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Fairlie L, Sawry S, Pals S, Sherman G, Williamson D, Le Roux J, Ngeno B, Berrie L, Diallo K, Cox MH, Mogashoa M, Chersich M, Modi S. More Frequent HIV Viral Load Testing With Point-Of-Care Tests Detects Elevated Viral Load Earlier in Postpartum HIV-Positive Women in a Randomized Controlled Trial in Two Clinics in Johannesburg, South Africa. J Acquir Immune Defic Syndr 2023; 94:412-420. [PMID: 37949444 DOI: 10.1097/qai.0000000000003295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 08/04/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Elevated maternal HIV viral load (VL) increases vertical transmission risk for breastfeeding children. This randomized controlled trial in Johannesburg primarily evaluated whether 3-monthly point-of-care testing, with laboratory-based standard-of-care testing (arm 2), compared with 6-monthly laboratory-based VL testing (arm 1) in postpartum women living with HIV receiving first-line tenofovir-emtricitabine-efavirenz antiretroviral treatment improved VL suppression, factors associated with nonsuppression, and drug resistance in those with virologic failure. METHODS Mother-child pairs were enrolled July 2018-April 2019 at the child's 6/10/14-week clinic visit. Women were randomized 1:1 to arm 1 or 2. Trained staff performed point-of-care VL testing using the Cepheid's Xpert HIV-1 VL assay. We fitted a generalized linear mixed model with VL suppression (<50 copies/mL (cps/mL) and <1000 cps/mL) at enrollment and 6, 12, and 18 months postpartum as the outcome and indicator variables for time, study site, study arm, and interaction variables. The final model tested for a difference by study arm, pooling across time points. RESULTS Of 405 women enrolled (204 arm 1 and 201 arm 2), 249 (61%) remained in follow-up through 18 months. There was no difference in VL suppression between arms at 6, 12, or 18 months. VL suppression rate (<50 cps/mL) at 18 months was 64.8% in arm 1 and 63.0% in arm 2 (P = 0.27). On bivariate analysis, there was an association with late antenatal booking and being in arm 2 for nonsuppressed VL, but no significant association with breastfeeding. HIV drug resistance was found in 12 of 23 participants (52.2%). CONCLUSION We found no significant difference in VL suppression with more frequent VL testing in postpartum women living with HIV receiving first-line efavirenz-based antiretroviral treatment.
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Affiliation(s)
- Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shobna Sawry
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherri Pals
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Gayle Sherman
- Paediatric HIV Surveillance in the Centre for HIV and STI, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
- Department of Paediatrics & Child Health, Faculty of Heath Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Dhelia Williamson
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Jean Le Roux
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bernadette Ngeno
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Leigh Berrie
- Division of Global HIV and TB (DGHT), CDC South Africa, Pretoria, South Africa
| | - Karidia Diallo
- Division of Global HIV and TB (DGHT), CDC South Africa, Pretoria, South Africa
| | - Mackenzie Hurlston Cox
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Mary Mogashoa
- Division of Global HIV and TB (DGHT), CDC South Africa, Pretoria, South Africa
| | - Matthew Chersich
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Surbhi Modi
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
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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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3
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Nematadzira TG, Murnane PM, Odiase OJ, Bacchetti P, Okochi H, Tallerico R, Chanaiwa VM, Vhembo T, Mutambanengwe-Jacob MT, Louie A, Chipato T, Gandhi M, Stranix-Chibanda L. Antiretroviral Therapy Adherence During and Postbreastfeeding Cessation Measured by Tenofovir Levels in Hair. J Acquir Immune Defic Syndr 2022; 91:237-241. [PMID: 35952357 PMCID: PMC9561228 DOI: 10.1097/qai.0000000000003076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We examined change in antiretroviral treatment (ART) adherence after breastfeeding (BF) cessation using hair tenofovir (TFV) concentrations as an objective metric of medication consumption. METHODS A subset of postpartum women in Zimbabwe randomized in IMPAACT PROMISE to take ART while BF and post-BF cessation had hair TFV measured longitudinally. Using linear mixed-effect models, we estimated differences in hair TFV levels after BF cessation, accounting for trends in levels over time regardless of BF status and change in slope after breastfeeding cessation. We also estimated the relative risk of viremia (>50 copies/mL) per doubling of hair TFV concentration. RESULTS Among 55 women (median age 26, interquartile range 24-29 years), hair TFV levels (n = 305) were available for a median of 9 visits per woman between 3 and 29 months postpartum. Hair TFV levels ranged from undetected to 0.25 ng/mg (median 0.04 ng/mg). Controlling for trends since delivery [decline of 2.2% per month, 95% confidence interval (CI): -5.3 to 1.0], TFV levels averaged 24.4% higher (95% CI: -5.1 to 63.1) post-BF cessation than during BF, with no change in slope (0.0% per month, 95% CI: -3.8 to 3.9). Postpartum, 42% of women were ever viremic. Higher TFV levels were strongly protective; relative risk of viremia per doubling of TFV was 0.52 (95% CI: 0.43 to 0.63; P < 0.0001). CONCLUSIONS Leveraging an objective metric of ART use, we observed modestly declining adherence across the postpartum period, but no additional decline associated with breastfeeding cessation. High viremia frequency and varying postpartum TFV levels observed highlight the importance of enhanced adherence support with viral load monitoring among postpartum women.
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Affiliation(s)
| | - Pamela M. Murnane
- Institute for Global Health Sciences, University of California-San Francisco, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Osamuedeme J. Odiase
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Hideaki Okochi
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Regina Tallerico
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Vongai M. Chanaiwa
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
| | - Tichaona Vhembo
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
| | | | - Alexander Louie
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Tsungai Chipato
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Monica Gandhi
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Lynda Stranix-Chibanda
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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4
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Boyce CL, Sils T, Ko D, Wong-On-Wing A, Beck IA, Styrchak SM, DeMarrais P, Tierney C, Stranix-Chibanda L, Flynn PM, Taha TE, Owor M, Fowler MG, Frenkel LM. Maternal HIV drug resistance is associated with vertical transmission and is prevalent in infected infants. Clin Infect Dis 2021; 74:2001-2009. [PMID: 34467974 DOI: 10.1093/cid/ciab744] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We aimed to assess if maternal HIV drug resistance is associated with an increased risk of HIV vertical transmission and to describe the dynamics of drug resistance in HIV-infected infants. METHODS A case-control study of PROMISE study participants. "Cases" were mother-infant pairs with HIV vertical transmission during pregnancy or breastfeeding and "controls" were mother-infant pairs without transmission matched 1:3 by delivery date and clinical site. Genotypic HIV drug resistance analyses were performed on mothers' and their infants' plasma at or near the time of infant HIV diagnosis. Longitudinal analysis of genotypic resistance was assessed in available specimens from infants, from diagnosis and beyond, including ART initiation and last study visits. RESULTS Our analyses included 85 cases and 255 matched controls. Maternal HIV drug resistance, adjusted for plasma HIV RNA load at infant HIV diagnosis, enrollment CD4 count, and antepartum regimens, was not associated with in utero/peripartum HIV transmission. In contrast, both maternal plasma HIV RNA load and HIV drug resistance were independent risk factors associated with vertical transmission during breastfeeding. Furthermore, HIV drug resistance was selected across infected infants during infancy. CONCLUSIONS Maternal HIV drug resistance and maternal viral load were independent risk factors for vertical transmission during breastfeeding, suggesting that nevirapine alone may be insufficient infant prophylaxis against drug-resistant variants in maternal breast milk. These findings support efforts to achieve suppression of HIV replication during pregnancy and suggest that breastfeeding infants may benefit from prophylaxis with a greater barrier to drug resistance than nevirapine alone.
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Affiliation(s)
- Ceejay L Boyce
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Tatiana Sils
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Daisy Ko
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Annie Wong-On-Wing
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Ingrid A Beck
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Sheila M Styrchak
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Patricia DeMarrais
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Camlin Tierney
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Patricia M Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Taha E Taha
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Maxensia Owor
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Lisa M Frenkel
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, USA.,Department of Pediatrics and Laboratory Medicine, University of Washington, Seattle, WA, USA
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5
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Stranix-Chibanda L, Tierney C, Pinilla M, George K, Aizire J, Chipoka G, Mallewa M, Naidoo M, Nematadzira T, Kusakara B, Violari A, Mbengeranwa T, Njau B, Fairlie L, Theron G, Mubiana-Mbewe M, Khadse S, Browning R, Fowler MG, Siberry GK. Effect on growth of exposure to maternal antiretroviral therapy in breastmilk versus extended infant nevirapine prophylaxis among HIV-exposed perinatally uninfected infants in the PROMISE randomized trial. PLoS One 2021; 16:e0255250. [PMID: 34415933 PMCID: PMC8378741 DOI: 10.1371/journal.pone.0255250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/04/2021] [Indexed: 11/25/2022] Open
Abstract
Background Malnutrition is highly prevalent in HIV-exposed perinatally uninfected infants (HEUs) increasing the risk of morbidity and mortality throughout the life course. We set out to compare the effect of postnatal exposure to maternal antiretroviral therapy (mART) in breastmilk versus infant Nevirapine prophylaxis (iNVP) on somatic growth of HEUs in the randomized PROMISE trial. Methods and findings We randomized 2431 mothers with HIV and their 2444 HEUs from six African countries and India 6–14 days after delivery to mART or iNVP for prevention of breastmilk HIV transmission. The mART regimen contained tenofovir/emtricitabine (99%) plus lopinavir/ritonavir. Infant growth parameters were compared at postnatal week 10, 26, 74 and 104 using World Health Organization (WHO) z-scores for length-for-age (LAZ), weight-for-age (WAZ), and head circumference-for-age (HCAZ). Week 26 LAZ was the primary endpoint measure. Student T-tests compared mean LAZ, WAZ, and HCAZ; estimated mean and 95% confidence interval (CI) are presented. Maternal and infant baseline characteristics were comparable between study arms. The estimated median breastfeeding duration was 70 weeks. After a mean follow-up of 88 weeks, mean LAZ and WAZ were below the WHO reference population mean at all timepoints, whereas mean HCAZ was not. The mART and iNVP arms did not differ for the primary outcome measure of LAZ at week 26 (p-value = 0.39; estimated mean difference (95%CI) of -0.05 (-0.18, 0.07)) or any of the other secondary growth outcome measures or timepoints (all p-values≥0.16). Secondary analyses of the primary outcome measure adjusting for week 0 LAZ and other covariates did not change these results (all p-values≥0.09). However, infants assigned to mART were more likely to have stunting compared to iNVP infants at week 26 (odds ratio (95% CI): 1.28 (1.05, 1.57)). Conclusions In HEUs, growth effects from postnatal exposure to mART compared to iNVP were comparable for measures on length, weight and head circumference with no clinically relevant differences between the groups. Despite breastfeeding into the second year of life, length and weight were below reference population means at all ages in both arms. Further investment is needed to optimize postnatal growth of infants born to women with HIV. Clinical trial registration ClinicalTrials.gov number NCT01061151.
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Affiliation(s)
- Lynda Stranix-Chibanda
- University of Zimbabwe Faculty of Medicine and Health Sciences, Child and Adolescent Health Unit, Harare, Zimbabwe
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
- * E-mail: ,
| | - Camlin Tierney
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research in the Department of Biostatistics, Boston, MA, United States of America
| | - Mauricio Pinilla
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research in the Department of Biostatistics, Boston, MA, United States of America
| | | | - Jim Aizire
- Makerere University—Johns Hopkins University Research Programme, Kampala, Uganda
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | | | - Megeshinee Naidoo
- University of KwaZulu-Natal, Centre Aids Prevention Research South Africa (CAPRISA), Durban, South Africa
| | | | - Bangani Kusakara
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Avy Violari
- Perinatal HIV Research Unit, Johannesburg, South Africa
| | - Tapiwa Mbengeranwa
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Boniface Njau
- Kilimanjaro Christian Medical Center, Moshi, United Republic of Tanzania
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Gerard Theron
- Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa
| | | | - Sandhya Khadse
- Department of Obstetrics and Gynaecology, BJ Government Medical College, Pune, India
| | - Renee Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, United States of America
| | - Mary Glenn Fowler
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - George K. Siberry
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, United States of America
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Schnittman SR, Byakwaga H, Boum Y, Kabakyenga J, Matthews LT, Burdo TH, Huang Y, Tracy RP, Haberer JE, Kembabazi A, Kaida A, Moisi D, Lederman MM, Bangsberg DR, Martin JN, Hunt PW. Changes in Immune Activation During Pregnancy and the Postpartum Period in Treated HIV Infection. Open Forum Infect Dis 2021; 8:ofab245. [PMID: 34159218 PMCID: PMC8214017 DOI: 10.1093/ofid/ofab245] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/12/2021] [Indexed: 12/30/2022] Open
Abstract
Background Pregnant women with HIV (PWWH) have high postpartum morbidity and mortality from infections like tuberculosis. Immunologic changes during pregnancy and postpartum periods may contribute to these risks, particularly the immunoregulatory kynurenine pathway of tryptophan catabolism, which contributes to both HIV and tuberculosis pathogenesis and increases in the early postpartum period. Methods Women with HIV initiating antiretroviral therapy (ART) in the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort who were pregnant at enrollment or became pregnant during observation were studied (n = 54). Plasma kynurenine/tryptophan (KT) ratio, soluble CD14 (sCD14), sCD163, sCD27, interferon-inducible protein 10 (IP-10), D-dimer, interleukin-6, and intestinal fatty-acid binding protein levels were assessed through the first year of ART and at 3-month intervals throughout pregnancy and 1 year postpartum. Biomarker changes were assessed with linear mixed models adjusted for ART duration. Hemoglobin concentration changes were used to estimate pregnancy-related changes in plasma volume. Results The median pre-ART CD4 count was 134. D-dimer increased through the third trimester before returning to baseline postpartum, while most other biomarkers declined significantly during pregnancy, beyond what would be expected from pregnancy-associated plasma volume expansion. IP-10 and sCD14 remained suppressed for at least 12 months postpartum. KT ratio was the only biomarker that increased above prepregnancy baseline postpartum (mean + 30%; P < .001) and remained higher than baseline for ≥9 months (P ≤ .045 for all time points). Conclusions Several immune activation markers decline during pregnancy and remain suppressed postpartum, but the kynurenine pathway of tryptophan catabolism increases above baseline for ≥9 months postpartum. The mechanisms underlying postpartum kynurenine pathway activity are incompletely understood but may contribute to increased tuberculosis risk in this setting.
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Affiliation(s)
| | - Helen Byakwaga
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Yap Boum
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Lynn T Matthews
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tricia H Burdo
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Yong Huang
- University of California San Francisco, San Francisco, California, USA
| | | | - Jessica E Haberer
- Massachusetts General Hospital and Harvard University, Boston, Massachusetts, USA
| | - Annet Kembabazi
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Angela Kaida
- Simon Fraser University, Vancouver, British Columbia, Canada
| | - Daniela Moisi
- Case Western Reserve University, Cleveland, Ohio, USA
| | | | - David R Bangsberg
- Mbarara University of Science and Technology, Mbarara, Uganda.,Oregon Health and Sciences University and Portland State University School of Public Health, Portland, Oregon, USA
| | - Jeffrey N Martin
- University of California San Francisco, San Francisco, California, USA
| | - Peter W Hunt
- University of California San Francisco, San Francisco, California, USA
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Brummel SS, Taha TE, Angelidou K(N, Saidi F, Atuhaire P, Dula D, Moodley D, Matubu A, Chareka G, Nevrekar N, Vhembo T, Fairlie L, Theron G, Mlay P, George K, Basar M, Chakhtoura N, Browning R, Fowler MG, Currier JS. Brief Report: Impact of ART on Maternal Health After Cessation of Breastfeeding. J Acquir Immune Defic Syndr 2021; 86:450-454. [PMID: 33273210 PMCID: PMC8143379 DOI: 10.1097/qai.0000000000002586] [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: 06/15/2020] [Accepted: 10/26/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT IMPAACT PROMISE 1077BF/FF was a sequentially randomized study of pregnant and postpartum women living with HIV to investigate the efficacy and safety of antiretroviral therapy (ART). This Maternal Health Component investigated efficacy for the risk of developing AIDS or death; and safety among women randomized to continue ART (CTART: N = 289) or discontinue ART (N = 268) after cessation of breastfeeding or after confirmation of infant infection. No AIDS-defining illnesses were reported during follow-up in either arm. Adverse events of grade 3 or higher were more frequent in the CTART arm [hazard ratio = 1.78, 95% confidence interval: (1.05 to 3.02), P-value = 0.03]. The difference in adverse events in the 2 groups was mostly driven by moderate weight loss for women on the CTART arm.
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Affiliation(s)
- Sean S. Brummel
- The Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Taha E. Taha
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Friday Saidi
- University of North Carolina (UNC) Project—Malawi, Kamuzu Central Hospital, Malawi
| | - Patience Atuhaire
- Makerere University –John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
| | - Dingase Dula
- Johns Hopkins-College of Medicine Research Project, Blantyre, Malawi
| | - Dhayendre Moodley
- Centre for AIDS Research in South Africa and Department of Obstetrics and Gynecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Allen Matubu
- Department of Obstetrics and Gynecology, UZ-UCSF Collaborative Project, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Gift Chareka
- Department of Obstetrics and Gynecology, UZ-UCSF Collaborative Project, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Neetal Nevrekar
- Byramjee Jeejeebhoy Government Medical College and Clinical Research Site, Pune, India
| | - Tichaona Vhembo
- University of Zimbabwe College of Health Sciences—Clinical Trials Research Centre, Harare, Zimbabwe
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gerhard Theron
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Pendo Mlay
- Kilimanjaro Christian Medical Center, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Michael Basar
- Frontier Science and Technology Research Foundation, Amherst, NY
| | - Nahida Chakhtoura
- National Institute for Child Health and Human Development, Washington, D.C
| | - Renee Browning
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | | | - Judith S. Currier
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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Angelidou K, Fowler MG, Flynn P, Coletti A, McCarthy K, Browning R, McIntyre J, Brummel SS, Shapiro DE, Tierney C. Enrollment and transition challenges in the International Maternal Pediatric and Adolescent AIDS Clinical Trials (IMPAACT) network's PROMISE trial for resource-limited regions. Clin Trials 2020; 17:437-447. [PMID: 32191142 DOI: 10.1177/1740774520912428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We describe enrollment and accrual challenges in the "Promoting Maternal and Infant Survival Everywhere" (PROMISE) trial conducted in resource-limited countries, as well as the challenges in transitioning participants from the antepartum to the postpartum components of the study. METHODS PROMISE was a large multi-national randomized controlled trial of the safety and efficacy of interventions to reduce perinatal transmission of HIV-1 (HIV) during pregnancy and breastfeeding and of interventions to preserve maternal health after cessation of perinatal transmission risk. The PROMISE study included two protocols for HIV-infected pregnant women in resource-limited countries who intended to either breastfeed or formula-feed their infants and did not meet country criteria for antiretroviral treatment. The PROMISE breastfeeding protocol (1077BF) used a sequential randomization design with up to three randomizations (Antepartum, Postpartum, and Maternal Health). The PROMISE formula-feeding protocol (1077FF) had two randomizations (Antepartum and Maternal Health). Women presenting to the clinic during early or active labor or in the immediate postpartum period were registered as Late Presenters and screened to determine whether eligible to participate in the Postpartum randomization. RESULTS The study was conducted at 14 sites in seven countries and opened to enrollment in April 2011. A total of 3259 pregnant women intending to breastfeed and an additional 284 pregnant women intending to formula feed were randomized in the Antepartum component. A total of 204 Late Presenters were registered during labor or after delivery. Enrollment was high among breastfeeding women (representing 96% of the target of 3400 women) but was lower than expected among women intending to formula feed (28% of 1000 expected) and late-presenting women (8% of 2500 expected). The successful overall enrollment and final primary study analyses results were attributed to substantial preparation before the study opened, collaboration among all stakeholders, close study monitoring during implementation and the flexibility to change and streamline the protocol. CONCLUSIONS Experiences from the PROMISE study illustrate the challenges of enrolling in longer term studies in the setting of rapidly evolving prevention and treatment standards priorities. The lessons learned will help the community, site investigators, and study coordinators in the design and implementation of future clinical trials.
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Affiliation(s)
- Konstantia Angelidou
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pat Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Anne Coletti
- IMPAACT Operations Center, FHI 360, Durham, NC, USA
| | | | - Renee Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - James McIntyre
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean S Brummel
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - David E Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Camlin Tierney
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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9
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Atuhaire P, S. Brummel S, Mmbaga BT, Angelidou K, Fairlie L, Violari A, Theron G, Mukuzunga C, Mawlana S, Mubiana-Mbewe M, Naidoo M, Makanani B, Mandima P, Nematadzira T, Suryavanshi N, Mbengeranwa T, Loftis A, Basar M, McCarthy K, Currier JS, Fowler MG. The impact of short term Antiretroviral Therapy (ART) interruptions on longer term maternal health outcomes-A randomized clinical trial. PLoS One 2020; 15:e0228003. [PMID: 31999753 PMCID: PMC6992010 DOI: 10.1371/journal.pone.0228003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/03/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Given well documented challenges faced by pregnant women living with HIV taking lifetime ART, it is critical to understand the impact of short-term ART exposure followed by treatment interruption on maternal health outcomes. METHODS HIV+ breastfeeding (BF) and Formula Feeding (FF) women with CD4 counts > 350 cells/mm3, enrolled in the 1077BF/1077FF PROMISE trial were followed to assess the effect of ART during pregnancy and breastfeeding respectively. The first analysis compared ART use limited to the antepartum period (AP-only) relative to women randomized to Zidovudine. The second analysis included women with no pregnancy combination ART exposure; and compared women randomized to either ART or no ART during postpartum (PP-only). Both analyses included follow-up time beyond breastfeeding period. The primary outcome was progression to AIDS and/or death. Secondary outcomes included adverse events and HIV-related events. RESULTS 3490 and 1137 HIV+ women were enrolled from 14 sites in Africa and India from April 2011 through September 2014 in cohort AP-only and PP-only, respectively. Most were Black African (96%); median age was 27 years; 97% were WHO Clinical Stage I; and most had a screening CD4 count ≥500 cells/mm3 (78%). The rate of progression to AIDS and/or death was similar and low across all comparison arms (AP comparison, HR = 1.14, 95%CI (0.44, 2.96), p-value = 0.79). In the PP-only cohort, the rate of WHO stage 2-3 events was lower for women randomized to ART(HR = 0.65, 95% CI 0.42, 1.01, p-value = 0.05). CONCLUSION The incidence of AIDS and/or death was low in pregnant/postpartum HIV+ women with highCD4 cell counts for all comparison arms. This provides some reassurance that there were limited consequences for short term ART interruption in this group of asymptomatic HIV+ women during up to 4 years of follow up; and underscores that even short term ART exposure postpartum may reduce the risk of WHO grade 2-3 disease progression.
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Affiliation(s)
- Patience Atuhaire
- Makerere University –John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
- * E-mail:
| | - Sean S. Brummel
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | | | - Konstantia Angelidou
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Lee Fairlie
- Wits RHI Shandukani Research Centre CRS, Johannesburg, South Africa
| | - Avy Violari
- Soweto IMPAACT CRS, Johannesburg, South Africa
| | | | | | | | | | | | | | | | | | | | | | - Amy Loftis
- UNC, Chapel Hill, North Carolina, United States of America
| | - Michael Basar
- Frontier Science, Amherst, Massachusetts, United States of America
| | - Katie McCarthy
- FHI 360, Durham, North Carolina, United States of America
| | - Judith S. Currier
- UCLA center for Clinical AIDS Research and Education, Los Angeles, California, United States of America
| | - Mary Glenn Fowler
- Departments of Pathology and Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States of America
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