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Todorović Z, Dragović G, Lukić R. Pharmacokinetic and toxicological considerations affecting antiretroviral drug dosing in pregnant women. Expert Opin Drug Metab Toxicol 2024; 20:419-437. [PMID: 38738389 DOI: 10.1080/17425255.2024.2353762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 05/07/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION To prevent mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV) during pregnancy, the appropriate dosing regimens of antiretroviral (ARV) drugs need to be determined. Reliable data about pharmacokinetic (PK) characteristics of ARVs from randomized clinical trials (RCTs) are lacking, and post-marketing observational studies may offer valuable, but sometimes insufficient data, especially in pregnant people living with HIV (PLWHIV). This review article is focused PK and toxicological considerations affecting ARV dosing in pregnant PLWHIV. AREAS COVERED In our search, we included studies focused on PKs of ARVs in pregnancy available on PubMed, abstracts from recent global conferences and data from modeling studies. There are no significant changes in PKs of nucleoside/nucleotide reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitors throughout pregnancy. In contrast, the PKs of PIs and INSTIs are more variable, especially in the second and third trimesters. EXPERT OPINION Pregnant women are left out of RCTs. To the greatest extent possible, future research should include pregnant persons in RCTs, including PK studies, strictly considering maternal and fetal safety. Alternative innovative approaches/models need to be developed to obtain reliable data about rational pharmacotherapy of ARVs in the effective PMTCT of HIV, with maximum safety.
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Affiliation(s)
- Zoran Todorović
- Faculty of Medicine, Department of Pharmacology, Clinical Pharmacology and Toxicology, University of Belgrade, Belgrade, Serbia
| | - Gordana Dragović
- Faculty of Medicine, Department of Pharmacology, Clinical Pharmacology and Toxicology, University of Belgrade, Belgrade, Serbia
| | - Relja Lukić
- Faculty of Medicine, Obstetrics and Gynaecology Clinic GAK "Narodni Front", University of Belgrade, Belgrade, Serbia
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Henderson AC, Cholli P, Lampe MA, Kourtis AP. Challenges, risks, and opportunities of antiretroviral drugs in women of reproductive potential. Expert Rev Anti Infect Ther 2024; 22:153-167. [PMID: 38517686 DOI: 10.1080/14787210.2024.2334054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/19/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The HIV/AIDS epidemic has been one of the greatest challenges in global health, significantly affecting women of reproductive potential. Considerable advances in antiretroviral therapy for women living with HIV have contributed to improvements in quality of life, better reproductive and birth outcomes, and a reduced risk of perinatal transmission. AREAS COVERED Despite the progress made, persistent challenges in access and adherence to antiretroviral drugs may limit their benefits for some women. More pharmacokinetic and safety studies in pregnant and lactating women are urgently needed, as are prospective surveillance systems to evaluate associations between fetal and infant antiretroviral exposures, drug-drug interactions, and pregnancy outcomes. EXPERT OPINION Multipurpose technologies, such as combined HIV and other STI or unintended pregnancy prevention, and innovative delivery methods, such as the development of long-acting antiretrovirals, have the potential to reduce adherence challenges and enhance quality of life for women with HIV. Parallel advances in drug safety testing and surveillance are needed to ensure the health and safety of women with or at risk for HIV and children at risk for perinatal transmission.
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Affiliation(s)
- Alexis C Henderson
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Preetam Cholli
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Margaret A Lampe
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Athena P Kourtis
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Ndapatani LN, Mapesa J, Muchina E. Assessment of the effect of pre-conception care on preventing mother-to-child transmission of HIV in Nyeri County. Pan Afr Med J 2024; 47:144. [PMID: 38933429 PMCID: PMC11204976 DOI: 10.11604/pamj.2024.47.144.37196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 03/20/2024] [Indexed: 06/28/2024] Open
Abstract
Introduction the provision of essential preconception care services for HIV-positive pregnant women is crucial to prevent HIV transmission to infants. This includes pregnancy intention screening services, adequate viral load monitoring and suppression before conception, and necessary nutritional support. In Nyeri County, the prevalence of Mother-to-Child Transmission (MTCT) of HIV is 5.3%, which is higher than the global threshold of 5%. This study aims to evaluate the impact of pre-conception care services in preventing HIV transmission to infants in Nyeri County. The study objectives are to assess the utilization of pre-conception care services among HIV-positive women, specifically focusing on pregnancy intention screening, viral load monitoring and suppression, and access to nutritional assessment services before pregnancy. Additionally, the study aims to investigate the relationship between the provision of pre-conception care services and infant HIV outcomes. Methods this cross-sectional retrospective descriptive study employed stratified sampling to select eight level 4 and level 5 hospitals in Nyeri County. The target population consisted of HIV-infected women seeking postnatal care in these facilities, with a sample size of 252 women who had HIV-exposed infants under two years old and were receiving post-natal care at the respective hospitals. Sociodemographic characteristics, including age, marital status, and education level, were collected. Data analysis involved both descriptive and inferential statistics. Results our findings revealed that only 34.2% of HIV-positive women seeking postnatal care had received information or services related to pregnancy intention screening, a crucial aspect of pre-conception care. Almost half (46.4%) of the women who participated in the study had undergone viral load measurements before pregnancy, which is another critical component of preconception care. Additionally, 85.6% of these women had received nutritional services during pregnancy from their healthcare providers. Interestingly, all women who received any pre-conception care services reported that their infants were alive and tested HIV-negative. Conclusion preconception care is crucial in preventing mother-to-child transmission of HIV. Efforts should be made to ensure that all HIV-infected women planning to conceive have access to preconception care services.
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Affiliation(s)
| | - Job Mapesa
- Kenya Methodist University, 45240 - 00100, Nairobi, Kenya
| | - Emily Muchina
- Kenya Methodist University, 45240 - 00100, Nairobi, Kenya
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Eke AC, Mirochnick M, Lockman S. Antiretroviral Therapy and Adverse Pregnancy Outcomes in People Living with HIV. N Engl J Med 2023; 388:344-356. [PMID: 36720135 PMCID: PMC10400304 DOI: 10.1056/nejmra2212877] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Ahizechukwu C Eke
- From the Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, and the Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore (A.C.E.); the Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine (M.M.), the Division of Infectious Diseases, Brigham and Women's Hospital (S.L.), and the Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health (S.L.) - all in Boston; and the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana (S.L.)
| | - Mark Mirochnick
- From the Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, and the Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore (A.C.E.); the Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine (M.M.), the Division of Infectious Diseases, Brigham and Women's Hospital (S.L.), and the Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health (S.L.) - all in Boston; and the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana (S.L.)
| | - Shahin Lockman
- From the Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, and the Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore (A.C.E.); the Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine (M.M.), the Division of Infectious Diseases, Brigham and Women's Hospital (S.L.), and the Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health (S.L.) - all in Boston; and the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana (S.L.)
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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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Partap U, Chowdhury R, Taneja S, Bhandari N, De Costa A, Bahl R, Fawzi W. Preconception and periconception interventions to prevent low birth weight, small for gestational age and preterm birth: a systematic review and meta-analysis. BMJ Glob Health 2022; 7:bmjgh-2021-007537. [PMID: 35948345 PMCID: PMC9379503 DOI: 10.1136/bmjgh-2021-007537] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 06/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Low birth weight (LBW), including preterm birth (PTB) and small for gestational age (SGA), contributes a significant global health burden. We aimed to summarise current evidence on the effect of preconception and periconception interventions on LBW, SGA and PTB. Methods In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Library and WHO Global Index Medicus for randomised controlled trials and quasi-experimental studies published by 28 November 2020, which assessed interventions delivered in preconception and periconception or preconception and pregnancy. Primary outcomes were LBW, SGA and PTB. Studies were categorised by intervention type and delivery during preconception and periconception or during preconception and pregnancy. Estimates were pooled using fixed-effects or random-effects restricted maximum likelihood method meta-analyses. Quality of evidence for primary outcomes was assessed using the Grades of Recommendations, Assessment, Development and Evaluation approach. Results We included 58 studies. Twenty-eight studies examined nutrition interventions (primarily micronutrient or food supplementation). Thirty studies (including one reporting a nutrition intervention) provided health interventions (general preconception health, early adverse pregnancy outcome prevention, non-communicable disease and infectious disease prevention and management). One study assessed a social intervention (reproductive planning). Studies varied in terms of specific interventions, including delivery across preconception or pregnancy, resulting in few studies for any single comparison. Overall, the evidence was generally very uncertain regarding the impact of any intervention on LBW, SGA and PTB. Additionally, preconception and periconception nutritional supplementation containing folic acid was associated with reduced risk of birth defects (10 studies, N=3 13 312, risk ratio: 0.37 (95% CI: 0.24 to 0.55), I2: 74.33%). Conclusion We found a paucity of evidence regarding the impact of preconception and periconception interventions on LBW, SGA and PTB. Further research on a wider range of interventions is required to clearly ascertain their potential effectiveness. Trial registration number This review was prospectively registered with PROSPERO (CRD42020220915).
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Affiliation(s)
- Uttara Partap
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Ranadip Chowdhury
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Sunita Taneja
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Nita Bhandari
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Ayesha De Costa
- Department of Maternal, Newborn, Child and Adolescent Health, and Ageing, World Health Organization, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health, and Ageing, World Health Organization, Geneva, Switzerland
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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Jiang W, Ronen K, Osborn L, Drake AL, Unger JA, Matemo D, Enquobahrie DA, Kinuthia J, John-Stewart G. Predictors of adverse pregnancy outcomes among Kenyan women with HIV on antiretroviral treatment in pregnancy. AIDS 2022; 36:1007-1019. [PMID: 35652673 PMCID: PMC9178912 DOI: 10.1097/qad.0000000000003215] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to understand predictors of adverse pregnancy outcomes (APOs) among women on antiretroviral treatment (ART). DESIGN A longitudinal cohort. METHODS Participants from the Mobile WAChX trial were evaluated for APOs, including stillbirth (fetal death at ≥20 weeks' gestation), preterm birth (PTB, livebirth at <37 weeks' gestation,) and neonatal death (NND, ≤28 days after live birth). Predictors were determined by univariable and multivariable Cox proportional hazards and log-binomial models. RESULTS Among 774 women included, median age was 27 years and 29.0% had unsuppressed HIV viral load (>1000 copies/ml) at enrollment. Half (55.1%) started ART prepregnancy, 89.1% on tenofovir-based regimens. Women with depression had a higher risk of stillbirth (adjusted hazard ratio [aHR] 2.93, 95% confidence interval (95% CI) 1.04-8.23), and women with lower social support score had higher risk of late stillbirth (aHR 11.74, 2.47-55.86). Among 740 livebirths, 201 (27.2%) were preterm and 22 (3.0%) experienced NND. PTB was associated with unsuppressed maternal viral load (adjusted prevalence ratio [aPR] 1.28, 95% CI 1.02-1.61), intimate partner violence (IPV) in pregnancy (aPR 1.94, 95% CI 1.28-2.94), and history of any sexually transmitted infection (STI) (aPR 1.63, 95% CI 1.06-2.51). NND was associated with PTB (aPR 2.53, 95% CI 1.10-5.78) and STI history (aPR 4.25, 95% CI 1.39-13.06). Most associations retained significance in the subgroup of women with viral suppression. CONCLUSION Maternal viremia during pregnancy predicted PTB as did IPV, lower education, and STI history, while psychosocial stressors predicted stillbirth. Implementing mental health services, ART adherence, partner support, and routine STI screening and treatment could reduce APOs among women with HIV in sub-Saharan Africa settings.
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Affiliation(s)
- Wenwen Jiang
- University of Washington, Seattle, Washington, USA
| | - Keshet Ronen
- University of Washington, Seattle, Washington, USA
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Theron G, Brummel S, Fairlie L, Pinilla M, McCarthy K, Owor M, Chinula L, Makanani B, Violari A, Moodley D, Chakhtoura N, Browning R, Hoffman R, Fowler MG. Pregnancy Outcomes of Women Conceiving on Antiretroviral Therapy (ART) Compared to Those Commenced on ART During Pregnancy. Clin Infect Dis 2021; 73:e312-e320. [PMID: 32564058 PMCID: PMC8516506 DOI: 10.1093/cid/ciaa805] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/17/2020] [Indexed: 11/13/2022] Open
Abstract
Background Globally, the number of infected women of childbearing age living with human immunodeficiency virus (HIV) and conceiving on antiretroviral therapy (ART) is increasing. Evidence of ART safety at conception and during pregnancy and adverse pregnancy outcomes remains conflicting. The Promoting Maternal and Infant Survival Everywhere (PROMISE) 1077 breastfeeding (BF) and formula feeding (FF) international multisite trials provide an opportunity to examine the impact of ART at conception on pregnancy outcomes with subsequent pregnancies. Methods The PROMISE 1077BF/1077FF trials were designed to address key questions in the management of HIV-infected women who did not meet clinical guidelines for ART treatment during the time of the trials. After the period of risk of mother-to-child transmission was over, women were randomized to either continue or discontinue ART. We compared subsequent pregnancy outcomes of nonbreastfeeding women randomized to continue ART following delivery, or breastfeeding women randomized to continue ART following breastfeeding cessation who conceived while on ART to women randomized to discontinue ART, who restarted ART after pregnancy was diagnosed. Results Pregnancy outcomes of 939 subsequent pregnancies of 826 mothers were recorded. The intention-to-treat analyses showed increased incidence of low birth weight (<2500 g) for women who conceived while on ART (relative risk, 2.65 [95% confidence interval {CI}, 1.20–5.81]), and also a higher risk of spontaneous abortion, stillbirth, or neonatal death (hazard ratio, 1.40 [95% CI, .99–1.98]) compared to women who restarted ART after they were found to be pregnant during trial follow-up. Conclusions We found an increased risk for adverse pregnancy outcomes in women conceiving on ART, emphasizing the need for improved obstetric and neonatal care for this group. Clinical Trials Registration NCT01061151.
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Affiliation(s)
- Gerhard Theron
- Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa
| | - Sean Brummel
- Harvard T. H. Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, Massachusetts, USA
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mauricio Pinilla
- Harvard T. H. Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, Massachusetts, USA
| | | | - Maxensia Owor
- Makerere University - Johns Hopkins University Research Collaboration Research Collaboration, Kampala, Uganda
| | - Lameck Chinula
- Division of Global Women's Health, Department of Obstetrics and Gynaecology, UNC Project-Malawi Common Reporting Standard, University of North Carolina at Chapel Hill, Lilongwe, Malawi
| | - Bonus Makanani
- College of Medicine, Johns Hopkins Research Project, Blantyre, Malawi
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - 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
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Renee Browning
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Risa Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Mary Glenn Fowler
- Johns Hopkins University, Department of Pathology, Baltimore, Maryland, USA
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Zhang W, Wang D, Yuan W, Yao S. Combined detection of ACL and β2-GP1 in diagnosis of adverse pregnancy. Am J Transl Res 2021; 13:5653-5658. [PMID: 34150172 PMCID: PMC8205803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/21/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To illustrate the significance of combined detection of anti cardiolipin (ACL) and anti-β2-glycoprotein 1 (β2-GP1) in the diagnosis of adverse pregnancy. METHODS 60 postnatal women with adverse pregnancy presented to our hospital from March 2019 to March 2020 were enrolled as the experimental group, and 60 postnatal women with normal delivery in the same period were selected as the control group. The levels of ACL, β2-GP1 were measured to analyze the significance of the integrated detection in the diagnosis of adverse pregnancy. RESULTS No obvious differences were observed in mean age, mean gestational week, mean height, number of cases of primigravida and multiparous women, educational background, place of residence between two groups (P > 0.05). The number of cases of positive β2-GP1-IgG and β2-GP1-IgM tests in experimental group were remarkably higher (P < 0.05). The number of β2-GP1-IgA positive cases in the two kinds of parturients was not notably different (P > 0.05). The ACL of the experimental parturients had a notably higher number of β2-GP1-positive cases (P < 0.001), and the combined positive cases of the experimental parturients had notably higher serum BPA and resistin levels (P < 0.001). The incidence of fetal growth restriction, premature delivery and placental abruption of experimental group were higher than those of control group (P < 0.05). There was no stillbirth in both groups. CONCLUSIONS The positive expression of ACL with β2-GP1 is the culprit of adverse pregnancy, and the combined diagnosis can greatly improve the clinical screening rate of adverse pregnancy and provide more evidence for subsequent treatment.
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Affiliation(s)
- Wei Zhang
- Department of Obstetrics, Hengshui People's Hospital Hengshui, China
| | - Dong Wang
- Department of Obstetrics, Hengshui People's Hospital Hengshui, China
| | - Weixin Yuan
- Department of Obstetrics, Hengshui People's Hospital Hengshui, China
| | - Shuiping Yao
- Department of Obstetrics, Hengshui People's Hospital Hengshui, China
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Adimora AA, Ramirez C, Poteat T, Archin NM, Averitt D, Auerbach JD, Agwu AL, Currier J, Gandhi M. HIV and women in the USA: what we know and where to go from here. Lancet 2021; 397:1107-1115. [PMID: 33617768 DOI: 10.1016/s0140-6736(21)00396-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 08/13/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023]
Abstract
New diagnoses of HIV infection have decreased among women in the USA overall, but marked racial and geographical disparities persist. The federal government has announced an initiative that aims to decrease the number of new infections in the nation by 90% within the next 10 years. With this in mind, we highlight important recent developments concerning HIV epidemiology, comorbidities, treatment, and prevention among women in the USA. We conclude that, to end the US HIV epidemic, substantially greater inclusion of US women in clinical research will be required, as will better prevention and treatment efforts, with universal access to health care and other supportive services that enable women to exercise agency in their own HIV prevention and care. Ending the epidemic will also require eliminating the race, class, and gender inequities, as well as the discrimination and structural violence, that have promoted and maintained the distribution of HIV in the USA, and that will, if unchecked, continue to fuel the epidemic in the future.
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Affiliation(s)
- Adaora A Adimora
- Department of Medicine, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA; School of Medicine, and Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA; Women's Research Initiative on HIV/AIDS, The Well Project, New York, NY, USA.
| | - Catalina Ramirez
- Department of Medicine, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Tonia Poteat
- Department of Social Medicine, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Nancie M Archin
- Department of Medicine, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Dawn Averitt
- Women's Research Initiative on HIV/AIDS, The Well Project, New York, NY, USA
| | - Judith D Auerbach
- Women's Research Initiative on HIV/AIDS, The Well Project, New York, NY, USA; Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
| | - Allison L Agwu
- Division of Infectious Diseases, Department of Medicine and Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Judith Currier
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Monica Gandhi
- Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
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Aleem S, Bhutta ZA. Infection-related stillbirth: an update on current knowledge and strategies for prevention. Expert Rev Anti Infect Ther 2021; 19:1117-1124. [PMID: 33517816 DOI: 10.1080/14787210.2021.1882849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Infections during pregnancy are a preventable public health concern globally, with the highest burden occurring in low- and middle-income countries. Despite clear interventions to reduce these infections, their impact on preventing stillbirths is unclear, with conflicting evidence.Areas covered: The purpose of this review is to discuss data regarding infectious causes of stillbirths, and interventions for the prevention and/or treatment of these infections. We discuss the limitations in evaluating the true effect of the interventions on stillbirths, and highlight the importance of preventing infections in the grand scheme of improving maternal and infant pregnancy outcomes. We used PubMed to identify relevant studies, reviews, and meta-analysis until January 2021.Expert opinion: Maternal infections during pregnancy, especially malaria and syphilis, are notable causes of stillbirth in low- and middle-income countries. Despite considerable global advocacy, there is scant recognition of the potential to reduce the burden of antepartum stillbirths related to infections. Reducing stillbirths overall must become an important indicator for quality of care and accountability, and progress must also be assessed by coverage of key interventions that impact stillbirths, which includes population-based screening, prevention and timely treatment of infections during pregnancy.
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Affiliation(s)
- Samia Aleem
- Department of Pediatrics, Duke University, Durham, North Carolina, United States
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research, and Learning, Toronto, ON, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,Centre of Excellence in Women, and Child Health, Aga Khan University, Karachi, Pakistan.,Epidemiology Division, Dalla Lana School of Public Health University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
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Gilmore JC, Serghides L, Bendayan R. Differential effects of antiretroviral drug toxicity in male versus female children who are HIV-exposed but uninfected. AIDS 2021; 35:1-14. [PMID: 33048885 DOI: 10.1097/qad.0000000000002707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
: In recent years, widespread use of antiretroviral therapy (ART) during pregnancy has been increasingly effective in reducing risk of vertical transmission of HIV, with over 80% of pregnant women living with HIV now accessing ART, and a 41% reduction in new infections in children between 2010 and 2018. Despite these strides, the developmental toxicity of widely administered antiretroviral drugs (ARVs) remains poorly described and existing literature often fails to account for fetal and infant sex as a variable. Recent reports have identified associations between in-utero exposure to commonly used antiretroviral regimens and alteration in neurodevelopment, growth, and metabolism amongst children who are HIV-exposed but uninfected, with findings of sex differences in the prevalence and severity of ARV toxicity. These differences are potentially explained by variable exposure to ARV drugs in utero or exacerbation of existing sex-linked risk factors. Fetal ARV exposure is mediated by placental and fetal drug transporters and metabolic enzymes, which may contribute to the manifestation of sex differences. Existing evidence of sex differences in ARV toxicity in fetal development is concerning, and demands further research to guide optimal treatment options for maternal health and prevention of vertical HIV transmission.
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Affiliation(s)
| | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network (UHN)
- Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Reina Bendayan
- Department of Pharmaceutical Sciences, University of Toronto
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Eckard AR, Kirk SE, Hagood NL. Contemporary Issues in Pregnancy (and Offspring) in the Current HIV Era. Curr HIV/AIDS Rep 2020; 16:492-500. [PMID: 31630334 DOI: 10.1007/s11904-019-00465-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Although antiretroviral therapy (ART) has dramatically reduced mother to child transmission of HIV, data continue to mount that infants exposed to HIV in utero but are not infected (HEU) have serious negative health consequences compared to unexposed infants. This review evaluates recent literature on contemporary issues related to complications seen in pregnant women with HIV and their offspring. RECENT FINDINGS Current studies show that HEU infants are at a high risk of adverse outcomes, including premature birth, poor growth, neurodevelopmental impairment, immune dysfunction, infectious morbidity, and death. Etiologies for the observed clinical events and subclinical alterations are complex and multifactorial, and the long-term consequences of many findings are yet unknown. HEU infants have an unacceptable rate of morbidity and mortality from perinatal HIV and ART exposure, even in the modern ART era. Continual monitoring and reporting is imperative to protect this vulnerable population in our everchanging landscape of HIV treatment and prevention.
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Affiliation(s)
- Allison Ross Eckard
- Departments of Pediatrics and Medicine, Divisions of Infectious Diseases, Medical University of South Carolina, 135 Rutledge Ave., MSC 752, Charleston, SC, USA.
| | - Stephanie E Kirk
- Departments of Pediatrics and Medicine, Divisions of Infectious Diseases, Medical University of South Carolina, 135 Rutledge Ave., MSC 752, Charleston, SC, USA
| | - Nancy L Hagood
- Departments of Pediatrics and Medicine, Divisions of Infectious Diseases, Medical University of South Carolina, 135 Rutledge Ave., MSC 752, Charleston, SC, USA
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Favarato G, Townsend CL, Peters H, Sconza R, Bailey H, Cortina-Borja M, Tookey P, Thorne C. Stillbirth in Women Living With HIV Delivering in the United Kingdom and Ireland: 2007-2015. J Acquir Immune Defic Syndr 2020; 82:9-16. [PMID: 31149953 DOI: 10.1097/qai.0000000000002087] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Women living with HIV have a higher risk of adverse birth outcomes, but questions remain regarding their specific risk factors for stillbirth and the extent to which maternal HIV is associated with stillbirth. METHODS Using data on pregnant women with HIV reported within population-based surveillance in the United Kingdom/Ireland, we described stillbirth rates in 2007-2015 stratified by type of antiretroviral therapy (ART) and evaluated risk factors using Poisson regression. General population stillbirth rates by maternal world region of origin were derived from national annual birth statistics, and compared with rates in women with HIV, using standardized stillbirth ratios with the general population as the reference. RESULTS Between 2007 and 2015, there were 10,434 singleton deliveries in 8090 women with HIV; 75% of pregnancies were in women of African origin; and 49% were conceived on ART. The stillbirth rate was 8.5 (95% confidence interval: 6.9 to 10.5) per 1000 births. Risk factors for stillbirth included pre-eclampsia, diabetes, Asian maternal origin (versus United Kingdom/Ireland), CD4 count <350 cells/mm, older maternal age, and primiparity. Conceiving on ART did not increase the risk. The stillbirth rates (per 1000 births) by type of ART were 14.3, 11.7, 8.3, and 6.0, respectively for NVP + XTC/TDF-, LPV/r + 3TC/ZDV-, NVP + XTC/ABC-, and NVP + XTC/ZDV-exposed pregnancies (P value = 0.40). The standardized stillbirth ratio was 129 (95% confidence interval: 101 to 165) in women with HIV compared with the general population. CONCLUSION After adjusting for maternal origin, the stillbirth rate remained higher in women with HIV than the general population. We recommend further studies to understand and prevent this excess.
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Affiliation(s)
- Graziella Favarato
- Population, Policy, Practice Programme, UCL Great Ormond Street Institute of Child Health, University College London, United Kingdom
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Pregnancy Loss in Women with HIV is not Associated with HIV Markers: Data from a National Study in Italy, 2001-2018. Mediterr J Hematol Infect Dis 2019; 11:e2019050. [PMID: 31528316 PMCID: PMC6736172 DOI: 10.4084/mjhid.2019.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/08/2019] [Indexed: 11/08/2022] Open
Abstract
Background There is limited information on pregnancy loss in women with HIV, and it is still debated whether HIV-related markers may play a role.Objectives: To explore potential risk factors for pregnancy loss in women with HIV, with particular reference to modifiable risk factors and markers of HIV disease. Methods Multicenter observational study of HIV-positive pregnant women. The main outcome measure was pregnancy loss, including both miscarriage (<22 weeks) and stillbirth (≥22 weeks). Possible associations of pregnancy loss were evaluated in univariate and multivariate analyses. Results Among 2696 eligible pregnancies reported between 2001 and 2018, 226 (8.4%) ended in pregnancy loss (miscarriage 198, 7.3%; stillbirth 28, 1.0%). In multivariate analyses, only older age (adjusted odds ratio [AOR] per additional year of age: 1.079, 95% confidence interval [CI] 1.046-1.113), HIV diagnosis before pregnancy (AOR: 2.533, 95%CI 1.407-4.561) and history of pregnancy loss (AOR: 1.625, 95%CI 1.178-2.243) were significantly associated with pregnancy loss. No significant association with pregnancy loss was found for parity, coinfections, sexually transmitted diseases, hypertension, smoking, alcohol and substance use, CD4 cell count, HIV-RNA viral load, and CDC HIV stage. Conclusions Older women and those with a previous history of pregnancy loss should be considered at higher risk of pregnancy loss. The severity of HIV disease and potentially modifiable risk factors did not increase the risk of pregnancy loss.
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