-Wide, and Cochrane databases from earliest available date to 26 November 2021, for randomized controlled trials (RCTs) having intervention arms with InSTI versus control arms without InSTI in patients initiating first-line antiretroviral therapy. The primary outcome was relative risk (RR) of IRIS, whereas the secondary outcome was RR of paradoxical tuberculosis-associated IRIS (TB-IRIS). Data were combined by random-effects meta-analysis according to the Mantel-Haenszel method. The protocol for this study is registered with PROSPERO, CRD42020213976. RESULTS We included 14 RCTs comprising 8696 participants from 6 continents for the primary outcome of IRIS and a subset of 674 participants (from 3 RCTs) for the secondary outcome of paradoxical TB-IRIS. Risk of IRIS was similar between InSTI and non-InSTI regimens (RR, 0.93; 95% confidence interval: 0.75 to 1.14). There was a trend towards a lower risk of paradoxical TB-IRIS with InSTI versus efavirenz regimens that was not statistically significant (RR, 0.64; 95% confidence interval: 0.34 to 1.19). CONCLUSIONS In this meta-analysis among treatment-naive patients commencing first-line antiretroviral therapy, InSTI regimens were not associated with higher risk of IRIS.
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Affiliation(s)
- Ying Zhao
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ameer Hohlfeld
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Phiona Namale
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark E Engel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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76
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Adverse perinatal outcomes associated with HAART and monotherapy: systematic review and meta-analysis. AIDS 2022; 36:1409-1427. [PMID: 35608111 DOI: 10.1097/qad.0000000000003248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Assess adverse perinatal outcomes in women living with HIV (WLHIV) receiving HAART or zidovudine (ZDV) monotherapy, compared with antiretroviral therapy (ART)-naive WLHIV and HIV-negative women. DESIGN Systematic review and meta-analysis. METHODS We conducted a systematic literature review by searching PubMed, CINAHL, Global Health, and EMBASE for studies published during 1 January 1980 to 20 April 2020. We included studies reporting on the association of pregnant WLHIV receiving HAART or ZDV monotherapy with 11 perinatal outcomes: preterm birth (PTB), very PTB, spontaneous PTB (sPTB), low birth weight (LBW), very LBW, term LBW, preterm LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Random-effects meta-analyses were conducted. RESULTS Sixty-one cohort studies assessing 409 781 women were included. WLHIV receiving ZDV monotherapy were associated with a decreased risk of PTB [relative risk 0.70, 95% confidence interval (CI) 0.62-0.79] and LBW (0.77, 0.67-0.88), and comparable risk of SGA, compared with ART-naive WLHIV. WLHIV receiving ZDV monotherapy had a comparable risk of PTB and LBW, and an increased risk of SGA (1.16, 1.04-1.30) compared with HIV-negative women. In contrast, WLHIV receiving HAART were associated with a comparable risk of PTB and LBW, and increased risk of SGA (1.38, 1.09-1.75), compared with ART-naive WLHIV. WLHIV receiving HAART were associated with an increased risk of PTB (1.55, 1.38-1.74), sPTB (2.09, 1.48-2.96), LBW (1.79, 1.51-2.13), term LBW (1.88, 1.23-2.85), SGA (1.80,1.34-2.40), and VSGA (1.22, 1.10-1.34) compared with HIV-negative women. CONCLUSION Pregnant WLHIV receiving HAART have an increased risk of a wide range of perinatal outcomes compared with HIV-negative women.
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Sahloff EG, Hamons N, Baumgartner K, Duggan JM. Is long-acting cabotegravir a pre-exposure prophylaxis option for women of child-bearing potential? Open Forum Infect Dis 2022; 9:ofac230. [PMID: 35836749 PMCID: PMC9274437 DOI: 10.1093/ofid/ofac230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/05/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Long-acting cabotegravir (CAB-LA) provides an exciting new option for pre-exposure prophylaxis (PrEP) in multiple populations. In this perspective, we consider the unique pharmacokinetics of CAB-LA and the potential impact on the prescribing of CAB-LA, specifically in cis-women of reproductive potential.
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Affiliation(s)
- Eric G. Sahloff
- University of Toledo College of Pharmacy and Pharmaceutical Sciences 3000 Arlington Ave, MS 1013 Toledo, OH,
| | - Niki Hamons
- University of Toledo Medical Center Department of Pharmacy Toledo, OH, USA
| | - Kevin Baumgartner
- University of Toledo College of Pharmacy and Pharmaceutical Sciences Toledo, OH, USA
| | - Joan M. Duggan
- University of Toledo Division of Infectious Diseases Toledo, OH, USA
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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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Cowdell I, Beck K, Portwood C, Sexton H, Kumarendran M, Brandon Z, Kirtley S, Hemelaar J. Adverse perinatal outcomes associated with protease inhibitor-based antiretroviral therapy in pregnant women living with HIV: A systematic review and meta-analysis. EClinicalMedicine 2022; 46:101368. [PMID: 35521067 PMCID: PMC9061981 DOI: 10.1016/j.eclinm.2022.101368] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 11/09/2022] Open
Abstract
Background The World Health Organization recommends protease inhibitor (PI)-based antiretroviral therapy (ART) as second-line and third-line regimens in pregnant women living with HIV (WLHIV). US, European, and UK guidelines include PI-based ART as first-line regimens, but advise against the use of lopinavir/ritonavir (LPV/r)-based ART, citing an increased risk of preterm birth (PTB). We aimed to assess the risk of adverse perinatal outcomes in WLHIV receiving PI-ART and the comparative risks associated with different PI-ART regimens. Methods We conducted a systematic literature review by searching PubMed, CINAHL, Global Health, and EMBASE for studies published between Jan 1, 1980, and April 20, 2020. Two investigators independently selected studies and extracted data from studies reporting on the association of pregnant WLHIV receiving PI-ART with 11 perinatal outcomes: PTB, very PTB (VPTB), spontaneous PTB (sPTB), low birth weight (LBW), very LBW (VLBW), term LBW, preterm LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Pairwise random-effects meta-analyses examined the risk of each adverse perinatal outcome in WLHIV receiving PI-ART compared to non-PI-based ART (non-PI-ART), and comparisons of different PI-ART regimens. Quality assessments of studies were performed, subgroup and sensitivity analyses were conducted based on country income status and study quality, heterogeneity assessed, and the effect of adjustment for confounding factors assessed. The protocol is registered with PROSPERO, CRD42021248987. Findings Of 94,594 studies identified, 34 cohort studies including 57,546 women met the inclusion criteria. Random-effects meta-analyses showed that PI-ART was associated with a significantly increased risk of SGA (Relative Risk [RR] 1.24, 95% CI 1.08-1.43; I2 =66.7%) and VSGA (RR 1.40, 1.09-1.81; I2 =0.0%), but not PTB (RR 1.09, 0.95-1.24; I2 =68.3%), VPTB (RR 1.30, 0.78-2.18; I2 =43.0%), sPTB (RR 1.91, 0.61-5.99; I2 =95.7%), LBW (RR 1.04, 0.85-1.27; I2 =63.9%), VLBW (RR 0.72, 0.37-1.43; I2 =37.9%), term LBW (RR 0.94, 0.30-3.02; I2 =0.0%), stillbirth (RR 1.04, 0.60-1.79; I2 =0.0%), and neonatal death (RR 1.82, 0.97-3.40; I2 =0.0%), compared to non-PI-ART. We found no significant differences in perinatal outcomes between ART regimens containing LPV/r, atazanavir/ritonavir (ATV/r), and darunavir/ritonavir (DRV/r), which are the most commonly used PIs. Interpretation PI-ART is associated with an increased risk of SGA and VSGA, but not PTB or other perinatal outcomes. No significant differences in perinatal outcomes were found between LPV/r, ATV/r, and DRV/r. These findings should inform clinical guidelines, and further efforts should be made to improve perinatal outcomes among pregnant WLHIV. Funding None.
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Affiliation(s)
- Imogen Cowdell
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Katharina Beck
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Clara Portwood
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Harriet Sexton
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, 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, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
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Latham AH, Nissim OA, Spitznagel MC, Kirk SE, Tarleton JL, Lazenby GB. Impact of Integrase Strand Transfer Inhibitor Use During Pregnancy on Viral Suppression at Delivery and Infant Outcomes: A Statewide Retrospective Cohort Study. J Acquir Immune Defic Syndr 2022; 89:448-453. [PMID: 35202051 DOI: 10.1097/qai.0000000000002882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/19/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND We sought to determine whether pregnant women with HIV prescribed integrase strand transfer inhibitor (INSTI) were more likely to have viral suppression at delivery and any increased risk of adverse infant outcomes. METHODS This was a retrospective, statewide cohort study of women with HIV and their HIV-exposed infants who delivered in South Carolina from 2008 to 2019. Women's antenatal AVRs were classified as INSTI or non-INSTI. We compared the percentage of women with undetectable HIV RNA viral load (<40 copies/mL) at delivery between groups. We compared the percentage of HIV-exposed singleton infants who were born preterm delivery, low birth weight, and small for gestational age and had confirmed perinatal HIV infection. Categorical outcomes were compared using the χ2 test or Fischer exact test. RESULTS A total of 832 infants, including 11 sets of twins, were exposed to maternal HIV. Detailed antiretroviral regimens were available for analysis in a third of mother-infant pairs (n = 315). Half of the infants were exposed to INSTI (159) and half to non-INSTI antiretrovirals (156). Most women had an undetectable viral load at delivery (80% INSTI and 73% non-INSTI, P= 0.11). The percentage of singleton infants with adverse outcomes was similar between INSTI and non-INSTI groups: preterm delivery (21% and 16%, P = 0.3), low birth weight (19% and 21%, P = 0.7), small for gestational age (11% vs 9%, P = 0.5), and perinatal HIV infection (2.5% and 1.3%, P = 0.7). CONCLUSIONS We observed that viral suppression before delivery was similar between pregnant women prescribed INSTI and non-INSTI antiretroviral therapy. The percentage of infants with adverse outcomes was similar when exposed to INSTI and non-INSTI antiretroviral therapy.
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Affiliation(s)
- A Hayden Latham
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC; and
| | - Oriel A Nissim
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC; and
| | | | - Stephanie E Kirk
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Jessica L Tarleton
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC; and
| | - Gweneth B Lazenby
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC; and
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81
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Davey DJ. Long-term use of ART in African women of reproductive age. THE LANCET HIV 2022; 9:e369-e370. [DOI: 10.1016/s2352-3018(22)00061-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 10/18/2022]
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82
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Amaral S, Brites C, Sprinz E. Integrase Inhibitors Use for HIV Infection in Pregnancy. Curr Infect Dis Rep 2022. [DOI: 10.1007/s11908-022-00774-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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83
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Wedderburn CJ, Groenewold NA, Roos A, Yeung S, Fouche JP, Rehman AM, Gibb DM, Narr KL, Zar HJ, Stein DJ, Donald KA. Early structural brain development in infants exposed to HIV and antiretroviral therapy in utero in a South African birth cohort. J Int AIDS Soc 2022; 25:e25863. [PMID: 35041774 PMCID: PMC8765561 DOI: 10.1002/jia2.25863] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 12/10/2021] [Indexed: 12/21/2022] Open
Abstract
Introduction There is a growing population of children who are HIV‐exposed and uninfected (HEU) with the successful expansion of antiretroviral therapy (ART) use in pregnancy. Children who are HEU are at risk of delayed neurodevelopment; however, there is limited research on early brain growth and maturation. We aimed to investigate the effects of in utero exposure to HIV/ART on brain structure of infants who are HEU compared to HIV‐unexposed (HU). Methods Magnetic resonance imaging using a T2‐weighted sequence was undertaken in a subgroup of infants aged 2–6 weeks enrolled in the Drakenstein Child Health Study birth cohort, South Africa, between 2012 and 2015. Mother–child pairs received antenatal and postnatal HIV testing and ART per local guidelines. We compared subcortical and total grey matter volumes between HEU and HU groups using multivariable linear regression adjusting for infant age, sex, intracranial volume and socio‐economic variables. We further assessed associations between brain volumes with maternal CD4 cell count and ART exposure. Results One hundred forty‐six infants (40 HEU; 106 HU) with high‐resolution images were included in this analysis (mean age 3 weeks; 50.7% male). All infants who were HEU were exposed to ART (88% maternal triple ART). Infants who were HEU had smaller caudate volumes bilaterally (5.4% reduction, p < 0.05) compared to HU infants. There were no group differences in other subcortical volumes (all p > 0.2). Total grey matter volume was also reduced in infants who were HEU (2.1% reduction, p < 0.05). Exploratory analyses showed that low maternal CD4 cell count (<350 cells/mm3) was associated with decreased infant grey matter volumes. There was no relationship between timing of ART exposure and grey matter volumes. Conclusions Lower caudate and total grey matter volumes were found in infants who were HEU compared to HU in the first weeks of life, and maternal immunosuppression was associated with reduced volumes. These findings suggest that antenatal HIV exposure may impact early structural brain development and improved antenatal HIV management may have the potential to optimize neurodevelopmental outcomes of children who are HEU.
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Affiliation(s)
- Catherine J Wedderburn
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.,The Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Nynke A Groenewold
- The Neuroscience Institute, University of Cape Town, Cape Town, South Africa.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Annerine Roos
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,The Neuroscience Institute, University of Cape Town, Cape Town, South Africa.,SA MRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
| | - Shunmay Yeung
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Jean-Paul Fouche
- The Neuroscience Institute, University of Cape Town, Cape Town, South Africa.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Andrea M Rehman
- MRC International Statistics & Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit, University College London, London, UK
| | - Katherine L Narr
- Departments of Neurology, Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, California, USA
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,SA MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- The Neuroscience Institute, University of Cape Town, Cape Town, South Africa.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.,SA MRC Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Kirsten A Donald
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,The Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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84
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Joseph Davey DL, Bekker LG, Bukusi EA, Chi BH, Delany-Moretlwe S, Goga A, Lyerly AD, Mgodi NM, Mugo N, Myer L, Noguchi LM, Stranix-Chibanda L, Slack C, Pintye J. Where are the pregnant and breastfeeding women in new pre-exposure prophylaxis trials? The imperative to overcome the evidence gap. THE LANCET HIV 2022; 9:e214-e222. [DOI: 10.1016/s2352-3018(21)00280-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/11/2021] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
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Thimm MA, Livingston A, Ramroop R, Eke AC. Pregnancy Outcomes in Pregnant Women with HIV on Tenofovir Disoproxil Fumarate (TDF) Compared to Tenofovir Alafenamide (TAF). JOURNAL OF AIDS AND HIV TREATMENT 2022; 4:6-13. [PMID: 35466327 PMCID: PMC9022578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective Our objective was to assess the safety, efficacy, and pregnancy outcomes of Tenofovir Disoproxil Fumarate (TDF) compared to Tenofovir Alafenamide (TAF) use in pregnant women with HIV (PWLHIV). Methods This retrospective cohort study of all women who received prenatal care at a single academic center between January 1st 2015 and June 30th, 2020 compared outcomes in PWLHIV using TDF compared to TAF. The primary outcome was weight-gain during pregnancy. Secondary outcomes included CD4 count, viral-load, gestational age at delivery, fetal and neonatal outcomes. Outcomes were analyzed using standard statistical tests. Multivariable linear-regression analysis models accounting for potential confounders were created for primary and secondary outcomes, with beta coefficients (β) and associated 95% confidence intervals as the primary measure of effect. Statistical analysis was done with STATA 16. Results There were 66 women in the TDF group and 34 women in the TAF group. In the overall cohort, the median (interquartile range, IQR) gestational age at delivery for PWLHIV on TDF and TAF were 38.6 (IQR 37.5-39.4) and 38.1 (31.1-39.1) weeks respectively; and most women (85%) were Black/African American. Compared to PWLHIV on a TDF regimen, women on TAF, on average, gained over 3 kg more weight in the 3rd trimester of pregnancy (β=3.20, 95% CI 1.64, 7.97; p=0.03). Women in the TAF arm were also more likely to have higher median CD4-count (470 cells/mm3 versus 669 cells/mm3, p=0.035) in the third trimester compared to women on TDF. There were no cases of neonatal/infant HIV or death. Conclusion Although TAF use was associated with more weight gain compared to TDF, both regimens appear safe and effective during pregnancy. PWLHIV should be counseled about the potential for weight gain with TAF based regimens during pregnancy.
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Affiliation(s)
- Matthew A. Thimm
- Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Alison Livingston
- Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Rosemary Ramroop
- Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Ahizechukwu C. Eke
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA,Correspondence should be addressed to Ahizechukwu C Eke,
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86
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Eke AC. Adherence Predictors in Pregnant Women Living with HIV on Tenofovir Alafenamide and Tenofovir Disoproxil Fumarate. JOURNAL OF PHARMACEUTICS AND DRUG RESEARCH 2022; 5:585-593. [PMID: 35845086 PMCID: PMC9281900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Medication adherence to antiretroviral medications is critical during pregnancy in women living with HIV (WLHIV) for multiple reasons. In this study, we report medication adherence to tenofovir alafenamide (TAF) compared to tenofovir disoproxil fumarate (TDF) during pregnancy in WLHIV. METHODS This is a retrospective cohort study of pregnant women living with HIV aged 18-48 years who received either tenofovir alafenamide (TAF) or tenofovir disoproxil fumarate (TDF) during pregnancy. Medication adherence was assessed during each visit in all trimesters of pregnancy, and was self-reported. Demographics and outcomes were analyzed using standard statistical tests. Logistic regression analysis models accounting for potential confounders, with adjusted odds-ratios (aORs) and associated 95% confidence intervals were reported. RESULTS One hundred women met inclusion criteria, with thirty-four women on TAF and sixty-six women on TDF. While medication adherence was higher in women using TAF compared to TDF, with 76% adherent to TDF vs 83% adherent to TAF; p=0.282, in the 1st trimester; 82% adherent to TDF vs 88% adherent to TAF; p=0.924, in the 2nd trimester, and 88% adherent to TDF vs 91% adherent to TAF; p=0.176, in the 3rd trimester of pregnancy, these differences in medication adherence were not statistically significant. In the third trimester of pregnancy, multiparous women were more likely to be adherent to TDF/TAF antiretroviral medications compared to nulliparous women - univariable odds ratio, OR 1.31, 95% CI 1.12, 1.57; p<0.05; multivariable (adjusted odds ratio, aOR 1.23, 95% CI 1.08, 1.52; p<0.05). CONCLUSIONS Pregnant women living with HIV on TDF and TAF achieved high adherence, but medication adherence was better in the third trimester compared to the first or second trimesters of pregnancy. These findings support the need to continually assess medication adherence during pregnancy.
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Affiliation(s)
- Ahizechukwu C Eke
- Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 2128, USA
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87
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Romo ML, Patel RC, Edwards JK, Humphrey JM, Musick BS, Bernard C, Maina MW, Brazier E, Castelnuovo B, Penner J, Wyka K, Cardoso SW, Ly PS, Kunzekwenyika C, Cortés CP, Panczak R, Kelvin EA, Wools-Kaloustian KK, Nash D. Disparities in Dolutegravir Uptake Affecting Females of Reproductive Age With HIV in Low- and Middle-Income Countries After Initial Concerns About Teratogenicity : An Observational Study. Ann Intern Med 2022; 175:84-94. [PMID: 34843382 PMCID: PMC8808594 DOI: 10.7326/m21-3037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The transition to dolutegravir-containing antiretroviral therapy (ART) in low- and middle-income countries (LMICs) was complicated by an initial safety signal in May 2018 suggesting that exposure to dolutegravir at conception was possibly associated with infant neural tube defects. On the basis of additional evidence, in July 2019, the World Health Organization recommended dolutegravir for all adults and adolescents living with HIV. OBJECTIVE To describe dolutegravir uptake and disparities by sex and age group in LMICs. DESIGN Observational cohort study. SETTING 87 sites that began using dolutegravir in 11 LMICs in the Asia-Pacific; Caribbean, Central and South America network for HIV epidemiology (CCASAnet); and sub-Saharan African regions of the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. PATIENTS 134 672 patients aged 16 years or older who received HIV care from January 2017 through March 2020. MEASUREMENTS Sex, age group, and dolutegravir uptake (that is, newly initiating ART with dolutegravir or switching to dolutegravir from another regimen). RESULTS Differences in dolutegravir uptake among females of reproductive age (16 to 49 years) emerged after the safety signal. By the end of follow-up, the cumulative incidence of dolutegravir uptake among females 16 to 49 years old was 29.4% (95% CI, 29.0% to 29.7%) compared with 57.7% (CI, 57.2% to 58.3%) among males 16 to 49 years old. This disparity was greater in countries that began implementing dolutegravir before the safety signal and initially had highly restrictive policies versus countries with a later rollout. Dolutegravir uptake was similar among females and males aged 50 years or older. LIMITATION Follow-up was limited to 6 to 8 months after international guidelines recommended expanding access to dolutegravir. CONCLUSION Substantial disparities in dolutegravir uptake affecting females of reproductive age through early 2020 are documented. Although this disparity was anticipated because of country-level restrictions on access, the results highlight its extent and initial persistence. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Matthew L Romo
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, and CUNY Institute for Implementation Science in Population Health, New York, New York (M.L.R., E.B., E.A.K., D.N.)
| | - Rena C Patel
- Department of Medicine and Department of Global Health, University of Washington, Seattle, Washington (R.C.P.)
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (J.K.E.)
| | - John M Humphrey
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana (J.M.H., K.K.W.)
| | - Beverly S Musick
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana (B.S.M.)
| | - Caitlin Bernard
- Department of Obstetrics & Gynecology, Indiana University School of Medicine, Indianapolis, Indiana (C.B.)
| | - Mercy W Maina
- Department of Pharmacy, Moi Teaching and Referral Hospital, Eldoret, Kenya (M.W.M.)
| | - Ellen Brazier
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, and CUNY Institute for Implementation Science in Population Health, New York, New York (M.L.R., E.B., E.A.K., D.N.)
| | - Barbara Castelnuovo
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda (B.C.)
| | - Jeremy Penner
- Family AIDS Care & Education Services, Kisumu, Kenya, and Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (J.P.)
| | - Katarzyna Wyka
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, New York (K.W.)
| | - Sandra Wagner Cardoso
- Instituto Nacional de Infectologia, Laboratório de Pesquisa Clínica em HIV/AIDS, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil (S.W.C.)
| | - Penh Sun Ly
- National Center for HIV/AIDS, Dermatology and STDs, Ministry of Health, Phnom Penh, Cambodia (P.S.L.)
| | | | - Claudia P Cortés
- Departamento de Medicina, Universidad de Chile & Fundación Arriarán, Santiago, Chile (C.P.C.)
| | - Radoslaw Panczak
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (R.P.)
| | - Elizabeth A Kelvin
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, and CUNY Institute for Implementation Science in Population Health, New York, New York (M.L.R., E.B., E.A.K., D.N.)
| | - Kara K Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana (J.M.H., K.K.W.)
| | - Denis Nash
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, and CUNY Institute for Implementation Science in Population Health, New York, New York (M.L.R., E.B., E.A.K., D.N.)
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88
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Ciaranello A, Mushavi A, Lockman S. Time for a Change: Optimizing Drug Data and Informed Choice in Pregnancy. Ann Intern Med 2022; 175:133-134. [PMID: 34843381 DOI: 10.7326/m21-4338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Andrea Ciaranello
- Division of Infectious Diseases and Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard University Center for AIDS Research, and Harvard Medical School, Boston, Massachusetts
| | - Angela Mushavi
- Ministry of Health and Child Care in Zimbabwe, Harare, Zimbabwe
| | - Shahin Lockman
- Division of Infectious Diseases, Brigham and Women's Hospital, Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, and Botswana Harvard AIDS Institute Partnership, Boston, Massachusetts
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Bukkems VE, Necsoi C, Tenorio CH, Garcia C, Alejandre IA, Weiss F, Lambert JS, van Hulzen A, Richel O, Te Brake LHM, van der Meulen E, Burger D, Konopnicki D, Colbers A. Tenofovir alafenamide plasma concentrations are reduced in pregnant women living with HIV: data from the PANNA Network. Clin Infect Dis 2021; 75:623-629. [PMID: 34864950 PMCID: PMC9464066 DOI: 10.1093/cid/ciab1010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Tenofovir alafenamide (TAF), a prodrug of tenofovir (TFV), is included in the majority of the recommended first-line antiretroviral regimens for patients living with HIV, but there are limited data on TAF use in pregnant women. We aimed to examine the plasma pharmacokinetics of TAF and TFV in pregnant women from Europe. METHODS Pregnant women living with HIV were included from treatment centers across Europe, and intensive pharmacokinetic sampling in the third trimester and postpartum was performed. Pharmacokinetic parameters of TAF and TFV were determined with noncompartmental analysis. The proportion of women with a TAF AUCtau below the target of 53.1 ng*h/mL was determined. Clinical efficacy and safety outcome parameters were reported. RESULTS In total, 20 pregnant women living with HIV were included. At the third trimester, geometric mean TAF AUClast and Cmax were decreased by 46% and 52%, respectively, compared with postpartum. TFV AUC0-24h, Cmax, and Ctrough decreased by 33%, 30% and 34%, respectively. The proportion of women with a TAF AUClast <53.1 ng*h/mL was 6% at third trimester and 0% postpartum. One out of 20 women had a viral load >50 copies/mL at third trimester and no mother-to-child transmission occurred. CONCLUSIONS TAF plasma concentrations were reduced by about half in women living with HIV during third trimester of pregnancy, but remained above the predefined efficacy target in the majority of the pregnant women. TFV concentrations were reduced by approximately 30% during third trimester. Despite the observed exposure decrease, high virologic efficacy was observed in this study.
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Affiliation(s)
- Vera E Bukkems
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, the Netherlands
| | - Coca Necsoi
- Saint-Pierre University Hospital, Brussels, Belgium
| | | | - Coral Garcia
- Hospital Universtario Virgen de las Nieves, Granada, Spain
| | - Irene Alba Alejandre
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Germany
| | - Fabian Weiss
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Germany
| | - John S Lambert
- Mater Misericordiae University Hospital, Dublin, Ireland.,Rotunda hospitals, Dublin, Ireland.,UCD school of medicine and medical science, Dublin, Ireland
| | - Astrid van Hulzen
- Department of internal medicine, Isala Hospital, Zwolle, the Netherlands
| | - Olivier Richel
- Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - Lindsey H M Te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, the Netherlands
| | - Eric van der Meulen
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, the Netherlands
| | - David Burger
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, the Netherlands
| | | | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, the Netherlands
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90
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Lyerly AD, Beigi R, Bekker L, Chi BH, Cohn SE, Diallo DD, Eron J, Faden R, Jaffe E, Kashuba A, Kasule M, Krubiner C, Little M, Mfustso‐Bengo J, Mofenson L, Mwapasa V, Mworeko L, Myer L, Penazzato M, Rid A, Shapiro R, Singh JA, Sullivan K, Vicari M, Wambui J, White A, Wickremsinhe M, Wolf L. Ending the evidence gap for pregnancy, HIV and co-infections: ethics guidance from the PHASES project. J Int AIDS Soc 2021; 24:e25846. [PMID: 34910846 PMCID: PMC8673925 DOI: 10.1002/jia2.25846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/21/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION While pregnant people have been an important focus for HIV research, critical evidence gaps remain regarding prevention, co-infection, and safety and efficacy of new antiretroviral therapies in pregnancy. Such gaps can result in harm: without safety data, drugs used may carry unacceptable risks to the foetus or pregnant person; without pregnancy-specific dosing data, pregnant people face risks of both toxicity and undertreatment; and delays in gathering evidence can limit access to beneficial next-generation drugs. Despite recognition of the need, numerous barriers and ethical complexities have limited progress. We describe the process, ethical foundations, recommendations and applications of guidance for advancing responsible inclusion of pregnant people in HIV/co-infections research. DISCUSSION The 26-member international and interdisciplinary Pregnancy and HIV/AIDS: Seeking Equitable Study (PHASES) Working Group was convened to develop ethics-centred guidance for advancing timely, responsible HIV/co-infections research with pregnant people. Deliberations over 3 years drew on extensive qualitative research, stakeholder engagement, expert consultation and a series of workshops. The guidance, initially issued in July 2020, highlights conceptual shifts needed in framing research with pregnant people, and articulates three ethical foundations to ground recommendations: equitable protection from drug-related risks, timely access to biomedical advances and equitable respect for pregnant people's health interests. The guidance advances 12 specific recommendations, actionable within the current regulatory environment, addressing multiple stakeholders across drug development and post-approval research, and organized around four themes: building capacity, supporting inclusion, achieving priority research and ensuring respect. The recommendations describe strategies towards ethically redressing the evidence gap for pregnant people around HIV and co-infections. The guidance has informed key efforts of leading organizations working to advance needed research, and identifies further opportunities for impact by a range of stakeholder groups. CONCLUSIONS There are clear pathways towards ethical inclusion of pregnant people in the biomedical research agenda, and strong agreement across the HIV research community about the need for - and the promise of - advancing them. Those who fund, conduct, oversee and advocate for research can use the PHASES guidance to facilitate more, better and earlier evidence to optimize the health and wellbeing of pregnant people and their children.
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Affiliation(s)
- Anne Drapkin Lyerly
- Department of Social Medicine and Center for BioethicsUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Richard Beigi
- Department of ObstetricsGynecology & Reproductive SciencesUPMC Magee‐Women's HospitalPittsburghPennsylvaniaUSA
| | - Linda‐Gail Bekker
- Desmond Tutu HIV Centre and Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Benjamin H. Chi
- Department of Obstetrics and GynecologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Susan E. Cohn
- Department of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | | | - Joseph Eron
- Department of Medicine and Center for AIDS ResearchUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Ruth Faden
- Johns Hopkins Berman Institute of BioethicsBaltimoreMarylandUSA
| | - Elana Jaffe
- Department of Social Medicine and Center for BioethicsUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Angela Kashuba
- Eshelman School of Pharmacy and Department of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Mary Kasule
- Botswana‐Baylor Centre for Clinical ExcellenceGabaroneBotswana
| | | | - Maggie Little
- Kennedy Institute for Ethics and Department of PhilosophyGeorgetown UniversityWashingtonDCUSA
| | - Joseph Mfustso‐Bengo
- Center of Bioethics for Eastern & Southern Africa and Department of Health Systems and PolicyCollege of MedicineUniversity of MalawiZombaMalawi
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS FoundationWashingtonDCUSA
| | | | - Lillian Mworeko
- International Community of Women Living with HIV Eastern AfricaKampalaUganda
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | - Annette Rid
- Department of BioethicsThe Clinical CenterNational Institutes of HealthBethesdaMarylandUSA
| | - Roger Shapiro
- Department of Immunology and Infectious DiseasesHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Jerome Amir Singh
- Howard College School of LawUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
- Dalla Lana School of Public Health Sciences, University of TorontoTorontoOntarioCanada
| | - Kristen Sullivan
- Department of Social Medicine and Center for BioethicsUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | | | - Jacque Wambui
- National Empowerment Network of People Living with HIV and AIDS in Kenya (NEPHAK)African Communities Advisory Board (AfroCAB)LusakaZambia
| | - Amina White
- Department of Obstetrics and GynecologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Marisha Wickremsinhe
- Ethox Centre and Wellcome Centre for Ethics and HumanitiesUniversity of OxfordOxfordUK
| | - Leslie Wolf
- Center for LawHealth & Society and College of Law and School of Public HealthGeorgia State UniversityAtlantaGeorgiaUSA
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91
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Price JT, Vwalika B, Freeman BL, Cole SR, Saha PT, Mbewe FM, Phiri WM, Peterson M, Muyangwa D, Sindano N, Mwape H, Smithmyer ME, Kasaro MP, Rouse DJ, Goldenberg RL, Chomba E, Stringer JSA. Weekly 17 alpha-hydroxyprogesterone caproate to prevent preterm birth among women living with HIV: a randomised, double-blind, placebo-controlled trial. Lancet HIV 2021; 8:e605-e613. [PMID: 34509197 PMCID: PMC8476342 DOI: 10.1016/s2352-3018(21)00150-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/08/2021] [Accepted: 06/22/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Women with HIV face an increased risk of preterm birth. 17 alpha-hydroxyprogesterone caproate (17P) has been shown in some trials to reduce early delivery among women with a history of spontaneous preterm birth. We investigated whether 17P would reduce this risk among women with HIV. METHODS We did a randomised, double-blind, placebo-controlled trial in pregnant women with HIV at the University Teaching Hospital and Kamwala District Health Centre in Lusaka, Zambia. Eligible patients were women aged 18 years or older with confirmed HIV-1 infection, viable intrauterine singleton pregnancy at less than 24 weeks of gestation, and were receiving or intending to commence antiretroviral therapy during pregnancy. Exclusion criteria were major uterine or fetal anomaly; planned or in situ cervical cerclage; evidence of threatened miscarriage, preterm labour, or ruptured membranes at screening; medical contraindication to 17P; previous participation in the trial; or history of spontaneous preterm birth. Eligible participants provided written informed consent and were randomly assigned (1:1) to receive 250 mg intramuscular 17P or placebo once per week, starting between 16 and 24 weeks of gestation until delivery, stillbirth, or reaching term (37 weeks). Participants and study staff were masked to assignment, except for pharmacy staff who did random assignment and prepared injections but did not interact with participants. The primary outcome was a composite of delivery before 37 weeks or stillbirth at any gestational age. Patients attended weekly visits for study drug injections and antenatal care. We estimated the absolute and relative difference in risk of the primary outcome and safety events between treatment groups by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03297216, and is complete. FINDINGS Between Feb 7, 2018 and Jan 13, 2020, we assessed 1042 women for inclusion into the study. 242 women were excluded after additional assessments, and 800 eligible patients were enrolled and randomly assigned to receive intramuscular 17P (n=399) or placebo (n=401). Baseline characteristics were similar between groups. Adherence to study drug injections was 98% in both groups, no patients were lost to follow-up, and the final post-partum visit was on Aug 6, 2020. 36 (9%) of 399 participants assigned to 17P had preterm birth or stillbirth, compared with 36 (9%) of 401 patients assigned to placebo (risk difference 0·1, 95% CI -3·9 to 4·0; relative risk 1·0, 95% CI 0·6 to 1·6; p=0·98). Intervention-related adverse events were reported by 140 (18%) of 800 participants and occurred in similar proportions in both randomisation groups. No serious adverse events were reported. INTERPRETATION Although 17P seems to be safe and acceptable to participants, available data do not support the use of the drug to prevent preterm birth among women whose risk derives solely from HIV infection. The low risk of preterm birth in both randomisation groups warrants further investigation. FUNDING US National Institutes of Health and the Bill and Melinda Gates Foundation.
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Affiliation(s)
- Joan T Price
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, NC, USA; Departments of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia.
| | - Bellington Vwalika
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, NC, USA; Departments of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Bethany L Freeman
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, NC, USA
| | - Stephen R Cole
- Epidemiology, University of North Carolina at Chapel Hill, NC, USA
| | - Pooja T Saha
- Biostatistics, University of North Carolina at Chapel Hill, NC, USA
| | | | | | - Marc Peterson
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, NC, USA
| | | | | | | | - Megan E Smithmyer
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, NC, USA
| | - Margaret P Kasaro
- Departments of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia; UNC Global Projects-Zambia, Lusaka, Zambia
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, Brown University School of Medicine, Providence, RI, USA
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Elwyn Chomba
- Paediatrics, University of Zambia School of Medicine, Lusaka, Zambia
| | - Jeffrey S A Stringer
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, NC, USA
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92
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Stinco M, Rubino C, Trapani S, Indolfi G. Treatment of hepatitis B virus infection in children and adolescents. World J Gastroenterol 2021; 27:6053-6063. [PMID: 34629819 PMCID: PMC8476329 DOI: 10.3748/wjg.v27.i36.6053] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 06/30/2021] [Accepted: 08/13/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B virus (HBV) infection is one of the main causes of morbidity and mortality worldwide. Most children acquire the infection perinatally or during early childhood and develop a chronic hepatitis characterized by a high viral replication and a low-inflammation phase of infection, with normal or only slightly raised aminotransferases. Although a conservative approach in children is usually recommended, different therapies exist and different therapeutic approaches are possible. The main goals of antiviral treatment for children with chronic HBV infection are to suppress viral replication and to warn the disease progression to cirrhosis and hepatocellular carcinoma, although these complications are rare in children. Both United States Food and Drug Administration (US-FDA) and European Medicines Agency (EMA) have approved interferon alfa-2b for children aged 1 year and older, pegylated interferon alfa-2a and lamivudine for children aged 3 years and older, entecavir for use in children aged 2 years and older, and adefovir for use in those 12 years of age and older. Tenofovir disoproxil fumarate is approved by EMA for children aged 2 years and older and by US-FDA for treatment in children aged 12 years and older. Finally, EMA has approved the use of tenofovir alafenamide for treatment of children aged 12 years and older or for children weighing more than 35 kg independent of age. This narrative review will provide the framework for summarizing indications to antiviral therapy in the management of chronic HBV infection in children and adolescents.
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Affiliation(s)
- Mariangela Stinco
- Department of Health Sciences, Pediatric Section, Meyer Children’s University Hospital, Florence 50139, Italy
| | - Chiara Rubino
- Department of Health Sciences, Pediatric Section, Meyer Children’s University Hospital, Florence 50139, Italy
| | - Sandra Trapani
- Department of Health Sciences, Pediatric Section, Meyer Children’s University Hospital, Florence 50139, Italy
| | - Giuseppe Indolfi
- Department Neurofarba, University of Florence and Meyer Children’s University Hospital, Florence 50139, Italy
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93
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Pohlman FW, McGee KS, McKellar MS. Case Report: Reversal of Integrase Inhibitor- and Tenofovir Alafenamide-Related Weight Gain After Switching Back to Efavirenz/Emtricitabine/Tenofovir DF. Open Forum Infect Dis 2021; 8:ofab403. [PMID: 34430674 PMCID: PMC8379714 DOI: 10.1093/ofid/ofab403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/26/2021] [Indexed: 12/15/2022] Open
Abstract
We report a case of substantial weight gain in a virologically suppressed patient with HIV after changing his antiretroviral therapy from efavirenz/emtricitabine/tenofovir DF to elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide with subsequent rapid weight loss upon switching back. The role of antiretrovirals in weight gain and loss and patient- and HIV-specific factors are discussed.
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Affiliation(s)
- F Will Pohlman
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Kara S McGee
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA.,Duke University School of Nursing, Durham, North Carolina, USA
| | - Mehri S McKellar
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
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94
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Gilleece Y, Krankowska D. ART in pregnant women living with HIV. Lancet 2021; 397:1240-1241. [PMID: 33812476 DOI: 10.1016/s0140-6736(21)00626-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/09/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Yvonne Gilleece
- Brighton and Sussex University Hospitals NHS Trust, Brighton BN2 5BE, UK.
| | - Dagny Krankowska
- Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Hospital for Infectious Diseases, Warsaw, Poland
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