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Eke AC, Gebreyohannes RD, Powell AM. Understanding clinical outcome measures reported in HIV pregnancy studies involving antiretroviral-naive and antiretroviral-experienced women. THE LANCET. INFECTIOUS DISEASES 2023; 23:e151-e159. [PMID: 36375478 PMCID: PMC10040432 DOI: 10.1016/s1473-3099(22)00687-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/02/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022]
Abstract
HIV infection is a clinically significant public health disease and contributes to increased risk of maternal and fetal morbidity and mortality. HIV pregnancy studies use outcome measures as metrics to show how people with HIV feel, function, or survive. These endpoints are crucial for tracking the evolution of HIV illness over time, assessing the effectiveness of antiretroviral therapy (ART), and comparing outcomes across studies. Although the need for ideal outcome measures is widely acknowledged, selecting acceptable outcome measures for these HIV pregnancy studies can be challenging. We discuss the many outcome measures that have been implemented over time to assess HIV in pregnancy studies, their benefits, and drawbacks. Finally, we offer suggestions for improving the reporting of outcome measures in HIV in pregnancy studies. Medical professionals can best care for pregnant women living with HIV receiving ART by having a thorough understanding of these outcome metrics.
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Affiliation(s)
- Ahizechukwu C Eke
- Division of Maternal Foetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Rahel D Gebreyohannes
- Department of Obstetrics and Gynaecology, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Anna M Powell
- Department of Gynaecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ludvigsson JF, Loboda A. Systematic review of health and disease in Ukrainian children highlights poor child health and challenges for those treating refugees. Acta Paediatr 2022; 111:1341-1353. [PMID: 35466444 PMCID: PMC9324783 DOI: 10.1111/apa.16370] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 12/24/2022]
Abstract
Aim Millions of Ukrainian children have been internally displaced or fled to other countries because of the Russian war. This systematic review focused on their health needs and future challenges for clinicians. Methods A systematic literature search of the Medline, Embase and MedRxiv databases from 1 January 2010 to 31 March 2022 identified 1628 papers on the health of Ukrainian children and 112 were relevant to this review. Results In 2019, under‐5 mortality was 8 per 1000 live births in Ukraine. Underweight and adverse childhood experiences, including child abuse, were frequent compared to other European countries, while childhood obesity seemed less common. Alcohol consumption was common in women of reproductive age, including during pregnancy, risking foetal alcohol syndrome. Neonatal screening programmes provided low coverage. Vaccine hesitancy was common and vaccination rates were low. Other concerns were measles, HIV, antibiotic resistance and multi‐resistant tuberculosis. Many children are expected to suffer from psychological and physical trauma due to the war. Other healthcare challenges include low COVID‐19 vaccination rates and a preference for secondary and tertiary care, rather than primary care. Many people cannot afford medication. Conclusion Ukrainian children often have poor health and host countries need to be aware of their needs.
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Affiliation(s)
- Jonas F. Ludvigsson
- Department of Medical Epidemiology and Biostatistics Karolinska Institutet Stockholm Sweden
- Department of Paediatrics Orebro University Hospital Orebro Sweden
- Department of Medicine Columbia University College of Physicians and Surgeons New York New York USA
| | - Andrii Loboda
- Department of Paediatrics, Academic and Research Medical Institute Sumy State University Sumy Ukraine
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Rasi V, Peters H, Sconza R, Francis K, Bukasa L, Thorne C, Cortina-Borja M. Trends in antiretroviral use in pregnancy in the UK and Ireland, 2008-2018. HIV Med 2022; 23:397-405. [PMID: 35178841 PMCID: PMC9306524 DOI: 10.1111/hiv.13243] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/11/2022] [Indexed: 12/21/2022]
Abstract
INTRODUCTION HIV treatment recommendations have evolved over time, reflecting both growing availability of new antiretrovirals and accumulating evidence on their safe and effective use. We analysed patterns of antiretroviral use among diagnosed pregnant women living with HIV delivering in the UK and Ireland between 2008 and 2018 using national surveillance data. METHODS All singleton pregnancies with known outcomes and known timing of antiretroviral initiation reported to the National Surveillance of HIV in Pregnancy and Childhood were included. Every individual instance of specific antiretroviral use was the unit of analysis in generating a snapshot of antiretroviral use overall and over calendar time. The final analysis was restricted to the 14 most frequently prescribed antiretrovirals. RESULTS There were 12 099 singleton pregnancies reported during 2008-2018 and a total of 38 214 individual uses of the 14 most commonly prescribed antiretrovirals, the majority of which were started before conception (70.9%). In 2008, 37.7% (482/1279) of pregnancies were conceived under treatment, reaching 80.9% (509/629) by 2018. Patterns of antiretroviral use have changed over time, particularly for third agents. Between 2008 and 2018 the most frequently used protease inhibitor shifted from lopinavir to darunavir, whereas use of integrase inhibitors increased steadily over time. CONCLUSIONS These national surveillance data enable investigation of the 'real-world' use of antiretrovirals in pregnancy on a population level. Findings demonstrate mixed responsiveness of antiretroviral prescription to changes in pregnancy guideline recommendations and may also reflect changes in commissioning and in the characteristics of pregnant women living with HIV.
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Affiliation(s)
- Virginia Rasi
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Helen Peters
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Rebecca Sconza
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Kate Francis
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Laurette Bukasa
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Claire Thorne
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Mario Cortina-Borja
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
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Cravat L, Merz WM, van Bremen K, Rockstroh JK, Wasmuth JC, Boesecke C, Haberl A, Schwarze-Zander C, Strizek B. [HIV Test in Pregnancy - 100% Not Reached in 2020]. Z Geburtshilfe Neonatol 2022; 226:167-172. [PMID: 35073586 DOI: 10.1055/a-1724-7539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION In 2019 38 million people were living with HIV worldwide, more than half of them girls and women. Knowledge about maternal HIV status enables HIV transmission prophylaxis, reducing mother-to-child transmission<1%. We aimed to investigate the implementation of the mandatory documentation of counseling and optional HIV testing in the maternity records as recommended in the German maternity guidelines. METHODS In the Obstetric Department of the University Hospital Bonn, maternity records were reviewed from June to October 2020, and pregnant women were interviewed regarding the patients' recall of counseling and HIV testing as well as their attitude towards a universal screening strategy using an anonymous questionnaire. RESULTS Documentation was incomplete in 11% of maternal records: in 8% there was neither documentation of counseling nor of HIV testing, in 3% documentation of counseling only. In 291 questionnaires 47% of pregnant women could not recall counselling. 90% of pregnant women were in favor of universal HIV testing in pregnancy, 9% were undecided, and 1% opposed it. 55% would support change from an "opt-in" to an "opt-out" screening policy in pregnancy. SUMMARY Documentation of counseling and HIV testing was incomplete in 11% of cases, and nearly half of the women could not recall counselling. New strategies from midwives and obstetricians need to be developed to achieve universal HIV testing in pregnant women leading to zero HIV mother-to-child transmissions.
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Affiliation(s)
- Laila Cravat
- Abteilung für Geburtshilfe und Pränatale Medizin, Zentrum für Frauenheilkunde, Bonn, Deutschland.,Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Waltraut M Merz
- Abteilung für Geburtshilfe und Pränatale Medizin, Zentrum für Frauenheilkunde, Bonn, Deutschland
| | - Kathrin van Bremen
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn, Bonn, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Köln-Bonn, Deutschland
| | - Juergen K Rockstroh
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn, Bonn, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Köln-Bonn, Deutschland
| | - Jan-Christian Wasmuth
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn, Bonn, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Köln-Bonn, Deutschland
| | - Christoph Boesecke
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn, Bonn, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Köln-Bonn, Deutschland
| | - Annette Haberl
- HIV-Center, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Zentrum der Inneren Medizin, Frankfurt am Main, Deutschland
| | - Carolynne Schwarze-Zander
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn, Bonn, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Köln-Bonn, Deutschland
| | - Brigitte Strizek
- Abteilung für Geburtshilfe und Pränatale Medizin, Zentrum für Frauenheilkunde, Bonn, Deutschland
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Birth Defects After Exposure to Efavirenz-Based Antiretroviral Therapy at Conception/First Trimester of Pregnancy: A Multicohort Analysis. J Acquir Immune Defic Syndr 2019; 80:316-324. [PMID: 30570524 DOI: 10.1097/qai.0000000000001922] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To investigate the association between efavirenz (EFV) use during conception or first trimester (T1) of pregnancy and the occurrence of birth defects. SETTING Seven observational studies of pregnant HIV-positive women across 13 European countries and Thailand. METHODS Individual-level data were pooled on singleton pregnancies included in participating cohorts in 2002-2015. Birth defects were coded according to ICD-10 and the EUROCAT classification. We performed mixed-effects logistic regression models to assess the association between EFV exposure in utero and likelihood of birth defects. RESULTS We included 24,963 live births from 21,093 women. At conception, 30.2% (7537) women were on a non-EFV-based regimen, 4.8% (1200) on EFV, and 65% (16,226) were unexposed to antiretroviral therapy (ART). There were 412 infants with ≥1 birth defect, a prevalence of 1.65% (95% confidence interval: 1.50 to 1.82). Limb/musculoskeletal and congenital heart defects were the most common defects reported. Birth defects were present in 2.4%, 1.6%, and 1.3% of infants exposed to non-EFV, EFV, and unexposed to ART during conception/T1 (P = 0.135), respectively. The association between exposure to ART during conception/T1 and birth defects remained nonsignificant in adjusted analyses, as did exposure to EFV versus non-EFV (adjusted odds ratio 0.61; 95% confidence interval: 0.36 to 1.03, P = 0.067). Among the 21 birth defects in 19 infants on EFV, no neural tube defects were reported. CONCLUSIONS Prevalence of birth defects after exposure to EFV-based compared with non-EFV-based ART in conception/T1 was not statistically different in this multicohort study, and even lower. EFV is at least as safe as other ART drugs currently recommended for antenatal use.
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Moseholm E, Fetters MD, Aho I, Mellgren Å, Johansen IS, Storgaard M, Pedersen G, Katzenstein TL, Weis N. Study protocol: becoming and being a mother living with HIV - a multicentre longitudinal mixed methods study among pregnant women living with HIV, non-pregnant women living with HIV and pregnant women not living with HIV in a high-income setting (the 2B MOM study). BMJ Open 2019; 9:e027761. [PMID: 31619417 PMCID: PMC6797316 DOI: 10.1136/bmjopen-2018-027761] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The success of combination antiretroviral therapy has decreased the risk of perinatal HIV transmission and normalised pregnancy in women living with HIV (WLWH). Despite these advances, WLWH still face complex medical and psychosocial issues during pregnancy and postpartum, and there is a gap of knowledge on the experiences of becoming and being a mother living with HIV in today's context. The overall aim of this study is to investigate psychosocial outcomes and experiences of WLWH in Scandinavia during pregnancy and early motherhood. METHODS AND ANALYSIS This is a multicentre longitudinal convergent mixed methods study consisting of a quantitative survey study, a qualitative interview study and a mixed methods analysis. The survey study aims to examine psychosocial outcomes of WLWH across the pregnancy - postpartum trajectory. Participants are pregnant WLWH living in Scandinavia. Two control groups of HIV-negative pregnant women and non-pregnant WLWH are also included. Data is collected in the third trimester, 3 and 6 months postpartum using standardised questionnaires. Statistical analysis will assess changes over time and identify predictors of adverse outcomes. The interview study seeks to understand experiences of pregnancy and becoming a mother while living with HIV. Pregnant WLWH who are enrolled in the survey study will be asked to participate in individual interviews in the third trimester and 6 months postpartum. Data will be analysed using narrative analysis. The survey and interview results will be merged in a mixed methods analysis to assess confirmation, expansion or discordance between the data sets. ETHICS AND DISSEMINATION Approval from the Danish Data Protection Agency (VD-2018-253), and the Finnish and Swedish Ethics Committees have been obtained (HUS/1330/2019 and Dnr: 2019-04451, respectively). Study results will be disseminated to patient organisations, through publications in peer-reviewed journals and at scientific conferences.
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Affiliation(s)
- Ellen Moseholm
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
| | - Micheal D Fetters
- Mixed Methods Program and Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Inka Aho
- Department of Infectious Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Åsa Mellgren
- Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Isik S Johansen
- Department of Infectious Diseases, Odense Universitetshospital, Odense, Denmark
| | - Merete Storgaard
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Gitte Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Terese L Katzenstein
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nina Weis
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Vaginal delivery in women with HIV in Italy: results of 5 years of implementation of the national SIGO-HIV protocol. Infection 2019; 47:981-990. [PMID: 31286456 DOI: 10.1007/s15010-019-01336-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the maternal and neonatal safety of vaginal delivery in women with HIV following the implementation of a national protocol in Italy. METHODS Vaginal delivery was offered to all eligible women who presented antenatally at twelve participating clinical sites. Data collection and definition of outcomes followed the procedures of the National Program on Surveillance on Antiretroviral Treatment in Pregnancy. Pregnancy outcomes were compared according to the mode of delivery, classified as vaginal, elective cesarean (ECS) and non-elective cesarean section (NECS). RESULTS Among 580 women who delivered between January 2012 and September 2017, 142 (24.5%) had a vaginal delivery, 323 (55.7%) had an ECS and 115 (19.8%) had an NECS. The proportion of vaginal deliveries increased significantly over time, from 18.9% in 2012 to 35.3% in 2017 (p < 0.001). Women who delivered vaginally were younger, more commonly nulliparous, diagnosed with HIV during current pregnancy, and antiretroviral-naïve, but had a slightly longer duration of pregnancy, with significantly higher birthweight of newborns. NECS was associated with adverse pregnancy outcomes. The rate of HIV transmission was minimal (0.4%). There were no differences between vaginal and ECS about delivery complications, while NECS was more commonly associated with complications compared to ECS. CONCLUSIONS Vaginal delivery in HIV-infected women with suppressed viral load appears to be safe for mother and children. No cases of HIV transmission were observed. Despite an ongoing significant increase, the rate of vaginal delivery remains relatively low compared to other countries, and further progress is needed to promote this mode of delivery in clinical practice.
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Favarato G, Bailey H, Burns F, Prieto L, Soriano-Arandes A, Thorne C. Migrant women living with HIV in Europe: are they facing inequalities in the prevention of mother-to-child-transmission of HIV?: The European Pregnancy and Paediatric HIV Cohort Collaboration (EPPICC) study group in EuroCoord. Eur J Public Health 2019; 28:55-60. [PMID: 28449111 DOI: 10.1093/eurpub/ckx048] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background In pregnancy early interventions are recommended for prevention of mother-to-child-transmission (PMTCT) of HIV. We examined whether pregnant women who live with HIV in Europe and are migrants encounter barriers in accessing HIV testing and care. Methods Four cohorts within the European Pregnancy and Paediatric HIV Cohort Collaboration provided data for pooled analysis of 11 795 pregnant women who delivered in 2002-12 across ten European countries. We defined a migrant as a woman delivering in a country different from her country of birth and grouped the countries into seven world regions. We compared three suboptimal PMTCT interventions (HIV diagnosis in late pregnancy in women undiagnosed at conception, late anti-retroviral therapy (ART) start in women diagnosed but untreated at conception and detectable viral load (VL) at delivery in women on antenatal ART) in native and migrant women using multivariable logistic regression models. Results Data included 9421 (79.9%) migrant women, mainly from sub-Saharan Africa (SSA); 4134 migrant women were diagnosed in the current pregnancy, often (48.6%) presenting with CD4 count <350 cells/µl. Being a migrant was associated with HIV diagnosis in late pregnancy [OR for SSA vs. native women, 2.12 (95% CI 1.67, 2.69)] but not with late ART start if diagnosed but not on ART at conception, or with detectable VL at delivery once on ART. Conclusions Migrant women were more likely to be diagnosed in late pregnancy but once on ART virological response was good. Good access to antenatal care enables the implementation of PMTCT protocols and optimises both maternal and children health outcomes generally.
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Affiliation(s)
- G Favarato
- Faculty of Population Health Sciences, UCL, UCL Great Ormond Street Institute of Child Health, London, UK
| | - H Bailey
- Faculty of Population Health Sciences, UCL, UCL Great Ormond Street Institute of Child Health, London, UK
| | - F Burns
- Research Department of Infection and Population Health, UCL, London, UK.,Royal Free London NHS Foundation Trust, London, UK
| | - L Prieto
- Department of Paediatrics, Hospital Universitario de Getafe, Madrid, Spain
| | - A Soriano-Arandes
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - C Thorne
- Faculty of Population Health Sciences, UCL, UCL Great Ormond Street Institute of Child Health, London, UK
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Machekano R, Tiam A, Kassaye S, Tukei V, Gill M, Mohai F, Nchepe M, Mokone M, Barasa J, Mohale S, Letsie M, Guay L. HIV incidence among pregnant and postpartum women in a high prevalence setting. PLoS One 2018; 13:e0209782. [PMID: 30592749 PMCID: PMC6310250 DOI: 10.1371/journal.pone.0209782] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/11/2018] [Indexed: 12/14/2022] Open
Abstract
In sub-Saharan Africa, most women who test HIV negative at the first antenatal care encounter are rarely tested again during pregnancy and postpartum, yet data suggests that pregnancy is associated with increased risk of HIV acquisition compared to non-pregnant women. We describe HIV incidence during pregnancy and postpartum in Lesotho, a high prevalence setting, and factors associated with HIV seroconversion. We enrolled a cohort of HIV negative women presenting at health facilities for antenatal care and followed them through delivery up to 24 months postpartum. Women were repeatedly tested for HIV according to the Lesotho Ministry of Health routine rapid HIV testing guidelines and responded to risk behavior questionnaire every three months. We estimated HIV incidence and associated 95% confidence intervals. We used mixed effects Cox regression models to identify independent factors associated with seroconversion accounting for repeated assessment. The estimated overall HIV incidence rate was 1.58 (95% CI: 1.05-2.28) per 100 person- years. The estimated HIV incidence rate during pregnancy (2.61 per 100 person-years, 95% CI: 1.12-5.14) was almost double the estimated HIV incidence during postpartum (1.36 per 100 person-years, 95% CI: 0.83-2.10). Women's age (14-24 years compared to 25-45 years), multiple sexual partnerships, urethral discharge and no condoms nor pre-exposure prophylaxis were independently associated with HIV infection. There is an increased need for counseling and support of HIV-uninfected pregnant and breastfeeding women to stay HIV-negative, including provision of pre-exposure prophylaxis during this high-risk period, particularly among adolescent and young women.
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Affiliation(s)
- Rhoderick Machekano
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
| | - Appolinaire Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- University of Bergen, Bergen, Norway
| | - Seble Kassaye
- Georgetown University, Washington, DC, United States of America
| | - Vincent Tukei
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Michelle Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
| | - Florence Mohai
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | | | | | - Janet Barasa
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Sesomo Mohale
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | | | - Laura Guay
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- George Washington University, Washington, DC, United States of America
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Waitt C, Low N, Van de Perre P, Lyons F, Loutfy M, Aebi-Popp K. Does U=U for breastfeeding mothers and infants? Breastfeeding by mothers on effective treatment for HIV infection in high-income settings. Lancet HIV 2018; 5:e531-e536. [PMID: 29960731 DOI: 10.1016/s2352-3018(18)30098-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 12/01/2022]
Abstract
Can the campaign Undetectable=Untransmittable (U=U), established for the sexual transmission of HIV, be applied to the transmission of HIV through breastfeeding? European AIDS Clinical Society and, to some extent, American guidelines now state that mothers with HIV who wish to breastfeed should be supported, with increased clinical and virological monitoring. This Viewpoint summarises existing evidence on transmission of HIV through breastfeeding, differences in HIV dynamics and viral load between breastmilk and plasma, and the effects of antiretroviral therapy on infants. At present, insufficient evidence exists to make clear recommendations for the required frequency of clinical and virological monitoring for mother and infant in a breastfeeding relationship or for the action to be taken in the event of viral rebound. We propose a roadmap for collaborative research to provide the missing evidence required to enable mothers who wish to breastfeed to make a fully informed choice.
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Affiliation(s)
- Catriona Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK; Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda; Royal Liverpool University Hospital, Liverpool, UK.
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Philippe Van de Perre
- Pathogenesis and Control of Chronic Infections, INSERM, University of Montpellier, Etablissement Français du Sang, CHU Montpellier, Montpellier, France
| | - Fiona Lyons
- Department of Genitourinary Medicine and Infectious Diseases, St James's Hospital, Dublin, Ireland
| | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karoline Aebi-Popp
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
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Aho I, Kaijomaa M, Kivelä P, Surcel HM, Sutinen J, Heikinheimo O. Most women living with HIV can deliver vaginally-National data from Finland 1993-2013. PLoS One 2018; 13:e0194370. [PMID: 29566017 PMCID: PMC5864005 DOI: 10.1371/journal.pone.0194370] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 03/01/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Vaginal delivery has been recommended for more than ten years for women living with HIV (WLWH) with good virological control. However, in Europe most WLWH still deliver by cesarean section (CS). Our aim was to assess the rate of vaginal delivery and the indications for CS in WLWH over 20 years in a setting of low overall CS rate. Materials and methods This was a retrospective study of all WLWH delivering in Finland 1993–2013. We identified the women by combining national health registers and extracted data from patient files. Results The study comprised 212 women with 290 deliveries. Over 35% of the women delivered several children during the study years. During 2000–2013, with consistent viral load monitoring, 80.0% showed HIV viral loads <50 copies/mL in the last measurement preceding the delivery. Altogether 74.5% of all WLWH delivered vaginally and the rate of both elective CS and emergency CS was 12.8% each. For most CSs (63.5%) the indication was obstetrical, for 28.4% it was avoiding HIV transmission and for 0.7% it was mother’s request. In hospitals with less than ten HIV-related deliveries during the study period, the rate of elective CS was higher than in more experienced hospitals (22.7% versus 10.6% [p = 0.024]). No perinatal HIV transmissions occurred. Conclusions Most WLWH can achieve good virological control and deliver vaginally. This will help them to maintain their future child bearing potential and reduce CS-related morbidity.
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Affiliation(s)
- Inka Aho
- Department of Infectious diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- * E-mail:
| | - Marja Kaijomaa
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pia Kivelä
- Department of Infectious diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Heljä-Marja Surcel
- National Institute of Health and Welfare, Oulu and Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Jussi Sutinen
- Department of Infectious diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Jiménez de Ory S, González-Tomé MI, Fortuny C, Mellado MJ, Soler-Palacin P, Bustillo M, Ramos JT, Muñoz-Fernández MA, Navarro ML. New diagnoses of human immunodeficiency virus infection in the Spanish pediatric HIV Cohort (CoRISpe) from 2004 to 2013. Medicine (Baltimore) 2017; 96:e7858. [PMID: 28953612 PMCID: PMC5626255 DOI: 10.1097/md.0000000000007858] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Vertical human immunodeficiency virus (HIV) infection has decreased in industrialized countries in recent decades, but there are no studies on the mechanisms of HIV transmission among infected children in Spain. Our aim was to study the characteristics and trends of diagnoses of vertically HIV-infected children in Spain from 2004 to 2013.Vertically HIV-infected children were selected if they were diagnosed from 2004 to 2013, were aged 0 to 18 years old, and were included in the Cohort of the Spanish Pediatric HIV Network (CoRISpe). Demographic, clinical, immunological, and virological data at diagnosis were obtained. The rate of diagnoses of vertically HIV-infected children was calculated as the number of cases per 100,000 inhabitants. Obstetric data of mothers of Spanish children and prophylaxis at childbirth and postpartum were obtained.A total of 218 HIV-infected children were included in the study. Of this sample, 182 children (83.5%) were perinatally HIV infected, and 125 out of those 182 children (68.7%) were born in Spain. The vertically HIV-infected Spanish children were diagnosed earlier and were in better clinical and immunological condition at diagnosis than were foreign children. The rate of vertically HIV-infected children declined from 0.09 in 2004 to 0.03 in 2013 due to the decrease in the rate of children born in Spain (0.08 in 2004 vs 0.01 in 2013). A total of 60 out of 107 mothers (56.1%) of Spanish children were diagnosed at or after childbirth. However, this number declined between 2004 and 2013.The rate of new HIV diagnoses of vertically HIV-infected children decreased significantly between 2004 and 2013 from 0.09 to 0.03 per 100,000 inhabitants.
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Affiliation(s)
- Santiago Jiménez de Ory
- Sección Inmunología, Laboratorio InmunoBiología Molecular, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón
- Spanish Human Immunodeficiency Virus Hospital Gregorio Marañón BioBank (Spanish HIV HGM BioBank)
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN)
- Servicio de Pediatría, Hospital Clínico San Carlos
| | - María Isabel González-Tomé
- Servicio de Infecciosas Pediátricas, Hospital Universitario Doce de Octubre, Instituto de Investigación Hospital 12 de Octubre
| | - Claudia Fortuny
- Unidad de Enfermedades Infecciosas, Servicio de Pediatría, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues del Llobregat, Barcelona
| | - Maria Jose Mellado
- Servicio de Pediatría Hospitalaria y Enfermedades Infecciosas y Tropicales Pediátricas, Hospital Universitario Infantil La Paz and Hospital Carlos III
| | - Pere Soler-Palacin
- Unitat de Patologia Infecciosa i Immunodeficiències de Pediatria, Hospital Universitari Vall d’Hebron, Institut de Recerca Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona
| | - Matilde Bustillo
- Servicio de Pediatría, Unidad Infectología, Hospital Infantil Universitario Miguel Servet, Zaragoza
| | | | - Maria Angeles Muñoz-Fernández
- Sección Inmunología, Laboratorio InmunoBiología Molecular, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón
- Spanish Human Immunodeficiency Virus Hospital Gregorio Marañón BioBank (Spanish HIV HGM BioBank)
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN)
| | - Maria Luisa Navarro
- Sección de Enfermedades Infecciosas, Servicio de Pediatría, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
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Abstract
Supplemental Digital Content is available in the text Objective and design: To inform WHO guidelines, we conducted a systematic review and meta-analysis to assess maternal and perinatal outcomes comparing cesarean section (c-section) before labor and rupture of membranes [elective c-section (ECS)] with other modes of delivery for women living with HIV. Methods: We searched PubMed, CINAHL, Embase, CENTRAL, and previous reviews to identify published trials and observational studies through October 2015. Results were synthesized using random-effects meta-analysis, stratifying for combination antiretroviral therapy (cART), CD4+/viral load (VL), delivery at term, and low-income/middle-income countries. Results: From 2567 citations identified, 36 articles met inclusion criteria. The single randomized trial, published in 1999, reported minimal maternal morbidity and significantly fewer infant HIV infections with ECS [odds ratio (OR) 0.2, 95% confidence interval (CI) 0.0–0.5]. Across observational studies, ECS was associated with increased maternal morbidity compared with vaginal delivery (OR 3.12, 95% CI 2.21–4.41). ECS was also associated with decreased infant HIV infection overall (OR 0.43, 95% CI 0.30–0.63) and in low-income/middle-income countries (OR 0.27, 95% CI 0.16–0.45), but not among women on cART (OR 0.82, 95% CI 0.47–1.43) or with CD4+ cell count more than 200/VL less than 400/term delivery (OR 0.59, 95% CI 0.21–1.63). Infant morbidity moderately increased with ECS. Conclusion: Although ECS may reduce infant HIV infection, this effect was not statistically significant in the context of cART and viral suppression. As ECS poses other risks, routine ECS for all women living with HIV may not be appropriate. Risks and benefits will differ across settings, depending on underlying risks of ECS complications and vertical transmission during delivery. Understanding individual client risks and benefits and respecting women's autonomy remain important.
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Pregnancy and neonatal outcomes among a cohort of HIV-infected women in a large Italian teaching hospital: a 30-year retrospective study. Epidemiol Infect 2017; 145:1658-1669. [PMID: 28325171 DOI: 10.1017/s095026881700053x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The primary study objective was to investigate three decades from 1985 to 2014 of changes in pregnancies among HIV-infected women. The secondary objective was to assess risk factors associated with preterm delivery and severe small-for-gestational-age (SGA) infants in HIV-infected women. A retrospective review of deliveries among pregnant HIV-infected women at the University of Genoa and IRCCS San Martino-IST in Genoa between 1985 and 2014 was performed. Univariate and multivariable analyses were used to study the variables associated with neonatal outcomes. Overall, 262 deliveries were included in the study. An increase in median age (26 years in 1985-1994 vs. 34 years in 2005-2014), in the proportion of foreigners (none in 1985-1994 vs. 27/70 (38·6%) in 2005-2014), and a decrease in intravenous drug use (75·2% (91/121) in 1985-1994 vs. 12·9% (9/70) in 2005-2014) among pregnant HIV-infected women was observed. Progressively, HIV infections were diagnosed sooner (prior to pregnancy in 80% (56/70) of women in the last decade). An increase in combined antiretroviral therapy (cART) prescription during pregnancy (50% (27/54) in 1995-2004 vs. 92·2% (59/64) in 2005-2014) and in HIV-RNA <50 copies/ml at delivery (19·2% (5/26) in 1995-2004 vs. 82·3% (53/64) in 2005-2014) was observed. The rate of elective caesarean section from 1985 to 1994 was 9·1%, which increased to 92·3% from 2004 to 2015. Twelve (10·1%) mother-to-child transmissions (MTCT) occurred in the first decade, and six (8·3%) cases occurred in the second decade, the last of which was in 2000. Preterm delivery (<37 weeks gestation) was 5% (6/121) from 1985 to 1994 and increased to 17·1% (12/70) from 2005 to 2014. In univariate and multivariable logistic regression analyses, advancing maternal age and previous pregnancies were associated with preterm delivery (odds ratio (OR) 2·7; 95% confidence intervals (CI) 1-7·8 and OR 2·6; 95% CI 1·1-6·7, respectively). In the logistic regression analysis, use of heroin or methadone was found to be the only risk factor for severe SGA (OR 3·1; 95% CI 1·4-6·8). In conclusion, significant changes in demographic, clinical and therapeutic characteristics of HIV-infected pregnant women have occurred over the last 30 years. Since 2000, MTCT has decreased to zero. An increased risk of preterm delivery was found to be associated with advancing maternal age and previous pregnancies but not with cART. The use of heroin or methadone has been confirmed as a risk factor associated with severe SGA.
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Peters H, Francis K, Harding K, Tookey PA, Thorne C. Operative vaginal delivery and invasive procedures in pregnancy among women living with HIV. Eur J Obstet Gynecol Reprod Biol 2016; 210:295-299. [PMID: 28092853 DOI: 10.1016/j.ejogrb.2016.12.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/12/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To describe the use and outcomes of operative delivery and invasive procedures in pregnancy amongst women living with HIV. STUDY DESIGN The National Study of HIV in Pregnancy and Childhood (NSHPC) is a comprehensive population-based surveillance study in the UK and Ireland. The NSHPC has collected data on operative delivery since 2008, and invasive procedures in pregnancy (amniocentesis, cordocentesis, chorionic villus sampling) from 2012. Descriptive analyses were conducted on 278 pregnancies expected to deliver from 1 January 2008 with outcome reported to the NSHPC by 31 March 2016. RESULTS Among 9372 pregnancies in 2008-2016, there were 9072 livebirths with 251 operative deliveries and 27 invasive procedures in pregnancy reported. Information was available for 3023/3490 vaginal deliveries, and use of forceps or vacuum reported in 251deliveries (8.2%), increasing over calendar time to almost 10% by 2014-16. Forceps were used twice as often as vacuum delivery, and forceps use increased over time. One infant delivered operatively is known to have acquired HIV. From 2012 there were 4063 pregnancies resulting in 3952 livebirths, 83 terminations and 28 stillbirths. 2163/4063 had information on use (or not) of invasive procedures in pregnancy. Amniocentesis was reported in 25/2163 pregnancies, there was one report of chorionic villus sampling and one of cordocentesis. There were no reported transmissions following invasive procedures in pregnancy. CONCLUSIONS This is the largest study to date to report on operative delivery in women living with HIV on combined antiretroviral therapy (cART), and provides an up-to-date picture of invasive procedures during pregnancy in this group. Findings from this comprehensive national study are reassuring but numbers are currently low; on-going monitoring is crucial as obstetric care of women with HIV becomes normalised.
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Affiliation(s)
- Helen Peters
- Population, Policy and Practice Programme, UCL GOS Institute of Child Health, University College London, London, United Kingdom.
| | - Kate Francis
- Population, Policy and Practice Programme, UCL GOS Institute of Child Health, University College London, London, United Kingdom
| | - Kate Harding
- Guys & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Pat A Tookey
- Population, Policy and Practice Programme, UCL GOS Institute of Child Health, University College London, London, United Kingdom
| | - Claire Thorne
- Population, Policy and Practice Programme, UCL GOS Institute of Child Health, University College London, London, United Kingdom.
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Ngo-Giang-Huong N, Wittkop L, Judd A, Reiss P, Goetghebuer T, Duiculescu D, Noguera-Julian A, Marczynska M, Giacquinto C, Ene L, Ramos JT, Cellerai C, Klimkait T, Brichard B, Valerius N, Sabin C, Teira R, Obel N, Stephan C, de Wit S, Thorne C, Gibb D, Schwimmer C, Campbell MA, Pillay D, Lallemant M. Prevalence and effect of pre-treatment drug resistance on the virological response to antiretroviral treatment initiated in HIV-infected children - a EuroCoord-CHAIN-EPPICC joint project. BMC Infect Dis 2016; 16:654. [PMID: 27825316 PMCID: PMC5101717 DOI: 10.1186/s12879-016-1968-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 10/25/2016] [Indexed: 12/14/2022] Open
Abstract
Background Few studies have evaluated the impact of pre-treatment drug resistance (PDR) on response to combination antiretroviral treatment (cART) in children. The objective of this joint EuroCoord-CHAIN-EPPICC/PENTA project was to assess the prevalence of PDR mutations and their association with virological outcome in the first year of cART in children. Methods HIV-infected children <18 years initiating cART between 1998 and 2008 were included if having at least one genotypic resistance test prior to cART initiation. We used the World Health Organization 2009 resistance mutation list and Stanford algorithm to infer resistance to prescribed drugs. Time to virological failure (VF) was defined as the first of two consecutive HIV-RNA > 500 copies/mL after 6 months cART and was assessed by Cox proportional hazards models. All models were adjusted for baseline demographic, clinical, immunology and virology characteristics and calendar period of cART start and initial cART regimen. Results Of 476 children, 88 % were vertically infected. At cART initiation, median (interquartile range) age was 6.6 years (2.1–10.1), CD4 cell count 297 cells/mm3 (98–639), and HIV-RNA 5.2 log10copies/mL (4.7–5.7). Of 37 children (7.8 %, 95 % confidence interval (CI), 5.5–10.6) harboring a virus with ≥1 PDR mutations, 30 children had a virus resistant to ≥1 of the prescribed drugs. Overall, the cumulative Kaplan-Meier estimate for virological failure was 19.8 % (95 %CI, 16.4–23.9). Cumulative risk for VF tended to be higher among children harboring a virus with PDR and resistant to ≥1 drug prescribed than among those receiving fully active cART: 32.1 % (17.2–54.8) versus 19.4 % (15.9–23.6) (P = 0.095). In multivariable analysis, age was associated with a higher risk of VF with a 12 % reduced risk per additional year (HR 0.88; 95 %CI, 0.82–0.95; P < 0.001). Conclusions PDR was not significantly associated with a higher risk of VF in children in the first year of cART. The risk of VF decreased by 12 % per additional year at treatment initiation which may be due to fading of PDR mutations over time. Lack of appropriate formulations, in particular for the younger age group, may be an important determinant of virological failure. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1968-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicole Ngo-Giang-Huong
- IRD UMI 174 - PHPT-Faculty of Associated Medical Sciences, Chiang Mai University, 110, Intrawarorot Road, Sripoom, Muang, Chiang Mai, 50200, Thailand. .,Harvard T.H. Chan School of Public Health, Boston, USA.
| | - Linda Wittkop
- Univ. Bordeaux, ISPED; INSERM, Centre INSERM U1219; CHU de Bordeaux, Pole de Sante Publique, F-33000, Bordeaux, France
| | - Ali Judd
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Peter Reiss
- Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Dan Duiculescu
- "Dr. Victor Babes" Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | | | | | | | - Luminita Ene
- "Dr. Victor Babes" Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | | | | | | | | | - Niels Valerius
- Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Niels Obel
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Claire Thorne
- University College London, Institute of Child Health, London, UK
| | - Diana Gibb
- Medical Research Council Clinical Trials Unit, London, UK
| | | | | | | | - Marc Lallemant
- IRD UMI 174 - PHPT-Faculty of Associated Medical Sciences, Chiang Mai University, 110, Intrawarorot Road, Sripoom, Muang, Chiang Mai, 50200, Thailand
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Aebi-Popp K, Kouyos R, Bertisch B, Staehelin C, Rudin C, Hoesli I, Stoeckle M, Bernasconi E, Cavassini M, Grawe C, Lecompte TD, Rickenbach M, Thorne C, Martinez de Tejada B, Fehr J. Postnatal retention in HIV care: insight from the Swiss HIV Cohort Study over a 15-year observational period. HIV Med 2015; 17:280-8. [PMID: 26268702 DOI: 10.1111/hiv.12299] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this study was to quantify loss to follow-up (LTFU) in HIV care after delivery and to identify risk factors for LTFU, and implications for HIV disease progression and subsequent pregnancies. METHODS We used data on pregnancies within the Swiss HIV Cohort Study from 1996 to 2011. A delayed clinical visit was defined as > 180 days and LTFU as no visit for > 365 days after delivery. Logistic regression analysis was used to identify risk factors for LTFU. RESULTS A total of 695 pregnancies in 580 women were included in the study, of which 115 (17%) were subsequent pregnancies. Median maternal age was 32 years (IQR 28-36 years) and 104 (15%) women reported any history of injecting drug use (IDU). Overall, 233 of 695 (34%) women had a delayed visit in the year after delivery and 84 (12%) women were lost to follow-up. Being lost to follow-up was significantly associated with a history of IDU [adjusted odds ratio (aOR) 2.79; 95% confidence interval (CI) 1.32-5.88; P = 0.007] and not achieving an undetectable HIV viral load (VL) at delivery (aOR 2.42; 95% CI 1.21-4.85; P = 0.017) after adjusting for maternal age, ethnicity and being on antiretroviral therapy (ART) at conception. Forty-three of 84 (55%) women returned to care after LTFU. Half of them (20 of 41) with available CD4 had a CD4 count < 350 cells/μL and 15% (six of 41) a CD4 count < 200 cells/μL at their return. CONCLUSIONS A history of IDU and detectable HIV VL at delivery were associated with LTFU. Effective strategies are warranted to retain women in care beyond pregnancy and to avoid CD4 cell count decline. ART continuation should be advised especially if a subsequent pregnancy is planned.
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Affiliation(s)
- K Aebi-Popp
- Division of Infectious Diseases, University Hospital Bern, Bern, Switzerland
| | - R Kouyos
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - B Bertisch
- Division of Infectious Diseases, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - C Staehelin
- Division of Infectious Diseases, University Hospital Bern, Bern, Switzerland
| | - C Rudin
- University Children's Hospital Basel, Basel, Switzerland
| | - I Hoesli
- University Women's Hospital Basel, Basel, Switzerland
| | - M Stoeckle
- Division of Infectious Diseases, University Hospital Basel, Basel, Switzerland
| | - E Bernasconi
- Division of Infectious Diseases, Regional Hospital, Lugano, Switzerland
| | - M Cavassini
- Division of Infectious Diseases, University Hospital Lausanne, Lausanne, Switzerland
| | - C Grawe
- University Women's Hospital Zurich, Zurich, Switzerland
| | - T D Lecompte
- Division of Infectious Diseases, University Hospital Geneva, Geneva, Switzerland
| | - M Rickenbach
- Data Centre of the Swiss HIV Cohort Study, Institute for Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland
| | - C Thorne
- Population, Policy and Practice Programme, UCL Institute of Child Health, University College London, London, UK
| | - B Martinez de Tejada
- Department of Obstetrics and Gynaecology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - J Fehr
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Baroncelli S, Pirillo MF, Tamburrini E, Guaraldi G, Pinnetti C, Degli Antoni A, Galluzzo CM, Stentarelli C, Amici R, Floridia M. Full Viral Suppression, Low-Level Viremia, and Quantifiable Plasma HIV-RNA at the End of Pregnancy in HIV-Infected Women on Antiretroviral Treatment. AIDS Res Hum Retroviruses 2015; 31:673-8. [PMID: 25769019 DOI: 10.1089/aid.2014.0288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is limited information on full viral suppression and low-level HIV-RNA viremia in HIV-infected women at the end of pregnancy. We investigated HIV-RNA levels close to delivery in women on antiretroviral treatment in order to define rates of complete suppression, low-level viremia, and quantifiable HIV-RNA, exploring as potential determinants some clinical and viroimmunological variables. Plasma samples from a national study in Italy, collected between 2003 and 2012, were used. According to plasma HIV-RNA levels, three groups were defined: full suppression (target not detected), low-level viremia (target detected but <37 copies/ml), and quantifiable HIV-RNA (≥37 copies/ml). Multivariable logistic regression was used to define determinants of full viral suppression and of quantifiable HIV-RNA. Among 107 women evaluated at a median gestational age of 35 weeks, 90 (84.1%) had HIV-RNA <37 copies/ml. Most of them (59/90, 65.6%) had full suppression, with the remaining (31/90, 34.4%) showing low-level viremia (median: 11.9 copies/ml; IQR 7.4-16.3). Among the 17 women with quantifiable viral load, median HIV-RNA was 109 copies/ml (IQR 46-251), with only one case showing resistance (mutation M184V; rate: 9.1%). In multivariable analyses, women with higher baseline HIV-RNA levels and with hepatitis C virus (HCV) coinfection were significantly more likely to have quantifiable HIV-RNA in late pregnancy. Full viral suppression was significantly more likely with nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimens and significantly less likely with higher HIV-RNA in early pregnancy. No cases of HIV transmission occurred. In conclusion, HIV-infected pregnant women showed a high rate of viral suppression and a low resistance rate before delivery. In most cases no target HIV-RNA was detected in plasma, suggesting a low risk of subsequent virological rebound and development of resistance. Women with high levels of HIV-RNA in early pregnancy and those who have concomitant HCV infection should be considered at higher risk of having quantifiable HIV-RNA at the end of pregnancy.
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Affiliation(s)
- Silvia Baroncelli
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Maria F. Pirillo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | | | - Giovanni Guaraldi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Anna Degli Antoni
- Department of Infectious Diseases and Hepatology, Azienda Ospedaliera, Parma, Italy
| | - Clementina M. Galluzzo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Chiara Stentarelli
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberta Amici
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Marco Floridia
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
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Hurst SA, Appelgren KE, Kourtis AP. Prevention of mother-to-child transmission of HIV type 1: the role of neonatal and infant prophylaxis. Expert Rev Anti Infect Ther 2015; 13:169-81. [PMID: 25578882 PMCID: PMC4470389 DOI: 10.1586/14787210.2015.999667] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The prevention of mother-to-child transmission (PMTCT) of HIV is one of the great public health successes of the past 20 years. Much concerted research efforts and dedicated work have led to the achievement of very low rates of PMTCT of HIV in settings that can implement optimal prophylaxis. Though several implementation challenges remain, global elimination of pediatric HIV infection seems now more than ever to be an attainable goal. Often overlooked, the role of prophylaxis of the newborn is nevertheless a very important component of PMTCT. In this paper, we focus on the role of neonatal and infant prophylaxis, discuss mechanisms of protection, and present the clinical trial-generated evidence that led to the current recommendations for preventing infections in breastfed and non-breastfed infants. PMTCT of HIV should not end at birth; a continuum of care extending postpartum and postnatally is required to minimize the risk of new pediatric HIV infections.
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Affiliation(s)
- Stacey A. Hurst
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Kristie E. Appelgren
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Athena P. Kourtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
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Abstract
OBJECTIVES To analyze mother-to-child HIV transmission (MTCT) rates over time in light of changes in management, demographic, and pregnancy characteristics. DESIGN Population-based surveillance data on diagnosed HIV-positive women and their infants are routinely collected in the UK and Ireland. METHODS A total of 12486 singleton pregnancies delivered in 2000-2011 were analyzed. HIV infection status was available for 11515 infants (92.2%). RESULTS The rate of MTCT declined from 2.1% (17/816) in 2000-2001 to 0.46% (nine of 1975, 95% confidence interval: 0.21-0.86%) in 2010-2011 (trend, P=0.01), because of a combination of factors including earlier initiation of antenatal combination antiretroviral therapy (cART). Excluding 63 infants who were breastfed or acquired HIV postnatally, MTCT risk was significantly higher for all modes of delivery in women with viral load of 50-399 copies/ml (1.0%, 14/1349), compared with viral load of less than 50 copies/ml (0.09%, six of 6347, P<0.001). Among the former (viral load 50-399 copies/ml), the risk of MTCT was 0.26% (two of 777) following elective cesarean section and 1.1% (two of 188) following planned vaginal delivery (P=0.17), excluding in-utero transmissions. MTCT probability declined rapidly with each additional week of treatment initially, followed by a slower decline up to about 15 weeks of cART, with substantial differences by baseline viral load. CONCLUSION MTCT rates in the UK and Ireland have continued to decline since 2006, reaching an all-time low of 5 per 1000 in 2010-2011. This was primarily because of a reduction in transmissions associated with late initiation or nonreceipt of antenatal cART, and an increase in the proportion of women on cART at conception.
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Abstract
Pregnant women are particularly susceptible to a number of infectious diseases, such as influenza, hepatitis E, malaria, and tuberculosis. The management of many other infections-including urinary tract infections, human immunodeficiency virus, and sexually transmitted diseases-is also made more complex by pregnancy; even if some infections do not pose a great risk to the expectant mother, they can impact fetal and neonatal development, thus posing a treatment challenge to physicians. By focusing on the most important diseases that physicians may encounter in pregnant patients, this review outlines the challenges associated with managing important infectious diseases in the pregnant population and references the most recent evidence and international treatment guidelines.
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Affiliation(s)
- Hugh Adler
- Mater Misericordiae University Hospital, Dublin, Ireland
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22
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Abstract
The goal of antiretroviral therapy for the prevention of mother-to-child transmission (PMTCT) of HIV is to achieve maximal suppression of maternal viral load with minimal maternal, fetal and infant toxicity during pregnancy, delivery and postpartum. In addition to the efficacy and toxicity of antiretroviral therapy, the consideration of HIV resistance in mothers and infected newborns further complicates therapeutic choices for PMTCT. This manuscript summarizes current approaches to PMTC in diverse international settings.
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Affiliation(s)
- Natella Y Rakhmanina
- Division of Infectious Disease, Washington, DC, USA; Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA; Elisabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA; Department of Pediatrics, the George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Johannes N van den Anker
- Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA; Department of Pediatrics, the George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Department of Pharmacology and Physiology, the George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Intensive Care, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Paediatric Pharmacology, University Children's Hospital Basel, Switzerland
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Gupta S, Gupta R, Singh S. Seroprevalence of HIV in pregnant women in North India: a tertiary care hospital based study. BMC Infect Dis 2007; 7:133. [PMID: 18005436 PMCID: PMC2198915 DOI: 10.1186/1471-2334-7-133] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 11/15/2007] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Estimating the seroprevalence of HIV in a low risk population such as pregnant women provides essential information for an effective implementation of AIDS control programmes, and also for the monitoring of HIV spread within a country. Very few studies are available from north India showing the current trend in HIV prevalence in the antenatal population;which led us to carry outthis study at a tertiary care hospital in north India METHODS Blood samples from pregnant women attending antenatal clinics at the All India Institute of Medical Sciences, New Delhi were collected after informed consent and pre-test counseling. The samples were tested for HIV antibodies as per the WHO guidelines, over a period of four years from January 2003 to December 2006. RESULTS Of the 3529 pregnant women tested in four years, 0.88% (CI 0.5 - 1.24) women were found to be HIV seroreactive. Majority of the seroreactive pregnant women (41.9%) were in the age group of 20-24 years followed by the 30-34 yrs (25.8%) and 25-29 years (22.6%) age group. The mean age of the HIV positive women was 24.9 years (SD +/- 1.49 yrs). The HIV seroprevalence rates showed an increasing trend from 0.7% (CI 0.14 - 2.04) in 2003-2004 to 0.9% (CI 0.49 - 1.5) in 2005-2006. This prevalence rate indicates concern, as Delhi and its adjoining states are otherwise considered as 'low prevalence states'. CONCLUSION Seroprevalence of HIV infection was found to be increasing in the last four years amongst pregnant women of North India. These findings are in contrast to the national projections.
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Affiliation(s)
- Swati Gupta
- Division of Clinical Microbiology, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi-110029. India
| | - Richa Gupta
- Division of Clinical Microbiology, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi-110029. India
| | - Sarman Singh
- Division of Clinical Microbiology, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi-110029. India
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