Associations between HIV, highly active anti-retroviral therapy, and hypertensive disorders of pregnancy among maternal deaths in South Africa 2011-2013

Is the central complement component C3 altered in the synergy of HIV infection and preeclampsia?

Objective

In light of complement activation in preeclampsia and HIV infection, this study evaluates the concentration of complement component 3 (C3) in HIV-associated preeclampsia.

Method

The study population (n = 76) was equally stratified by pregnancy type (normotensive pregnant and preeclampsia) and by HIV status (HIV positive and HIV negative). The plasma concentration of C3 was determined using a Bioplex immunoassay procedure.

Results

We report a significant increase in C3 concentration in the HIV-negative versus the HIV-positive groups (p < 0.05), regardless of pregnancy type. However, based on pregnancy type and irrespective of HIV status, C3 concentration was similar between normotensive versus preeclampsia. Concentration of C3 was significantly increased in the HIV-positive preeclamptic compared HIV-negative preeclamptic groups (p = 0.04). The correlation of C3 with all study groups was non-significant.

Conclusion

This study demonstrates that C3 was upregulated in HIV-associated PE compared to HIV- associated normotensive pregnancies. The dysregulation of C3 expression by HIV infection may be attributed to antiretroviral therapy.

Evaluating the association of antiretroviral therapy and immune status with hypertensive disorders of pregnancy among people with HIV

OBJECTIVE

The aim of this study was to examine the association of timing of antiretroviral therapy (ART) initiation and ART class with risk of new-onset hypertensive disorders of pregnancy (HDP) among people with HIV (PWH).

DESIGN

An observational study of participants in the multisite Surveillance Monitoring for ART Toxicities (SMARTT) study.

METHODS

Data were abstracted from medical records of pregnant PWH enrolled in SMARTT (January 30, 2015 to March 25, 2019). New-onset HDP included gestational hypertension, preeclampsia/eclampsia, or HELLP syndrome. We examined the associations of clinical risk factors and three exposures of interest, each in a separate model, with risk of new-onset HDP. Log-binomial regression models were fit using generalized estimating equations to account for correlations within people. Exposures included timing of ART initiation, antiretroviral class among those on therapy at conception, and antiretroviral class among those initiating treatment during pregnancy.

RESULTS

Of 1038 pregnancies in this cohort, 973 were singletons with complete data on HDP, with ART use in 948. Overall, 9% had a new-onset HDP, 10% had chronic hypertension, and 81% had no hypertension. Diabetes [adjusted relative risk (aRR) 2.44, 95% confidence interval (95% CI) 1.42-4.21] and first/second trimester CD4 + cell count less than 200 cells/μl (aRR 1.99, 95% CI 1.21-3.27) were associated with a greater risk of new-onset HDP. Risk of new-onset HDP was similar by antiretroviral class, but those initiating ART after 20 weeks' gestation had a greater risk (aRR 1.93, 95% CI 1.12-3.30) compared with those receiving ART at conception.

CONCLUSION

In this large, diverse cohort of pregnant PWH, worse early pregnancy immune status and later ART initiation were associated with an increased risk of HDP while ART class was not.

Influence of HIV and its treatment on hypertensive disorders of pregnancy in women from a low- to middle-income country

OBJECTIVE

To establish a potential relationship between hypertensive disorders of pregnancy (HDP) and HIV infection.

METHODS

This cross-sectional observational study involving 300 women with HDP was undertaken from September 2018 to February 2019 in a regional hospital in Durban, South Africa, a setting with a background HIV prevalence of 45% among pregnant women. All women with new-onset elevation of blood pressure after the 20th week of pregnancy were enrolled and, following informed consent, the relevant information was extracted from their files.

RESULTS

Of the 300 women with HDP, the HIV prevalence was 30%, compared with the historical seroprevalence of 45% within the hospital (P = 0.028). For all categories of HDP, there were fewer primigravid women among women living with HIV (WLHIV), compared with those uninfected (30% vs 50.2%, respectively; P = 0.001). HDP developed later in gestation in WLHIV compared with uninfected women (32.6 weeks vs 34 weeks, respectively; P = 0.023), however, there were significant maternal complications of abruption and elevated liver enzymes among WLHIV (P = 0.02 and P = 0.014, respectively). Despite this, the perinatal outcomes were similar in both groups.

CONCLUSION

HIV or its treatment seems to have a protective effect in the development of HDP; however, the complications of HDP may be significant in WLHIV receiving treatment.

The effectiveness of the Congo Red Dot paper test in hypertensive disorders of pregnancy: A systematic review and meta-analysis

Background

Congo Red Dot Paper Test (CRDPT) appears to be a simple, cost-effective, non-invasive diagnostic tool for hypertensive disorders of pregnancy (HDP). The main objective of the study is to assess the effectiveness of CRDPT in detecting HDP.

Methods

This is a systemic review and meta-analysis of published studies on the effectiveness of CRDPT in the detection of HDP. The study was conducted in line with the PRISMA-DTA guidelines. The PICOS framework was used to search for relevant articles using Medline, PubMed, Google Scholar, Web of Science, and the Cochrane Library databases. The articles were screened against a set of inclusion and exclusion criteria and analysed using the Review Manager 5.4 software.

Results

A title, abstract and full article screening was conducted on 18,153 potential articles based on the inclusion and exclusion criteria. The screening yielded five articles for meta-analysis. The total number of normotensive pregnant women (n = 3,380) in the included studies was five times higher than the total number of women with pre-eclampsia (n = 535). A difference between the HDP and normotensive group was noted. This is indicated by a significantly decreased in the effectiveness of CRDPT in detecting HDP as compared to normotensive group [Risk Ratio (RR) = 6.32 (2.17, 18.43) p < 0.00001]. The included studies had a high nature of heterogeneity (I ² = 98%, p < 0.00001) partially due to different study designs included in the analysis and different regions where studies were conducted given that none of these studies were conducted in African countries where HDP is prominent.

Conclusions

According to results generated from 5 studies in this meta-analysis, it was found that CRDPT might not be effective in the detection of hypertensive disorder of pregnancy. Moreover, more research, especially in African women where hypertensive disorders of pregnancy are prevalent, are re-quired to ascertain these findings.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021283679, identifier: CRD42021283679.

Vascular Endothelial Growth Factor Receptor 2: Molecular Mechanism and Therapeutic Potential in Preeclampsia Comorbidity with Human Immunodeficiency Virus and Severe Acute Respiratory Syndrome Coronavirus 2 Infections

This review explored the role of vascular endothelial growth factor receptor-2 (VEGFR-2) in the synergy of preeclampsia (PE), human immunodeficiency virus (HIV), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Downregulation of VEGFR-2 in PE promotes endothelial dysfunction and prevents endothelial cell (EC) migration, proliferation, and differentiation. The HIV-1 accessory protein, tat (trans-activator of transcription), prevents VEGFR-2 signaling via the vascular endothelial growth factor A (VEGF-A) ligand. Combined antiretroviral therapy (cART) may cause immune reconstitution, impaired decidualization, and endothelial injury, thus may be a risk factor for PE development. The VEGF/VEGFR-2 interaction may be associated with SARS-CoV-2-related pulmonary oedema. Endothelial dysfunction and heightened inflammation are both associated with PE, HIV, and SARS-CoV-2 infection; therefore, it is plausible that both characteristics may be exacerbated in the synergy of these events. In addition, this review explored microRNAs (miR) regulating VEGFR-2. An overexpression of miR-126 is evident in PE, HIV, and SARS-CoV-2 infection; thus, modulating the expression of miR-126 may be a therapeutic strategy. However, the involvement of microRNAs in PE, HIV, and SARS-CoV-2 infection needs further investigating. Since these conditions have been evaluated independently, this review attempts to predict their clinical manifestations in their synergy, as well as independently; thereby providing a platform for early diagnosis and therapeutic potential in PE, HIV, and SARS-CoV-2 infection.

HIV at 40: kidney disease in HIV treatment, prevention, and cure

Four decades after the first cases of HIV were reported, kidney disease remains an important comorbidity in people with HIV (PWH). Both HIV-associated nephropathy and immune complex kidney disease were recognized as complications of HIV infection in the early years before treatment was available. Although the introduction of effective antiretroviral therapy in the late 1990s resulted in dramatic improvements in survival and health in PWH, several commonly used antiretroviral agents have been associated with kidney injury. HIV infection and treatment may also promote the progression of comorbid chronic kidney disease due to traditional risk factors such as diabetes, and HIV is one of the strongest "second hits" for the high-risk APOL1 genotype. Unique considerations in the management of chronic kidney disease in PWH are largely related to the need for lifelong antiretroviral therapy, with potential for toxicity, drug-drug interactions, and polypharmacy. PWH who develop progressive chronic kidney disease are candidates for all modalities of kidney replacement therapy, including kidney transplantation, and at some centers, PWH may be candidates to serve as donors for recipients with HIV. Transplantation of kidney allografts from donors with HIV also offers a unique opportunity to study viral dynamics in the kidney, with implications for kidney health and for research toward HIV cure. In addition, HIV-transgenic animal models have provided important insights into kidney disease pathogenesis beyond HIV, and experience with HIV and HIV-related kidney disease has provided important lessons for future pandemics.

Association between pre-eclampsia and HIV: a case-control study in urban South Africa

BACKGROUND

Preeclampsia is a considerable cause of maternal and infant morbidity and mortality. Although its etiology is unknown, preeclampsia has been described as a state of exaggerated maternal inflammatory response. Therefore, it has been hypothesized that preeclampsia would occur less commonly in states of immune deficiency.

OBJECTIVE

This study aimed to compare the prevalence of treated and untreated HIV infections among preeclamptic cases and controls, determine infant outcomes, and evaluate the association between HIV and preeclampsia after adjusting for known predictor variables, including maternal age, gravidity, body mass index, and smoking.

STUDY DESIGN

This case-control study investigated the association between preeclampsia and HIV infection using secondary data from an unrelated study. We defined preeclamptic cases as pregnant women who were normotensive until 20 weeks of gestation and thereafter had at least 1 high blood pressure measurement either before or at delivery and proteinuria, defined as protein excretion of ≥300 mg within 24 hours or >2 protein on dipstick urinalysis. The prevalence of HIV infection was compared between cases and controls. Multivariate logistic regression analysis was used to assess the association between preeclampsia and potential confounding variables and reported using odds ratios and 95% confidence intervals.

RESULTS

There were 571 cases with preeclampsia and 596 normotensive controls included in this study. The median age was 27 years for cases and 26 years for controls (P=.008). Most participants (69%) had ≥2 previous pregnancies with no difference between the cases and controls (P=.176). Overall, 43% of the participants were obese, with a mean body mass index of 29 (interquartile range, 24.5–34.2), with higher proportions of women who were overweight and obese in the group with preeclampsia (P=.031). The prevalence of HIV was significantly lower in cases than in controls (24% vs 30%, respectively; P=.014). Compared with 16% of infants born preterm to normotensive controls, 48% of infants were born preterm born to women with preeclampsia (P<.001). Compared with 14% of infants born with low birthweight to normotensive controls, 53% of infants were born with low birthweight to women with preeclampsia (P<.0001). Untreated HIV infection was negatively associated with preeclampsia (unadjusted odds ratio, 0.330; 95% confidence interval, 0.197–0.552; P<.0001), whereas factors associated with preeclampsia were advanced maternal age (odds ratio, 1.673; 95% confidence interval, 1.209–2.316; P=.002) and obesity (odds ratio, 1.611; 95% confidence interval, 1.023–2.537; P=.040). After adjusting for maternal age, gravidity, smoking, and body mass index in the multivariate regression, only obesity remained significantly associated with preeclampsia (adjusted odds ratio, 1.624; 95% confidence interval, 1.024–2.575; P=.039).

CONCLUSION

Before the large-scale rollout of antiretroviral therapy in a setting with a high burden of HIV and preeclampsia, untreated HIV infection was found to have a protective effect against preeclampsia. The protective effect against preeclampsia was not apparent for HIV infection treated with antiretroviral therapy.

Maternal HIV Infection and Spontaneous Versus Provider-Initiated Preterm Birth in an Urban Zambian Cohort

OBJECTIVE

We investigated the effect of maternal HIV and its treatment on spontaneous and provider-initiated preterm birth (PTB) in an urban African cohort.

METHODS

The Zambian Preterm Birth Prevention Study enrolled pregnant women at their first antenatal visit in Lusaka. Participants underwent ultrasound, laboratory testing, and clinical phenotyping of delivery outcomes. Key exposures were maternal HIV serostatus and timing of antiretroviral therapy initiation. We defined the primary outcome, PTB, as delivery between 16 and 37 weeks' gestational age, and differentiated spontaneous from provider-initiated parturition.

RESULTS

Of 1450 pregnant women enrolled, 350 (24%) had HIV. About 1216 (84%) were retained at delivery, 3 of whom delivered <16 weeks. Of 181 (15%) preterm deliveries, 120 (66%) were spontaneous, 56 (31%) were provider-initiated, and 5 (3%) were unclassified. In standardized analyses using inverse probability weighting, maternal HIV increased the risk of spontaneous PTB [RR 1.68; 95% confidence interval (CI): 1.12 to 2.52], but this effect was mitigated on overall PTB [risk ratio (RR) 1.31; 95% CI: 0.92 to 1.86] owing to a protective effect against provider-initiated PTB. HIV reduced the risk of preeclampsia (RR 0.32; 95% CI: 0.11 to 0.91), which strongly predicted provider-initiated PTB (RR 17.92; 95% CI: 8.13 to 39.53). The timing of antiretroviral therapy start did not affect the relationship between HIV and PTB.

CONCLUSION

The risk of HIV on spontaneous PTB seems to be opposed by a protective effect of HIV on provider-initiated PTB. These findings support an inflammatory mechanism underlying HIV-related PTB and suggest that published estimates of PTB risk overall underestimate the risk of spontaneous PTB.

The Role of HIV Infection in the Pathophysiology of Gestational Diabetes Mellitus and Hypertensive Disorders of Pregnancy

Purpose of the Review: The main objective of this study is to investigate mechanisms associated with gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) in HIV infected pregnant women by looking how placental hormones such as (progesterone and prolactin) and basic haemostatic parameters are regulated in HIV infected pregnancies.

Recent Findings: HIV/AIDS are a major global obstetric health burden that lead to increased rate of morbidity and mortality. HIV/AIDS has been associated with the pathophysiology of GDM and HDP. Increased risk of GDM due to highly active antiretroviral therapy (HAART) usage has been reported in HIV infected pregnancies, which causes insulin resistance in both pregnant and non-pregnant individuals. HAART is a medication used for lowering maternal antepartum viral load and pre-exposure and post-exposure prophylaxis of the infant. In pregnant women, HAART induces diabetogenic effect by causing dysregulation of placental hormones such as (progesterone and prolactin) and predispose HIV infected women to GDM. In addition to HIV/AIDS and GDM, Studies have indicated that HIV infection causes haemostatic abnormalities such as hematological disorder, deregulated haematopoiesis process and the coagulation process which results in HDP.

Summary: This study will help on improving therapeutic management and understanding of the pathophysiology of GDM and HDP in the absence as well as in the presence of HIV infection by reviewing studies reporting on these mechanism.

The Involvement of MicroRNAs in SARS-CoV-2 Infection Comorbid with HIV-Associated Preeclampsia

Purpose of Review

This review investigated the potential role of microRNAs (miRNAs) in the synergy of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, preeclampsia (PE), and human immunodeficiency virus (HIV) infection. Maternal health is a great concern when treating pregnant women fighting this triad of diseases, which is highly prevalent in South Africa. MicroRNAs are involved in fine-tuning of physiological processes. Disruptions to the balance of this minute protein can lead to various physiological changes that are sometimes pathological.

Recent Findings

MicroRNAs have recently been implicated in PE and have been linked to the anti-angiogenic imbalance evident in PE. Recent in silico studies have identified potential host miRNAs with anti-viral properties against SARS-CoV-2 infection. Studies have demonstrated dysregulated expression of several miRNAs in HIV-1 infection along with the ability of HIV-1 to downregulate anti-viral host microRNAs.

Summary

This review has highlighted the significant gap in literature on the potential of miRNAs in women with HIV-associated PE in synergy with the novel SARS-CoV-2 infection. In addition, this review has provided evidence of the critical role that the epigenetic regulatory mechanism of miRNA plays in viral infections and PE, thereby providing a foundation for further research investigating the potential of therapeutic miRNA development with fewer side-effects for pregnant women.

Classification and Design of HIV-1 Integrase Inhibitors Based on Machine Learning

A key enzyme in human immunodeficiency virus type 1 (HIV-1) life cycle, integrase (IN) aids the integration of viral DNA into the host DNA, which has become an ideal target for the development of anti-HIV drugs. A total of 1785 potential HIV-1 IN inhibitors were collected from the databases of ChEMBL, Binding Database, DrugBank, and PubMed, as well as from 40 references. The database was divided into the training set and test set by random sampling. By exploring the correlation between molecular descriptors and inhibitory activity, it is found that the classification and specific activity data of inhibitors can be more accurately predicted by the combination of molecular descriptors and molecular fingerprints. The calculation of molecular fingerprint descriptor provides the additional substructure information to improve the prediction ability. Based on the training set, two machine learning methods, the recursive partition (RP) and naive Bayes (NB) models, were used to build the classifiers of HIV-1 IN inhibitors. Through the test set verification, the RP technique accurately predicted 82.5% inhibitors and 86.3% noninhibitors. The NB model predicted 88.3% inhibitors and 87.2% noninhibitors with correlation coefficient of 85.2%. The results show that the prediction performance of NB model is slightly better than that of RP, and the key molecular segments are also obtained. Additionally, CoMFA and CoMSIA models with good activity prediction ability both were constructed by exploring the structure-activity relationship, which is helpful for the design and optimization of HIV-1 IN inhibitors.

Differential upregulations of SMAC and LAMIN B levels in the buffy coat of HIV associated preeclamptic women

OBJECTIVE

To assess HIV positivity as an apoptotic confounding variable in pregnancies complicated by preeclampsia.

METHODS AND MATERIALS

Using a Bio-plex Multiplex Immunoassay, Smac and Lamin B concentrations (ng/ml) were analyzed in a buffy coat collected from 128 pregnant women attending a large regional hospital in Durban, South Africa. Study groups consisted of Normotensive and Preeclamptic pregnant women stratified according to their HIV status. All HIV positive groups received highly active antiretroviral therapy (HAART).

RESULTS

Our findings showed significant (p < .05) upregulation in the levels of both SMAC and LAMIN B in the HIV positive patients and a concomitant downregulation of the same apoptotic makers were observed in preeclampsia regardless of HIV status.

CONCLUSIONS

These results could be associated with the fact that apoptosis promotes deregulation of mitochondrial dynamics, contributing to the associated severe obstetric events observed in pregnancies among HIV-infected women on HAART.

Non-communicable Diseases in Pregnant and Postpartum Women Living with HIV: Implications for Health Throughout the Life Course

PURPOSE OF REVIEW

The development of non-communicable diseases (NCDs) in pregnant women living with HIV can be a harbinger of future NCD-related morbidity and mortality. This review focuses on the NCDs that complicate pregnancy and the postpartum period, including hypertensive complications, hyperglycemic disorders, excessive gestational weight gain, and bone mineral density losses. For each disease process, we explore the role of HIV as a possible driver of excess risk, the immediate consequences of these complications on pregnancy outcomes and maternal and infant health, and possible implications for long-term women's health.

RECENT FINDINGS

Countries with the highest burden of HIV also shoulder a high burden of NCDs that complicate pregnancy, including hypertensive disorders, hyperglycemic disorders, weight gain, and osteopenia. This double burden of disease is a significant public health threat for reproductive-age women, with the potential for serious short- and long-term consequences for both women and their infants. Additionally, as the global first-line antiretroviral therapy regimens increasingly include integrase inhibitors, unhealthy weight gain associated with this drug class poses additional risk for NCD-related pregnancy complications and their persistence postpartum. Further research is needed to better define prevalence of NCD complications in pregnancy, elucidate HIV-specific and traditional factors associated with poor outcomes, and to develop interventions to reduce risk and avoid downstream complications in those at highest risk.

A Narrative Review of the Renin-Angiotensin-Aldosterone System in the Placenta and Placental Bed of HIV Infected Women of African Ancestry with Preeclampsia

PURPOSE OF REVIEW

Both HIV infection and preeclampsia (PE), a pregnancy-specific disorder of hypertension and multi-system organ involvement, have high prevalence rates especially in low-to-middle-income countries. The immunoexpression of specific renin-angiotensin-aldosterone system (RAAS) receptors in the placenta and placental bed interface may forecast the risk of PE.

RECENT FINDINGS

Preeclampsia is a leading risk factor for mortality worldwide and remains a challenge in HIV-infected individuals especially those on antiretroviral therapy (ART). Irregular RAAS stimulation may be linked to the pathophysiology of hypertension in HIV infection and in PE. The AT1 receptor is expressed across all trimesters of pregnancy, within placental tissue, eliciting vasoconstriction. This increased expression is associated with the severity of PE, implying that the increased expression may be involved in the pathogenesis of this pregnancy disorder. The AT2 receptor expression in normotensive pregnancies was shown to be lower as compared to non-pregnant individuals. Furthermore, in the PE placental bed, the AT2 receptor is the predominant receptor subtype and is found in extravillous trophoblast cells where they facilitate vasodilation. However, AT4R in placentae of PE pregnancies are found to be significantly reduced compared to normotensives pregnancies. The data on the role played by the RAAS pathway in pregnancy is conflicting. Investigation into a tissue-based RAAS with emphasis on immune-expression within the placenta and placental bed may help resolve this conundrum.

Repeat Pregnancies Among US Women Living With HIV in the SMARTT Study: Temporal Changes in HIV Disease Status and Predictors of Preterm Birth

BACKGROUND

Birth rates among women living with HIV (WLHIV) have increased recently, with many experiencing multiple pregnancies. Yet, viral suppression is often not sustained between pregnancies. In addition, protease inhibitors (PIs) have been associated with preterm birth, but associations between integrase strand transfer inhibitors (INSTIs) and preterm birth are less well characterized.

METHODS

We studied WLHIV with ≥2 live-born infants enrolled into the Pediatric HIV/AIDS Cohort Study Surveillance Monitoring for Antiretroviral Treatment Toxicities (SMARTT) study between 2007 and 2018, comparing CD4 counts and viral loads (VLs) between 2 consecutive SMARTT pregnancies. We evaluated associations of covariates with CD4 and viral suppression and the association of PI/INSTI use during pregnancy with odds of preterm birth.

RESULTS

There were 736 women who had ≥2 live-born children enrolled in SMARTT (1695 pregnancies). Median CD4 counts remained stable over repeat pregnancies. Although >80% of women achieved VL suppression during pregnancy, more than half had a detectable VL early in their subsequent pregnancy. In adjusted models including all singleton pregnancies, an increased odds of preterm birth was observed for women with first trimester PI initiation (adjusted odds ratio: 1.97; 95% confidence interval: 1.27 to 3.07) compared with those not receiving PIs during pregnancy and for first trimester INSTI initiation (adjusted odds ratio: 2.39; 95% confidence interval: 1.04 to 5.46) compared with those never using INSTIs during pregnancy.

CONCLUSIONS

Most WLHIV achieved VL suppression by late pregnancy but many were viremic early in subsequent pregnancies. First trimester initiation of PIs or INSTIs was associated with a higher risk of preterm birth.

The impact of the duration of HAART on cytokine profiles in pregnancy

OBJECTIVE

To determine the cytokine profile of HIV infected women treated with highly active anti-retroviral therapy (HAART) of variable duration in pregnancy.

METHODS

HIV infected women were enrolled at a large tertiary hospital in Durban, South Africa in their antenatal period and stratified into those that initiated HAART before pregnancy (pre-pregnancy HAART or PPH group) and those who initiated HAART during pregnancy (in-pregnancy HAART or IPH group). These were compared with HIV negative women (HN group), matched for gestational age at the time of enrolment. Serum was obtained and Th1 and Th2 cytokines expression determined using the Bio-Plex Pro™ Human Cytokine Treg Panels.

RESULTS

The overall cytokine profile of the cohort was pro-inflammatory as a result of significant IL-6 and TNF alpha expression. The anti-inflammatory markers (i.e. Th2 cytokines, namely IL4 and IL10) were poorly expressed by the whole cohort, with IL 4 seen almost exclusively in the IPH group, thus counter-balancing the predominantly pro-inflammatory milieu only in this group. PPH group had a pro-inflammatory milieu comparable to the HN control. IL 6 was the predominant cytokine in all groups, and as expected, it increased with advancing gestation in all the groups. This highly pro-inflammatory milieu was unexpected and needs further review CONCLUSION: Long use of HAART suppresses the anti-inflammatory markers previously reported to be conducive for the wellbeing of pregnancy. This effect needs further review as it was similarly observed in our HIV uninfected controls.

The Role of Highly Active Antiretroviral Therapy (HAART) on Interleukin 17A (IL-17A) in Normotensive and Preeclamptic Black South African Women

Introduction

Interleukin 17A has been implicated in the pathophysiology of both human immune deficiency virus and preeclampsia. This study evaluated serum levels of IL-17A based on pregnancy type, gestational age, HIV status, and duration of HAART. Material and Methods. A sample size of 250 was analysed: normotensives (n = 150; N) and preeclamptics (n = 100; PE). Normotensives were further stratified into HIV negative (n = 90), HAART-acute (n = 30), and HAART-chronic (n = 30). The PE group was divided into early onset (n = 50; EOPE) and late onset (n = 50; LOPE). The EOPE and LOPE groups were subdivided into HIV negative (n = 30), HAART-acute (n = 10), and HAART-chronic (n = 10). Analysis of IL-17A was performed using a multiple Bio-Plex immunoassay method.

Results

Pregnancy type: the levels of IL-17A were increased in PE compared to N (P = 0.0014). Gestational age: the levels of IL-17A were increased in EOPE compared to N group (P = 0.0113). A significant increase in the levels of IL-17A in LOPE compared to N was observed (P = 0.0063). HIV status: the levels of IL-17A were increased in PE compared to N (P = 0.0114) and in EOPE compared to N groups (P = 0.0071). HAART duration: the concentration of IL-17A was increased in HAART-chronic PE compared to N groups (P = 0.0062). There was also an increase in the levels of IL-17A in EOPE compared to N (P = 0.0029).

Conclusion

The study demonstrates that IL-17A is involved in the pathophysiology of PE and that in the presence of HIV infection, chronic HAART administration predisposes women to the development of EOPE.

Are concentrations of clusterin and beta-2-glycoprotein I dysregulated in HIV associated preeclampsia?

OBJECTIVE

To evaluate the levels of serum beta-2-glycoprotein I (β₂GP1) and clusterin in the duality of Pre-eclampsia and HIV.

METHOD

Stored serum samples collected from 72 pregnant women were stratified according to the pregnancy type (pre-eclamptic and healthy normotensive groups) and HIV status (positive or negative). A Bio-Plex multiplex immunoassay was used to determine the concentrations of clusterin and β₂GP1.

RESULTS

Clusterin concentrations differed significantly (p = 0.01) between the HIV positive (+) (mean = 123 800 ng/ml; 95 % CI: 105 400-142 200) vs. HIV negative (-) (mean = 92 190 ng /ml; 95 %CI: 75 840-108 500) groups and across all groups (p = 0.0006). Beta-2-glycoprotein I concentration differed significantly based on HIV status (p < 0.0001); HIV+ (mean = 393 649 ng/ml; 95 %CI: 30 300-467 000) vs HIV- (mean = 224 309 ng/ml; 95 %CI: 154 000-294 700) and across all groups (p < 0.0001). No significant difference was observed between normotensive and Pre-eclamptic groups for both clusterin and β₂GPI.

CONCLUSION

Serum concentrations of clusterin and β₂GPI were significantly increased in HIV positive pregnancies. It is postulated that both clusterin and β₂GPI may have a role in HIV disease progression. These findings need to be confirmed in studies having larger sample sizes and detailed information on anti-retroviral therapy.

Prevention of cardiovascular disease among people living with HIV in sub-Saharan Africa

As longevity has increased for people living with HIV (PLWH) in the United States and Europe, there has been a concomitant increase in the prevalence of cardiovascular disease (CVD) risk factors and morbidity in this population. Whereas the availability of HIV antiretroviral therapy has resulted in dramatic increases in life expectancy in sub-Saharan Africa (SSA), where over two thirds of PLWH reside, if and how these trends impact the epidemiology of CVD is less clear. In this review, we describe the current state of the science on how both HIV and its treatment impact CVD risk factors and outcomes among PLWH in sub-Saharan Africa, including regional factors (unique to SSA) likely to differentiate these relationships from the global North. We then outline how current regional guidelines address CVD prevention among PLWH and which clinical and structural interventions are best poised to confront the co-epidemics of HIV and CVD in the region. We conclude with a discussion of key research gaps that need to be addressed to optimally develop an actionable public health response.

Human Immunodeficiency Virus and risk of pre-eclampsia and eclampsia in pregnant women: A meta-analysis on cohort studies

Maternal HIV infection is related to several perinatal adverse outcomes. This study is aimed at establishing whether maternal HIV infection is associated with the development of pre-eclampsia (PE) and eclampsia. We comprehensively searched MEDLINE/PubMed, Web of Science, SCOPUS and Embase databases for relevant studies published up to 20 November 2018, without time and language restrictions. We have limited our literature searches to observational studies in humans. We applied a random-effects model to calculate the relative risks (RR) and 95% confidence intervals (CI) for the meta-analyses. We also systematically reviewed eligible studies to determine the effects of HIV infection on imbalance of angiogenic and anti-angiogenic factors, which are effective in increased risk of PE or eclampsia. We identified a total of 11,186 publications, out of which 22 eligible studies (11 prospective and 11 retrospective cohort studies) comprising 90,514 HIV-positive and 66,085,278 HIV-negative pregnant women were included in meta-analysis. Results of the meta-analyses suggested that maternal HIV infection is not significantly associated with the development of PE (RR, 1.04; 95%CI, 0.89-1.21) and eclampsia (RR, 1.05; 95%CI, 0.63-1.75). Six studies were included to understand the effects of HIV infection on imbalance of angiogenic and anti-angiogenic factors. All six studies demonstrated that HIV infection had no significant effect on expression levels of these factors in pre-eclamptic and normotensive pregnant women. Our study showed that maternal HIV infection was not significantly associated with increased or reduced risks of pre-eclampsia and eclampsia. More well-designed studies with large sample size and well defined outcomes are recommended to confirm or refute the present findings.

Angiogenesis, Lymphangiogenesis, and the Immune Response in South African Preeclamptic Women Receiving HAART

Purpose of the review: This review highlights the role of angiogenesis, lymphangiogenesis, and immune markers in human immunodeficiency virus (HIV)-associated preeclamptic (PE) pregnancies in an attempt to unravel the mysteries underlying the duality of both conditions in South Africa. Recent findings: Studies demonstrate that HIV-infected pregnant women develop PE at a lower frequency than uninfected women. In contrast, women receiving highly active anti-retroviral therapy (HAART) are more inclined to develop PE, stemming from an imbalance of angiogenesis, lymphangiogenesis, and immune response. Summary: In view of the paradoxical effect of HIV infection on PE development, this study examines angiogenesis, lymphangiogenesis, and immune markers in the highly HIV endemic area of KwaZulu-Natal. We believe that HAART re-constitutes the immune response in PE, thereby predisposing women to PE development. This susceptibility is due to an imbalance in the angiogenic/lymphangiogenic/immune response as compared to normotensive pregnant women. Further large-scale studies are urgently required to investigate the effect of the duration of HAART on PE development.

A Review of Angiogenic Imbalance in HIV-Infected Hypertensive Disorders of Pregnancy

PURPOSE OF REVIEW

This review provides a comprehensive insight into the angiogenic profile of hypertensive and normotensive pregnancies compromised by HIV infection. Furthermore, we evaluate the economic implementation of the sFlt-1/PlGF ratio and review the reports on therapeutic apheresis in limiting sFlt-1 production.

RECENT FINDINGS

In preeclampsia, an increased expression of sFlt-1 triggers angiogenic imbalance. Women of African ancestry have high levels of angiogenic factors than other racial groups. The sFlt-1/PlGF ratio shows promise in the early assessment of preeclampsia, while sFlt-1 apheresis restores angiogenic imbalance. Studies suggest antiretroviral therapy does not impact the angiogenic shift in preeclampsia development. The angiogenic profile in pregnant women of different races influences preeclampsia development. Despite the opposing immune response in HIV infection and preeclampsia, the HIV tat protein strongly mimics vascular endothelial growth factor (VEGF); hence, it is plausible to assume that HIV infection may ameliorate the angiogenic imbalance in preeclampsia.

Combined antiretroviral therapy for HIV and the risk of hypertensive disorders of pregnancy: A systematic review

OBJECTIVE

To assess if there is a relationship between use of combined antiretroviral therapy among pregnant women living with HIV and hypertensive disorders of pregnancy (HDP).

DESIGN

Due to the heterogeneity of study designs in the literature and the utilization of different outcome measures in regards to assessing the presence of HDP, a systematic review was performed.

METHODS

ClinicalTrials.gov and MEDLINE, via PubMed, EMBASE, Scopus, CINAHL, ProQuest Dissertations & Theses Global, EBSCOHost, DARE, and the Cochrane Library, were queried from January 1997 to October 2017. Studies were included if they reported HDP and focused on pregnant women living with HIV who used combined antiretroviral therapy. The Cochrane Collaboration's tool for assessment of risk of bias and the U.S. Preventive Services Task Force grading scale were used to assess the studies.

RESULTS

Of 1055 abstracts, 28 articles met inclusion criteria. The data are marked by multiple biases and poor study design. All studies demonstrate an increased risk of HDP among pregnant women living with HIV who used combined antiretroviral therapy when compared to seropositive pregnant women not using antiretroviral therapy. Three studies suggest protease inhibitors may be associated with a higher risk of HDP.

CONCLUSION

Despite all studies indicating a higher frequency of HDP among pregnant women living with HIV using combined antiretroviral therapy when compared with seropositive pregnant women not using antiretroviral therapy, the quality of the studies is mixed, necessitating further research.

Dysregulation of circulating sTie2 and sHER2 in HIV-infected women with preeclampsia

OBJECTIVE

This study assesses whether circulating sTie2 and sHER2 are altered in HIV-negative and HIV-positive pregnant normotensive and preeclamptic women.

METHODS

Serum samples were obtained from 80 pregnant women, stratified into four groups, namely, HIV-negative normotensives (20); HIV-positive normotensives (20); HIV-negative preeclamptics (20); and HIV-positive preeclamptics (20). The concentration of sTie2 and sHER2 was analyzed by Bio-Plex multiplex immunoassay and generated from a standard curve.

RESULTS

sTie2 differed significantly by pregnancy type (p = 0.0403) but not by HIV status (p = 0.5214). sHER2 did not show a significant difference between normotensive and preeclampsia (p = 0.3677) and by HIV status (p = 0.5249).

CONCLUSION

Irrespective of HIV status, reduced concentrations of sTie2 were evident in preeclampsia (PE) reflecting a dysregulation of the angiogenic process. sHER2 was similar between pregnancy types, attributable to the oxidative stressed microenvironment which promotes dysregulation of the MAPK and P13K/Akt signaling. HIV status did not influence sTie2 and sHER2 expression, reflecting the immune reconstitution of highly active antiretroviral therapy. sTie2 and sHER2 were not influenced by PE comorbid with HIV infection.

Outcomes of patients admitted to the intensive care unit for complications of hypertensive disorders of pregnancy at a South African tertiary hospital - a 4-year retrospective review

Background

Hypertensive disorders of pregnancy (HDP) are a major cause of maternal mortality and adverse outcomes. A previous study in the intensive care unit (ICU) at King Edward VIII Hospital, Durban, South Africa, in 2000 found 10.5% mortality among eclampsia patients.

Objectives

To describe the mortality and adverse neurological outcomes associated with HDP in a tertiary ICU, compare these with results from 2000 and describe factors associated therewith.

Methods

The data of 85 patients admitted with HDP to ICU at King Edward VIII Hospital from 2010 to 2013 were retrospectively reviewed. Mortality and adverse neurological outcome (Glasgow Coma Scale (GCS) ≤14 on discharge from ICU) were assessed. Two sets of analyses were conducted. The first compared those alive on discharge from ICU with those who died in ICU. The second compared good neurological outcome with poor outcome (adverse neurological outcome, or death).

Results

The mortality was 11.6%, and overall, 9% had adverse neurological outcomes. There was no significant difference in mortality between patients with eclampsia in 2010 - 2013 (11.0%) and those in 2000 (10.5%) (p=0.9). Factors associated with mortality were: intra- or postpartum onset of seizures; twins; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; respiratory failure; and lower respiratory tract infections. Factors associated with poor outcomes (adverse neurological outcome, or death) were: parity (better outcomes in primiparous patients); time of antenatal onset of hypertension (worse if earlier onset); HIV infection; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; use of anticonvulsants other than magnesium sulphate or benzodiazepines in eclampsia.

Conclusion

The lack of improvement in ICU eclampsia mortality demonstrates a need to develop and implement a protocol for HDP management.

Contributions of the study

The study provides a comparison of present mortality among eclamptic patients with hyperensive disorders of pregnancy (HDP) with the mortality of eclamptic patients described in an article from the year 2000. It further looks at adverse maternal outcomes, specifically adverse neurological outcomes.In addition, it analyses other factors that may affect outcomes in HDP patients. This information is useful in making recommendations in an attempt to improve the outcomes.

Pre-eclampsia: the role of highly active antiretroviral therapy and immune markers

PURPOSE OF THE REVIEW

This review highlights the role immune cells and markers such as natural killer (NK) cells, cytokines and human leukocyte antigen (HLA-G) play in predisposing HIV-infected women who are on HAART to develop PE, thus contributing to a better understanding and early diagnosis of PE with a subsequent reduction in maternal foetal and neonatal deaths.

RECENT FINDINGS

Pregnant women infected with the Human Immunodeficiency Virus (HIV) have a 25% risk of mother to child transmission. This risk, however, decreases to 2% if the women is on treatment. Highly active antiretroviral therapy (HAART) is the recommended treatment for both pregnant and non-pregnant women infected with HIV. Treatment with HAART is reported to potentiate predisposition to the development of hypertensive disorders of pregnancy such as pre-eclampsia (PE). Pre-eclampsia accounts for 7-10% of abnormal pregnancies worldwide. Studies demonstrate that pregnant women with HIV have PE at lower frequencies than uninfected women, however, the converse is observed upon HAART initiation. HIV-infected women on HAART exhibit a greater tendency to develop PE, emanating from immune reconstitution induced by HAART. There is paucity of information as to the pathogenesis of PE upon HAART initiation and there are, therefore, controversial data as to whether HAART predisposes women to a lower, equal or higher risk of PE development compared to the general population, further investigations on the impact of HIV infection and HAART on the immune response and rate of PE development in HIV infected pregnant women are urgently needed.