HIV-1 disease progression and fertility in Dar es Salaam, Tanzania

Pseudorabies virus inhibits progesterone-induced inactivation of TRPML1 to facilitate viral entry

Viral infection is a significant risk factor for fertility issues. Here, we demonstrated that infection by neurotropic alphaherpesviruses, such as pseudorabies virus (PRV), could impair female fertility by disrupting the hypothalamus-pituitary-ovary axis (HPOA), reducing progesterone (P4) levels, and consequently lowering pregnancy rates. Our study revealed that PRV exploited the transient receptor potential mucolipin 1 (TRPML1) and its lipid activator, phosphatidylinositol 3,5-bisphosphate (PI(3,5)P2), to facilitate viral entry through lysosomal cholesterol and Ca2+. P4 antagonized this process by inducing lysosomal storage disorders and promoting the proteasomal degradation of TRPML1 via murine double minute 2 (MDM2)-mediated polyubiquitination. Overall, the study identifies a novel mechanism by which PRV hijacks the lysosomal pathway to evade P4-mediated antiviral defense and impair female fertility. This mechanism may be common among alphaherpesviruses and could contribute significantly to their impact on female reproductive health, providing new insights for the development of antiviral therapies.

Effect of HIV Infection and Antiretroviral Treatment on Pregnancy Rates in the Western Cape Province of South Africa

BACKGROUND

Previous studies suggest that untreated human immunodeficiency virus (HIV) infection is associated with a reduced incidence of pregnancy, but studies of the effect of antiretroviral treatment (ART) on pregnancy incidence have been inconsistent.

METHODS

Routine data from health services in the Western Cape province of South Africa were linked to identify pregnancies during 2007-2017 and maternal HIV records. The time from the first (index) pregnancy outcome date to the next pregnancy was modeled using Cox proportional hazards models.

RESULTS

During 2007-2017, 1 042 647 pregnancies were recorded. In all age groups, pregnancy incidence rates were highest in women who had started ART, lower in HIV-negative women, and lowest in ART-naive HIV-positive women. In multivariable analysis, after controlling for the most recent CD4+ T-cell count, pregnancy incidence rates in HIV-positive women receiving ART were higher than those in untreated HIV-positive women (adjusted hazard ratio, 1.63; 95% confidence interval, 1.59-1.67) and those in HIV-negative women.

CONCLUSION

Among women who have recently been pregnant, receipt of ART is associated with high rates of second pregnancy. Better integration of family planning into HIV care services is needed.

Challenges in estimating HIV prevalence trends and geographical variation in HIV prevalence using antenatal data: Insights from mathematical modelling

BACKGROUND

HIV prevalence data among pregnant women have been critical to estimating HIV trends and geographical patterns of HIV in many African countries. Although antenatal HIV prevalence data are known to be biased representations of HIV prevalence in the general population, mathematical models have made various adjustments to control for known sources of bias, including the effect of HIV on fertility, the age profile of pregnant women and sexual experience.

METHODS AND FINDINGS

We assessed whether assumptions about antenatal bias affect conclusions about trends and geographical variation in HIV prevalence, using simulated datasets generated by an agent-based model of HIV and fertility in South Africa. Results suggest that even when controlling for age and other previously-considered sources of bias, antenatal bias in South Africa has not been constant over time, and trends in bias differ substantially by age. Differences in the average duration of infection explain much of this variation. We propose an HIV duration-adjusted measure of antenatal bias that is more stable, which yields higher estimates of HIV incidence in recent years and at older ages. Simpler measures of antenatal bias, which are not age-adjusted, yield estimates of HIV prevalence and incidence that are too high in the early stages of the HIV epidemic, and that are less precise. Antenatal bias in South Africa is substantially greater in urban areas than in rural areas.

CONCLUSIONS

Age-standardized approaches to defining antenatal bias are likely to improve precision in model-based estimates, and further recency adjustments increase estimates of HIV incidence in recent years and at older ages. Incompletely adjusting for changing antenatal bias may explain why previous model estimates overstated the early HIV burden in South Africa. New assays to estimate the fraction of HIV-positive pregnant women who are recently infected could play an important role in better estimating antenatal bias.

The effects of human immunodeficiency virus, human papillomavirus, herpes simplex virus-1 and -2, human herpesvirus-6 and -8, cytomegalovirus, and hepatitis B and C virus on female fertility and pregnancy

Female infertility may be defined as a woman of reproductive age being unable to become pregnant after a year of regular unprotected sexual intercourse. Social, genetic, endocrine, physiological, and psychological factors as well as lifestyle habits (i.e., smoking and alcohol consumption), either alone or in combination with male factors, are major causes. However, approximately 15-30% of cases of female infertility remain unexplained. Numerous investigations have also indicated that microbiomes play an important role in human reproduction. All parts of the female reproductive system may be influenced by infectious and pathological agents, especially viruses, and these may interfere with reproductive function and so are risk factors for infertility, although in many cases an exact role is unclear. We present an overview of the impact of common viral infections on female reproduction, searching Medline, PubMed, Scopus, and Google scholar databases for potentially relevant studies of viruses known to have a potential effect. Human immunodeficiency virus (HIV), herpes simplex virus (HSV) and human herpesvirus (HHV) increase infertility rates whilst human papillomavirus (HPV), cytomegalovirus (CMV), and hepatitis B and C virus (HBV, HCV) infections mostly lead to higher abortion and miscarriage rates. Moreover, HPV infection is linked to increased tubal infertility, endometriosis, and pelvic inflammatory disease. HPV was the most frequently observed infection and with lower pregnancy rate and foetal death in women undergoing IVF treatments. Assisted reproductive treatment could be a safe and effective approach for HIV and HBV infected women.

The effects of HIV on fertility by infection duration: evidence from African population cohorts before antiretroviral treatment availability

OBJECTIVES

To estimate the relationship between HIV natural history and fertility by duration of infection in east and southern Africa before the availability of antiretroviral therapy and assess potential biases in estimates of age-specific subfertility when using retrospective birth histories in cross-sectional studies.

DESIGN

Pooled analysis of prospective population-based HIV cohort studies in Masaka (Uganda), Kisesa (Tanzania) and Manicaland (Zimbabwe).

METHODS

Women aged 15-49 years who had ever tested for HIV were included. Analyses were censored at antiretroviral treatment roll-out. Fertility rate ratios were calculated to see the relationship of duration of HIV infection on fertility, adjusting for background characteristics. Survivorship and misclassification biases on age-specific subfertility estimates from cross-sectional surveys were estimated by reclassifying person-time from the cohort data to simulate cross-sectional surveys and comparing fertility rate ratios with true cohort results.

RESULTS

HIV-negative and HIV-positive women contributed 15 440 births and 86 320 person-years; and 1236 births and 11 240 000 person-years, respectively, to the final dataset. Adjusting for age, study site and calendar year, each additional year since HIV seroconversion was associated with a 0.02 (95% confidence interval 0.01-0.03) relative decrease in fertility for HIV-positive women. Survivorship and misclassification biases in simulated retrospective birth histories resulted in modest underestimates of subfertility by 2-5% for age groups 20-39 years.

CONCLUSION

Longer duration of infection is associated with greater relative fertility reduction for HIV-positive women. This should be considered when creating estimates for HIV prevalence among pregnant women and prevention of mother-to-child transmission need over the course of the HIV epidemic and antiretroviral treatment scale up.

Cohort profile: the Hlabisa pregnancy cohort, KwaZulu-Natal, South Africa

PURPOSE

The Hlabisa pregnancy cohort was established to evaluate the effectiveness of prevention of mother-to-child transmission (PMTCT) guideline revisions. The objectives of the Hlabisa pregnancy cohort are to: (1) provide cohort-level information on maternal health up to 6 weeks postpartum in a high HIV prevalence setting; and to (2) evaluate aspects of PMTCT care that have policy relevance.

PARTICIPANTS

The pregnancy cohort is located in primary health clinics in the Hlabisa subdistrict of rural KwaZulu-Natal, South Africa. Baseline data collection between 2010 and 2014 has been completed with the enrolment of 25 608 pregnancies; age ranged from 15-49 years. Pregnant women were assessed during routine antenatal visits: first visit, follow-up 1 week later, 32 weeks (HIV test), infant delivery and 6 weeks postpartum. Demographic, pregnancy, clinical, laboratory and HIV data were collected through Department of Health interviews, laboratory tests and routine data linkage. Treatment data for HIV-infected pregnant women were linked to the Africa Centre Hlabisa HIV Treatment and Care Programme for detailed antiretroviral therapy (ART) history and laboratory tests.

FINDINGS TO DATE

The proportion of women initiated on ART post-2013 were higher (n=437; 100%) than pre-2013 (n=768; 84.2%). The proportion of women in care at 6 weeks (73.8%) was also higher post-2013 relative to earlier years (58.5%). The majority of HIV-infected pregnant women were either on lifelong ART or ART prophylaxis; pre-2013, ∼ 9.6% of women were not on any ART. Pregnancy viral load monitoring was inadequate.

FUTURE PLANS

This cohort will be used to: (1) determine HIV acquisition risk during pregnancy and postpartum; (2) determine the effect of HIV and ART on birth outcomes; (3) examine the effect of pregnancy on virological response to ART; and (4) characterise the effect of sequential pregnancies on access to clinical care, response to prolonged ART and birth outcomes.

Reproductive intentions and family planning practices of pregnant HIV-infected Malawian women on antiretroviral therapy

The objective of this study was to describe the pregnancy intentions of pregnant HIV-infected Malawian women on antiretroviral therapy (ART) for at least 6 months prior to the current pregnancy, and to assess whether time on ART was associated with pregnancy intention. We conducted a cross-sectional analysis of HIV-infected Malawian women receiving antenatal care at a government hospital with a survey assessing ART history, reproductive history, and family planning use at conception. We used Pearson's chi-square tests and Fisher's exact tests to compare these parameters between women on ART greater than 24 months with those on ART less than 24 months. Modified Poisson regression was performed to assess the association between time on ART and pregnancy intention. Most women (75%) reported that their current pregnancy was unintended, defined as either Mistimed (21%) or Unwanted (79%). Women on ART for longer than 2 years were more likely to report an unintended pregnancy (79% versus 65%, p = .03), though there was no significant association between time on ART and pregnancy intention in multivariate analysis. Most women (79%) were using contraception at the time of conception, with condoms being most popular (91%), followed by injectables (9%) and the implant (9%). HIV-infected women on ART continue to experience high rates of unintended pregnancy in the Option B+ era. As Option B+ continues to be implemented in Malawi and increasing numbers of HIV-infected women initiate lifelong ART, ensuring that the most effective forms of contraception are accessible is necessary to decrease unintended pregnancy.

Fertility treatment options for HIV-infected individuals

Many HIV-serodiscordant couples desire children and physician-assisted techniques can help individuals achieve pregnancy while reducing the risk of seroconversion in their seronegative partner. For HIV-seropositive males, sperm washing with intrauterine insemination (SW-IUI) was introduced in Europe in the early 1990s, while in the USA in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI) has been primarily used to reduce the risk of viral transmission. When properly applied to well-selected populations, no seroconversion has been reported with either of these methods. Within the last 5 years, randomized controlled studies have demonstrated the efficacy of daily pre-exposure prophylaxis in reducing the risk of seroconversion in couples having intercourse when an HIV-seropositive male has undetectable viral loads. In both the USA and Europe, favorable reproductive outcomes have been reported for HIV-seropositive females undergoing IUI and IVF-ICSI. Herein, we review the use of various contemporary reproductive techniques available to HIV-serodiscordant couples interested in having children, including new data on cumulative clinical pregnancy rates and cumulative live-birth rates after IVF-ICSI for male serodiscordant couples. We conclude by proposing that pre-exposure prophylaxis with SW-IUI may be a safe, economical and effective alternative for achieving pregnancy in well-selected, monogamous HIV-serodiscordant couples where the male partner is seropositive.

Incidence of pregnancy among women accessing antiretroviral therapy in urban Malawi: a retrospective cohort study

Although previous studies investigated pregnancy rates among women on antiretroviral therapy (ART), incidence of, and factors associated with pregnancy among these women remain poorly understood. We, therefore, conducted a retrospective cohort study at a large public HIV clinic in Lilongwe, Malawi, between July 2007 and December 2010. At each clinic visit, pregnancy status was assessed. Time to event analysis was conducted using Poisson regression. Among 4,738 women, 589 pregnancies were observed. Pregnancy incidence was 9.3/100 person-years. After 6 months on ART, women on ART had similar total fertility rates to women in the urban population. In multivariable analysis, increasing age and advanced WHO clinical stage were associated with decreased probability of becoming pregnant while higher body mass index and longer time on ART were associated with increased probability of becoming pregnant. We recommend that ART clinics integrate comprehensive family planning services to address reproductive health needs among women on ART.

Reproductive assistance in HIV serodiscordant couples

BACKGROUND

Three quarters of individuals infected with human immunodeficiency virus (HIV) are in their reproductive years and may consider pregnancy planning. Techniques have been developed which can minimize the risk of HIV transmission in these couples, and the current literature on this topic is reviewed here.

METHODS

We reviewed the literature for the following topics: risk of HIV transmission, effects of HIV infection on fertility, reproductive assistance in industrialized and low-income countries, pre-exposure chemoprophylaxis (PrEP) and timed intercourse in HIV-discordant couples for both male and female positivity. Relevant publications were identified through searches of the EMBASE Medline and PubMed databases, the Google-indexed scientific literature and periodic specialized magazines from the on-line Library Service of the University of Milan, Italy.

RESULTS

In serodiscordant couples in which the man is positive, the primary method used to prevent HIV transmission is 'sperm washing', followed by IUI or IVF. Data show that sperm washing in HIV-positive men has not produced seroconversion in women or their offspring; however, the evidence is limited. Recently, increasing evidence describing PrEP for HIV prevention has been published and PrEP could be an alternative to ART for fertile couples. Usually HIV-infected women undergo self-insemination around the time of ovulation. Few studies have been published on IVF outcome in HIV-infected women.

CONCLUSIONS

Assisted reproduction programmes should be integrated into global public health services against HIV. For HIV serodiscordant couples with infected men, sperm washing should be the first choice. However, timed intercourse and PrEP for HIV prevention has been reported. Recent data highlight the possible impairment of fertility in HIV-infected women. Efforts to design a multicentric study should be strengthened.

Fertility choices and management for HIV-positive women

PURPOSE OF REVIEW

It is becoming increasingly important to address the issue of reproductive counselling and management of HIV-infected individuals during their reproductive years. Sexual and reproductive health-related needs and aspirations are similar to those of uninfected individuals but some differences require specific attention, which are discussed in this review.

RECENT FINDINGS

Hormonal contraception should be used with caution in women on antiretroviral treatment. Its impact on both HIV infectivity and disease progression is still controversial. An intrauterine device can be considered for pregnancy prevention and pregnancy termination should be offered in safe conditions. HIV-infected women have a lower spontaneous fertility rate, which may persist after assisted reproduction. Data on safety of antiretroviral treatment during conception are reassuring. No clear association can be found between exposure to antiretrovirals and fetal abnormalities. Secondary prevention remains crucial and condom use remains a key method.

SUMMARY

Different topics related to fertility choices among HIV-infected patients should be addressed. Family planning methods and termination of pregnancy have specific aspects among infected individuals. When needed, medically assisted reproduction may be required and antiretroviral treatment should be adapted before conception. Secondary prevention has a key role in reducing newly acquired infections.

More on the cohort-component model of population projection in the context of HIV/AIDS: A Leslie matrix representation and new estimates

This article presents an extension of the cohort-component model of population projection (CCMPP) first formulated by Heuveline (2003) that is capable of modeling a population affected by HIV. Heuveline proposes a maximum likelihood approach to estimate the age profile of HIV incidence that produced the HIV epidemics in East Africa during the 1990s. We extend this work by developing the Leslie matrix representation of the CCMPP, which greatly facilitates the implementation of the model for parameter estimation and projection. The Leslie matrix also contains information about the stable tendencies of the corresponding population, such as the stable age distribution and time to stability. Another contribution of this work is that we update the sources of data used to estimate the parameters, and use these data to estimate a modified version of the CCMPP that includes (estimated) parameters governing the survival experience of the infected population. A further application of the model to a small population with high HIV prevalence in rural South Africa is presented as an additional demonstration. This work lays the foundation for development of more robust and flexible Bayesian estimation methods that will greatly enhance the utility of this and similar models.

Fertility of HIV-infected women: insights from Demographic and Health Surveys

Objective

To analyse the data from Demographic and Health Survey (DHS) linking HIV serological data and fertility, and to recommend new age-specific fertility rate (ASFR) ratios of HIV-positive women to HIV-negative women to be used in the WHO/UNAIDS HIV estimates.

Methods

The authors obtained ASFRs and ASFR ratios from HIV-infected women and HIV-uninfected women from 20 DHS surveys collected between 2003 and 2007. The authors then computed mean and median ASFR ratios, and performed general linear modelling to estimate the overall ASFR ratio for each age group, and finally performed an analysis to identify determinants to national ASFR ratio for women aged 15–19 years old.

Results

The overall ASFR ratio estimated by regression was highest among women aged 15–19 years old (ASFR ratio of 1.20), and decreased with age (ASFR ratio of 0.76, 0.71, 0.65, 0.59 and 0.53, respectively for every 5-year bracket of 20–44 years old). The mean and median of ASFR ratios among 20 countries were similar to the results above. The analysis suggested that country-specific proportion of sexually active women aged 15–19 years old could be a determinant of the ASFR ratio for this group. The higher proportion of sexually active women in this group suggested a lower ASFR ratio in young women.

Conclusion

This study confirmed previous findings of a high ASFR ratio among women younger than 20 years old, and of decreasing ASFR ratios with age among those aged 20 years or older, based on nationally representative data from a large number of countries. The study updated the assumptions used in the annual WHO/UNAIDS HIV epidemic estimates. Countries should compute their own ASFR ratio of 15–19-year-old women accounting for the sexually active rate among young females.

Impact of antiretroviral therapy on incidence of pregnancy among HIV-infected women in Sub-Saharan Africa: a cohort study

BACKGROUND

With the rapid expansion of antiretroviral therapy (ART) services in sub-Saharan Africa there is growing recognition of the importance of fertility and childbearing among HIV-infected women. However there are few data on whether ART initiation influences pregnancy rates.

METHODS AND FINDINGS

We analyzed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multicountry HIV care and treatment program for women, children, and families. From 11 programs in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals; ART was initiated according to national guidelines on the basis of immunological and/or clinical criteria. Standardized forms were used to collect sociodemographic and clinical data, including incident pregnancies. Overall 589 incident pregnancies were observed among the 4,531 women included in this analysis (pregnancy incidence, 7.8/100 person-years [PY]). The rate of new pregnancies was significantly higher among women receiving ART (9.0/100 PY) compared to women not on ART (6.5/100 PY) (adjusted hazard ratio, 1.74; 95% confidence interval, 1.19-2.54). Other factors independently associated with increased risk of incident pregnancy included younger age, lower educational attainment, being married or cohabiting, having a male partner enrolled into the program, failure to use nonbarrier contraception, and higher CD4 cell counts.

CONCLUSIONS

ART use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioral or biomedical mechanisms that may underlie this association require further investigation, these data highlight the importance of pregnancy planning and management as a critical but neglected component of HIV care and treatment services. Please see later in the article for the Editors' Summary.

Repeated pregnancy among women with known HIV status in Pune, India

HIV-positive women of reproductive age face challenges in decision making related to pregnancy. Understanding factors influencing repeat pregnancies in women with known HIV status are necessary to guide interventions and counseling strategies to better inform and support them. We compared three groups of women attending a large antenatal clinic in Pune, India. They include: Group A--63 HIV-positive women coming for care for a repeat pregnancy after being diagnosed in a previous pregnancy; Group B--64 HIV-negative (repeat) pregnant women attending this antenatal clinic; and Group C--63 HIV-positive non-pregnant women currently enrolled in an ongoing clinical trial. Comparisons of Group A and B indicate that the likelihood of unplanned repeat pregnancies was significantly higher in HIV-positive (70%) than HIV-negative (36%) women (OR=4.1, CI: 2.0-8.7). Inability to terminate the pregnancy (31%) and familial obligations (40%) appear to be important for continuing the unplanned repeat pregnancy. Despite high reported contraceptive use by HIV-positive women, pregnancies still occurred. Death of their youngest child is an important factor as 21% of HIV-positive pregnant women lost their youngest child compared with 3% of HIV-negative women and 3% of HIV-positive non-pregnant women (p<0.001). Repeat pregnancies were more likely to occur for women who did not disclose their HIV status to their spouse. Thus the majority of the repeat pregnancies for HIV-positive women were both unplanned and unwanted.

Mitochondrial DNA Depletion in Oocytes of HIV-Infected Antiretroviral-Treated Infertile Women

Background

HIV-infected women under highly active antiretroviral therapy (HAART) undergoing in vitro fertilization (IVF) have a lower pregnancy rate than non-infected controls, which depends on oocyte-related factors. We hypothesized that mitochondrial toxicity caused by antiretrovirals could be the underlying mechanism of such disturbance.

Methods

We have studied 16 and 19 frozen-thawed oocytes obtained after oocyte retrieval IVF cycles from 8 and 14 infertile HIV-infected and uninfected women, respectively, matched by age. At inclusion, HIV-positive women had been infected for >13 years and had received HAART for >9 years, including at least one nucleoside reverse transcriptase inhibitor. All of them had undetectable HIV viral load and a good immunological status. Mitochondrial DNA (mtDNA) content was determined by quantitative real-time PCR in each individual oocyte.

Results

HIV-infected infertile women on HAART showed significant oocyte mtDNA depletion when compared with uninfected controls (32% mtDNA decrease, P<0.05). This oocyte mtDNA depletion was even greater on those HIV-infected women who failed to become pregnant when compared with controls (39% mtDNA decrease, P=0.03). No significant correlation was found between mtDNA oocyte content and cumulative doses of antiretrovirals or the immunological status of HIV patients.

Conclusions

Oocytes from infertile HIV-infected HAART-treated women show decreased mtDNA content, and this could explain their poor reproductive outcome.

Special care issues of women living with HIV-AIDS

Many HIV-infected women are benefiting from highly active antiretroviral therapy and living longer. Their reproductive choices vary over the life cycle, and there is a need to understand the appropriate contraceptives for those not intending pregnancy. There are specific gynecologic issues relevant to HIV-infected women, such as genital tract infections, risk for cervical cancer, and menstrual irregularities. More women are expected to reach menopause. Health care providers should be aware of these unique needs of HIV-infected women.

The potential impact of antiretroviral therapy on fertility in sub-Saharan Africa

Approximately 14 million women of child-bearing age are living with HIV/AIDS in sub-Saharan Africa. Women with HIV infection have between 25% and 40% lower fertility than noninfected women. As antiretroviral (ARV) therapy becomes increasingly accessible in sub-Saharan Africa, it is important to understand whether and how the associated clinical improvements correspond with changes in the incidence of pregnancy and fertility. Accordingly, this paper reviews the literature on the potential impact of ARV therapy on the fertility of women with HIV infection in sub-Saharan Africa. We use Bongaarts' proximate determinants of fertility framework (adapted for conditions of a generalized HIV epidemic) to examine the underlying mechanisms through which use of ARV therapy may impact the fertility of women with HIV infection. A conceptual framework is proposed to guide future research aimed at understanding how widespread use of ARV therapy may impact fertility in sub-Saharan Africa.

Reproduction and fertility in human immunodeficiency virus type-1 infection

Human immunodeficiency virus type-1 (HIV-1) affects mostly men and women in their reproductive years. For those who have access to highly active antiretroviral therapy (HAART), the course of HIV-1 infection has shifted from a lethal to a chronic disease. As a result of this, many patients with HIV-1 consider having offspring, as do other patients of reproductive age with chronic illnesses. This article summarizes the current knowledge on the presence of HIV in the male and female genital tract, the effects of HIV-1 infection and HAART on male and female fertility and the results of various assisted reproduction techniques (ART) in HIV-1-infected men and women who wish to have offspring.