[HIV and pregnancy: 2013 guidelines from the French expert working group]

Variations in CD4 counts during pregnancy in women living with HIV

OBJECTIVE

Our objective was to determine the frequency at which CD4 counts drop below 200 cells/mm3 during pregnancy in women living with HIV and to identify factors associated with this.

METHODS

Data from 2005 to 2020 from two prospective Canadian cohorts of pregnant women living with HIV were extracted. As per national guidelines, women received antiretroviral therapy and CD4 counts were monitored once per trimester and at delivery.

RESULTS

Among 775 included cases, 72 (9.3%) had CD4 counts <200 cells/mm3 at the first pregnancy visit. Of the 703 remaining pregnancies with CD4 counts ≥200 cells/mm3 at the initial visit, 20 (2.8%) were associated with a drop to <200 cells/mm3 . In univariate analysis, factors associated with this drop were coinfection with hepatitis B virus or hepatitis C virus (odds ratio [OR] 4.0, 95% confidence interval [CI] 1.52-10.50), lower first visit CD4 counts (OR 0.165, 95% CI 0.08-0.34), and baseline haemoglobin levels <11 g/dL (OR 2.89, 95% CI 1.04-8.00). In multivariable analysis, only CD4 count at first visit remained independently associated with this drop. A cut-off CD4 count ≤450 cells/mm3 at the first pregnancy visit had a sensitivity of 100% to detect cases of CD4 drop to <200 cells/mm3 .

CONCLUSION

A drop of CD4 count to <200 cells/mm3 is uncommon during pregnancy in women living with HIV. Our results suggest that CD4 monitoring only once in pregnancy would be safe in women whose CD4 count is >450 cells/mm3 at the first pregnancy visit.

Intrapartum use of zidovudine in a large cohort of pregnant women living with HIV in Italy

BACKGROUND

Intravenous administration of zidovudine (ZDV) during labour is a key step for vertical HIV transmission (VT) prevention, but there is no evidence of benefit when maternal HIV-RNA at delivery is <50 copies/mL. The aim of this study is evaluating the appropriateness of intrapartum ZDV use in Italy.

METHODS

Observational study including mother-infant pairs with perinatal HIV exposure during 2002-2019, enrolled in the Italian Register for HIV Infection in Children. Univariable and multivariable logistic regression were used to evaluate factors associated with VT.

RESULTS

A total of 3,861 infants, born from 3,791 pregnancies were included. The frequency of ZDV use was 79.9%, 92.1%, 93.7% and 92.8% when HIV-RNA was not available, ≥400 copies, between 50 and 399 copies, and <50 copies/mL. Thirty-three out of 3861 (0.85%) infants were subsequently diagnosed with HIV, 25/3861 (0.6%) of them born to mothers receiving intrapartum ZDV, and 31 (93.9%) to mothers with HIV-RNA ≥50 copies/mL or not available. In women with HIV-RNA < 50 copies/mL, ART discontinuation during pregnancy was the strongest risk factor for VT (odds ratio, OR, 23.1, 95%CI 2.4-219.3), while a higher gestational age (OR 0.6, 95%CI 0.4-0.8) and PEP administration to the newborn (aOR 0.004, 95%CI <0.0001-0.4) were protective factors. Intrapartum ZDV administration did not influence the final outcome in this group.

CONCLUSIONS

In ART era, more transmission events may occur in utero, limiting value of intrapartum ZDV, particularly for women with suppressed HIV-RNA load. More attention to the HIV-RNA testing of mothers before delivery may avoid unnecessary ZDV use.

[12-months efficacy of option B+ for prevention of mother-to-child transmission of HIV in Yaoundé, Cameroon]

BACKGROUND

Cameroon has adopted the option B+ for the prevention of mother-to-child transmission (MTCT) program of HIV in August 2014 in order to eradicate MTCT of HIV.

OBJECTIVE

To analyze in routine life settings, efficacy of option B+ for PMTCT and associate factors.

METHODS

We conducted a cross-sectional study over a 6-month period in the ESSOS hospital center. Study population comprised HIV-positive mothers and their infants aged 0-24 months. Variables included were : moment of HIV maternal testing, timing of commencement of maternal antiretroviral therapy (ART) and self-reported adherence to ART. Efficacy was measured through early and late MTCT rate and associated factors.

RESULTS

We included 200 mothers and 124 infants. Under option B+, the rate of transmission was at 4.20% at 6 weeks and 5.83% at 12 months. The rate of HIV transmission in breastfed infants stood at 3.7%. In unadjusted analysis, bottle-feeding, term at birth, early screening and management during pregnancy were associated with lower risk of HIV transmission. After adjustment, term at delivery after 37 weeks adjusted odds ratio (AOR) [0.059; (0.0061; 0.56)] was protective; while lack of prophylaxis was among HIV-exposed infants emerged as the main factor associated with residual transmission of HIV [AOR 117.23 ; (3.55 ; 3874.9)].

CONCLUSION

In this setting of Yaoundé, routine option B+ posted laudable results at 12 months even amongst breastfed children and should therefore be made sustainable.

Hypoxia inducible factor one alpha and human viral pathogens

If the oxygen tension level is 21% in ambient air, it is only between 14% and 1% in vivo. Consequently, viral pathogens are exposed and must adapt to these fluctuating oxygen levels to colonize the host and cause diseases. The problem is that for many years, the virological studies have been performed at 21% oxygen levels and consequently this is a real handicap to have a correct view of the mechanistic aspects of human viral infections. In this brief review, we describe for some selected examples the interactions of human viruses with this relative hypoxia observed in vivo.

Heterosexual practices of women and men living with HIV attending hospital outpatient services (ANRS-VESPA2 survey): a French comparative study with the general population (CSF survey)

HAART has improved the well-being of many people living with HIV (PLWH). This study aimed at (i) comparing heterosexual practices between PLWH and the general population by gender, and (ii) identifying factors associated with sexual practices and at-risk behaviors in the two populations. Self-reported data were collected among PLWH attending hospitals (VESPA2 survey; n = 3022) and the general population (CSF survey; n = 10,280). Significant differences between the two samples were corrected for by implementing propensity score matching on both socio-demographic characteristics and sexual behavior in terms of number of partners. Men not reporting heterosexual intercourse were excluded. After matching, 61% of women (out of 707) and 68% of men (out of 709) were sexually active in both populations. PLWH practiced oral sex less than the general population and used condoms more consistently over the previous 12-month period, irrespective of having multiple sexual partners or not. For women living with HIV: those with several sexual partners and those consuming drugs over the previous 12 months were more likely to practice oral sex; those living in a couple for at least 6 years and migrants were less likely to practice anal intercourse. For men living with HIV: those reporting bisexual relationships and those with multiple sexual partners over the previous 12 months were more likely to practice anal heterosexual intercourse; migrants reported less oral sex, irrespective of HIV status. Error term correlations showed that anal intercourse was not linked to condom use for women or men from either population. Our results show that PLWH had a lower rate of heterosexual practices compared with the general population, and used condoms more often, irrespective of the number of sexual partners and strong cultural background (e.g., for Sub-Saharan African women). Further preventive information needs to be disseminated on the risk of infection transmission through heterosexual anal intercourse.

Characterization of potentially avoidable cases in a 1-year series of consecutive cesarean sections in the tertiary maternity unit of Guadeloupe (French West Indies)

AIM

The global increase in the rate of cesarean sections (CS) is currently an issue. We aimed to assess the rate of CS locally and to identify cases in which this procedure may have been avoidable.

METHODS

In this prospective consecutive series, we analyzed the 478 CS carried out in our unit in 2009. We analyzed the characteristics of each case, and classified each as potentially avoidable or unavoidable.

RESULTS

The total rate of CS was 24.0%, including 1.7% that was scored as potentially avoidable. Parity, gestational age at birth, birthweight, cases requiring cervical ripening, cases of labor induction, and CS during labor were all significantly higher or more frequent among potentially avoidable CS. Multivariate analysis indicated that the risk of potentially avoidable CS was positively associated with gestational age and tended to be negatively associated with parity. The main indications for potentially avoidable CS were cervical dystocia and abnormal fetal heart rate, and for unavoidable CS they were abnormal fetal heart rate and history of previous CS.

CONCLUSION

Labor, especially when induced, seems to be the key period for the prevention of 'avoidable' CS. This is particularly important given that potentially avoidable CS are more frequently associated with uncomplicated pregnancies than are unavoidable CS. A woman's first CS increases the likelihood of CS for subsequent deliveries, so the prevention of the first CS is a key aim for reducing the overall rate of CS.

The global burden of oral diseases in pediatric HIV-infected populations: a workshop report

OBJECTIVES

To achieve a comprehensive understanding about the global burden of oral diseases in HIV-infected children and to identify research needs.

MATERIALS AND METHODS

A literature search was conducted in PubMed (2009-2014) to address five questions: (i) prevalence of oral diseases in HIV-infected compared with uninfected children, (ii) impact of oral diseases on quality of life, (iii) effect of antiretroviral exposure in utero on craniofacial and dental development, (iv) important co-infections and antiretroviral complications, and (v) value of atraumatic restorative treatment.

RESULTS

Studies showed a high prevalence of dental caries in HIV-infected children but the relationship between HIV infection and dental caries remains unclear. Also quality of life needs further investigation supported by better study designs and improvement of the instruments used. Up-to-date evidence suggested long-term harms associated with in utero antiretroviral exposure were minor but would require long-term follow-up through National Registries. The reviews also revealed the wide spectrum of metabolic disease due to antiretroviral therapy and co-infections such as tuberculosis. Finally, atraumatic restorative technique appears to be a simple and safe technique to treat dental caries but outcomes need further evaluation.

CONCLUSIONS

The impact of antiretroviral therapy in HIV-infected children has raised novel challenging questions in the field of oral health warranting future research.

"It pains me because as a woman you have to breastfeed your baby": decision-making about infant feeding among African women living with HIV in the UK

Objectives

UK guidance advises HIV-positive women to abstain from breast feeding. Although this eliminates the risk of postnatal vertical transmission of HIV, the impact of replacement feeding on mothers is often overlooked. This qualitative study examines, for the first time in the UK, decision-making about infant feeding among African women living with HIV.

Methods

Between 2010 and 2011, we conducted semistructured interviews with 23 HIV-positive African women who were pregnant or had recently given birth. We recruited participants from three HIV antenatal clinics in London.

Results

Women highlighted the cultural importance of breast feeding in African communities and the social pressure to breast feed, also describing fears that replacement feeding would signify their HIV status. Participants had significant concerns about physical and psychological effects of replacement feeding on their child and felt their identity as good mothers was compromised by not breast feeding. However, almost all chose to refrain from breast feeding, driven by the desire to minimise vertical transmission risk. Participants’ resilience was strengthened by financial assistance with replacement feeding, examples of healthy formula-fed children and support from partners, family, peers and professionals.

Conclusions

The decision to avoid breast feeding came at considerable emotional cost to participants. Professionals should be aware of the difficulties encountered by HIV-positive women in refraining from breast feeding, especially those from migrant African communities where breast feeding is culturally normative. Appropriate financial and emotional support increases women's capacity to adhere to their infant-feeding decisions and may reduce the emotional impact.

Tolerance of the newborn to antiretroviral drug exposure in utero

INTRODUCTION

The prevention of mother-to-child HIV-1 transmission by antiretroviral drug treatment is remarkably effective. The risk of transmission to the child is now almost zero for women optimally treated during pregnancy. The rapid expansion of this prophylactic treatment has led the World Health Organization to aspire to the virtual elimination of mother-to-child transmission and pediatric AIDS over the next few years. In 2014, more than 900,000 women worldwide were treated with antiretroviral drugs during pregnancy. The issue of fetal and neonatal antiretroviral drug tolerance is therefore extremely important.

AREAS COVERED

This review focuses on the possible impact of in utero exposure to antiretroviral drug on newborn health. To restrict analysis to this period is justified by the specificities of transplacental drug exposure and fetal vulnerability. Relevant data are available from trials and observational cohorts. The significance of various bio-markers detectable at birth is still unresolved, but merits a careful evaluation. Long-term assessment is associated with various logistical difficulties.

EXPERT OPINION

The health of 'exposed but not infected' children poses no major problem in the immense majority of cases, but a series of biological, clinical and imaging-based warning signs have emerged indicating the need for careful attention to be paid to this issue. Some effects that are straightforward to manage in industrialized countries may have more severe consequences in countries in which access to effective healthcare is limited. Nucleoside/nucleotide analogs are potentially genotoxic to mitochondrial and nuclear DNA, and the principal question to be addressed concerns their potential long-term effects.