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Navér L, Albert J, Carlander C, Gisslén M, Pettersson K, Soeria-Atmadja S, Sönnerborg A, Westling K, Yilmaz A, Pettersson K. Prophylaxis and treatment of HIV infection in pregnancy, Swedish guidelines 2024. Infect Dis (Lond) 2024; 56:657-668. [PMID: 38805265 DOI: 10.1080/23744235.2024.2360029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/21/2024] [Indexed: 05/30/2024] Open
Abstract
In May 2024, the Swedish Reference Group on Antiviral Therapy updated the guidelines on management of HIV infection in pregnancy. The most important recommendations and revisions were: (i) ART during pregnancy should be started as early as possible and continue after delivery; (ii) Suppressive ART should normally not be modified; (iii) The treatment target of HIV RNA <20 copies/ml remains; (iv) Dolutegravir/emtricitabine/tenofovir DF is the first-line drug combination also in pregnant women and women planning pregnancy; (v) There is no evidence of an increased risk of neural tube defects associated with dolutegravir; (vi) Mode of delivery for women with effective ART and HIV RNA <200 copies/ml should follow standard obstetric procedures; (vii) Caesarean section is recommended if HIV RNA ≥200 copies/ml; (viii) Scalp electrode, foetal blood sampling and/or vacuum delivery should be used on strict indications, but does not necessitate intensified infant prophylaxis; (ix) Management and mode of delivery in case of premature or full-term rupture of membranes should follow standard obstetric procedures; (x) Recommended infant antiretroviral prophylaxis has been updated; (xi) The duration of infant antiretroviral prophylaxis (gestational age ≥35 weeks and mother on effective ART and HIV RNA <200 copies/ml) has been changed from 4 to 2 weeks; (xii) Infants born to women with HIV RNA ≥200 copies/ml should receive 4 weeks of combination prophylaxis; (xiii) Fertility evaluation and assisted reproduction should be offered to women on suppressive ART according to the same principles as for other women; (xiv) Women living with HIV should still be advised against breastfeeding; (xv) Women who nevertheless opt to breastfeed should be offered intensified support and follow-up.
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Affiliation(s)
- Lars Navér
- Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Jan Albert
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Christina Carlander
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Gisslén
- Department of Infectious Diseases, University of Göteborg, Göteborg, Sweden
- Department of Infectious, Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Göteborg, Sweden
- Public Health Agency of Sweden, Solna, Sweden
| | - Kristina Pettersson
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Sandra Soeria-Atmadja
- Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Anders Sönnerborg
- Department of Clinical Virology, Karolinska University Hospital, Stockholm, Sweden
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Katarina Westling
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Aylin Yilmaz
- Department of Infectious Diseases, University of Göteborg, Göteborg, Sweden
- Department of Infectious, Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Karin Pettersson
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Yin DE, Palin AC, Lombo TB, Mahon RN, Poon B, Wu DY, Atala A, Brooks KM, Chen S, Coyne CB, D’Souza MP, Fackler OT, Furler O’Brien RL, Garcia-de-Alba C, Jean-Philippe P, Karn J, Majji S, Muotri AR, Ozulumba T, Sakatis MZ, Schlesinger LS, Singh A, Spiegel HM, Struble E, Sung K, Tagle DA, Thacker VV, Tidball AM, Varthakavi V, Vunjak-Novakovic G, Wagar LE, Yeung CK, Ndhlovu LC, Ott M. 3D human tissue models and microphysiological systems for HIV and related comorbidities. Trends Biotechnol 2024; 42:526-543. [PMID: 38071144 PMCID: PMC11065605 DOI: 10.1016/j.tibtech.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 03/03/2024]
Abstract
Three-dimensional (3D) human tissue models/microphysiological systems (e.g., organs-on-chips, organoids, and tissue explants) model HIV and related comorbidities and have potential to address critical questions, including characterization of viral reservoirs, insufficient innate and adaptive immune responses, biomarker discovery and evaluation, medical complexity with comorbidities (e.g., tuberculosis and SARS-CoV-2), and protection and transmission during pregnancy and birth. Composed of multiple primary or stem cell-derived cell types organized in a dedicated 3D space, these systems hold unique promise for better reproducing human physiology, advancing therapeutic development, and bridging the human-animal model translational gap. Here, we discuss the promises and achievements with 3D human tissue models in HIV and comorbidity research, along with remaining barriers with respect to cell biology, virology, immunology, and regulatory issues.
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Goulding AN, Meeks K, Shay L, Casey S, Applegarth C, McKinney J. Antiretroviral Therapy in Pregnancy: A 2023 Review of the Literature. Curr HIV/AIDS Rep 2024; 21:1-10. [PMID: 38277098 PMCID: PMC11095844 DOI: 10.1007/s11904-024-00688-y] [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] [Accepted: 01/04/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE OF REVIEW Selection of antiretroviral therapy during pregnancy must consider maternal physiology and resulting pharmacokinetic changes in pregnancy, resistance and efficacy profiles, tolerability and frequency of adverse effects, teratogenicity, and maternal, neonatal, and pregnancy outcomes. The objective of this review is to summarize the underlying data that informs the current clinical perinatal guidelines in the USA. RECENT FINDINGS Data now supports the use of dolutegravir at all stages of pregnancy with no significant increase in neural tube defects. Safety and pharmacokinetic data on newer antiretroviral medications in pregnancy continue to lag behind the general population. While there are multiple safety and tolerability concerns with older regimens, there are now multiple options of regimens that are highly efficacious and have good safety data in pregnancy. Most pregnant patients who are virally suppressed on a well-tolerated regimen are able to safely continue those medications during pregnancy.
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Affiliation(s)
- Alison N Goulding
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Kasey Meeks
- School of Medicine, Saint Louis University, Saint Louis, MO, USA
| | - Lena Shay
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Sarah Casey
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Colton Applegarth
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jennifer McKinney
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA.
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Prediction of Maternal and Fetal Doravirine Exposure by Integrating Physiologically Based Pharmacokinetic Modeling and Human Placenta Perfusion Experiments. Clin Pharmacokinet 2022; 61:1129-1141. [PMID: 35579825 PMCID: PMC9349081 DOI: 10.1007/s40262-022-01127-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/25/2022]
Abstract
Background and Objective Doravirine is currently not recommended for pregnant women living with human immunodeficiency virus because efficacy and safety data are lacking. This study aimed to predict maternal and fetal doravirine exposure by integrating human placenta perfusion experiments with pregnancy physiologically based pharmacokinetic (PBPK) modeling. Methods Ex vivo placenta perfusions were performed in a closed–closed configuration, in both maternal-to-fetal and fetal-to-maternal directions (n = 8). To derive intrinsic placental transfer parameters from perfusion data, we developed a mechanistic placenta model. Next, we developed a maternal and fetal full-body pregnancy PBPK model for doravirine in Simcyp, which was parameterized with the derived intrinsic placental transfer parameters to predict in vivo maternal and fetal doravirine exposure at 26, 32, and 40 weeks of pregnancy. The predicted total geometric mean (GM) trough plasma concentration (Ctrough) values were compared with the target (0.23 mg/L) derived from in vivo exposure–response analysis. Results A decrease of 55% in maternal doravirine area under the plasma concentration–time curve (AUC)0–24h was predicted in pregnant women at 40 weeks of pregnancy compared with nonpregnant women. At 26, 32, and 40 weeks of pregnancy, predicted maternal total doravirine GM Ctrough values were below the predefined efficacy target of 0.23 mg/L. Perfusion experiments showed that doravirine extensively crossed the placenta, and PBPK modeling predicted considerable fetal doravirine exposure. Conclusion Substantially reduced maternal doravirine exposure was predicted during pregnancy, possibly resulting in impaired efficacy. Therapeutic drug and viral load monitoring are advised for pregnant women treated with doravirine. Considerable fetal doravirine exposure was predicted, highlighting the need for clinical fetal safety data. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-022-01127-0.
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van Hove H, Mathiesen L, Freriksen J, Vähäkangas K, Colbers A, Brownbill P, Greupink R. Placental transfer and vascular effects of pharmaceutical drugs in the human placenta ex vivo: A review. Placenta 2022; 122:29-45. [DOI: 10.1016/j.placenta.2022.03.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/15/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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