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Purswani MU, Jacobson DL, DiMeglio LA, Yao TJ, Kopp JB, Van Dyke RB, Yu W, Siberry GK. Phosphaturia in HIV-Exposed Uninfected Neonates Associated with Maternal Use of Tenofovir Disoproxil Fumarate in Late Pregnancy. J Pediatric Infect Dis Soc 2024; 13:396-405. [PMID: 38820092 DOI: 10.1093/jpids/piae054] [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: 09/17/2023] [Accepted: 05/29/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF) is often used in treating pregnant women living with HIV. Third-trimester TDF exposure is associated with a 12% reduction in bone mineral content in HIV-exposed uninfected (HEU) neonates. The potential mechanisms underlying this observation are unknown. METHODS The TDF study enrolled newborns of gestational age ≥36 weeks from the Surveillance Monitoring for Antiretroviral Therapy and Toxicities study based on in utero TDF exposure (TDF use ≥8 weeks in the third trimester vs none). Blood and urine samples were collected cross-sectionally within 30 days of birth to assess renal function (serum creatinine, serum phosphate, eGFR, percent tubular reabsorption of phosphate [PTRP]), and bone turnover (serum parathyroid hormone, 25-OH vitamin D [25(OH)D], and urinary cross-linked N-telopeptide of type 1 collagen). For each biomarker, a LOESS plot was fit using values at age at specimen collection; regression lines over age were fit among samples collected from 4 to 30 days, to compare slopes by TDF exposure. RESULTS Among 141 neonates, 77 were TDF-exposed and 64 TDF-unexposed. Between age 4 and 30 days, PTRP decreased more rapidly in the TDF-exposed compared to the unexposed group with slopes of -0.58 vs -0.08/day (difference -0.50/day [95% CI -0.88, -0.11]). Slopes for 25(OH)D were similar in both groups, but serum levels were lower in TDF-exposed neonates (median [IQR]: 22 [19, 29] vs 26 [22, 37] ng/mL). No differences were observed for other biomarkers. CONCLUSIONS Third-trimester in utero exposure to TDF is associated with increased urinary loss of phosphate and lower serum concentrations of 25(OH)D in HEU neonates.
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Affiliation(s)
- Murli U Purswani
- Division of Pediatric Infectious Disease, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, New York, USA
| | - Denise L Jacobson
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Linda A DiMeglio
- Division of Pediatric Endocrinology and Diabetology, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tzy-Jyun Yao
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Jeffrey B Kopp
- Kidney Disease Section, NIDDK, NIH, Bethesda, Maryland, USA
| | - Russell B Van Dyke
- Section of Pediatric Infectious Diseases, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Wendy Yu
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - George K Siberry
- Prevention Care and Treatment Division, Office of HIV/AIDS, United States Agency for International Development, Washington, District of Columbia, USA
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Stranix-Chibanda L, Tierney C, Pinilla M, George K, Aizire J, Chipoka G, Mallewa M, Naidoo M, Nematadzira T, Kusakara B, Violari A, Mbengeranwa T, Njau B, Fairlie L, Theron G, Mubiana-Mbewe M, Khadse S, Browning R, Fowler MG, Siberry GK. Effect on growth of exposure to maternal antiretroviral therapy in breastmilk versus extended infant nevirapine prophylaxis among HIV-exposed perinatally uninfected infants in the PROMISE randomized trial. PLoS One 2021; 16:e0255250. [PMID: 34415933 PMCID: PMC8378741 DOI: 10.1371/journal.pone.0255250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/04/2021] [Indexed: 11/25/2022] Open
Abstract
Background Malnutrition is highly prevalent in HIV-exposed perinatally uninfected infants (HEUs) increasing the risk of morbidity and mortality throughout the life course. We set out to compare the effect of postnatal exposure to maternal antiretroviral therapy (mART) in breastmilk versus infant Nevirapine prophylaxis (iNVP) on somatic growth of HEUs in the randomized PROMISE trial. Methods and findings We randomized 2431 mothers with HIV and their 2444 HEUs from six African countries and India 6–14 days after delivery to mART or iNVP for prevention of breastmilk HIV transmission. The mART regimen contained tenofovir/emtricitabine (99%) plus lopinavir/ritonavir. Infant growth parameters were compared at postnatal week 10, 26, 74 and 104 using World Health Organization (WHO) z-scores for length-for-age (LAZ), weight-for-age (WAZ), and head circumference-for-age (HCAZ). Week 26 LAZ was the primary endpoint measure. Student T-tests compared mean LAZ, WAZ, and HCAZ; estimated mean and 95% confidence interval (CI) are presented. Maternal and infant baseline characteristics were comparable between study arms. The estimated median breastfeeding duration was 70 weeks. After a mean follow-up of 88 weeks, mean LAZ and WAZ were below the WHO reference population mean at all timepoints, whereas mean HCAZ was not. The mART and iNVP arms did not differ for the primary outcome measure of LAZ at week 26 (p-value = 0.39; estimated mean difference (95%CI) of -0.05 (-0.18, 0.07)) or any of the other secondary growth outcome measures or timepoints (all p-values≥0.16). Secondary analyses of the primary outcome measure adjusting for week 0 LAZ and other covariates did not change these results (all p-values≥0.09). However, infants assigned to mART were more likely to have stunting compared to iNVP infants at week 26 (odds ratio (95% CI): 1.28 (1.05, 1.57)). Conclusions In HEUs, growth effects from postnatal exposure to mART compared to iNVP were comparable for measures on length, weight and head circumference with no clinically relevant differences between the groups. Despite breastfeeding into the second year of life, length and weight were below reference population means at all ages in both arms. Further investment is needed to optimize postnatal growth of infants born to women with HIV. Clinical trial registration ClinicalTrials.gov number NCT01061151.
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Affiliation(s)
- Lynda Stranix-Chibanda
- University of Zimbabwe Faculty of Medicine and Health Sciences, Child and Adolescent Health Unit, Harare, Zimbabwe
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
- * E-mail: ,
| | - Camlin Tierney
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research in the Department of Biostatistics, Boston, MA, United States of America
| | - Mauricio Pinilla
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research in the Department of Biostatistics, Boston, MA, United States of America
| | | | - Jim Aizire
- Makerere University—Johns Hopkins University Research Programme, Kampala, Uganda
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | | | - Megeshinee Naidoo
- University of KwaZulu-Natal, Centre Aids Prevention Research South Africa (CAPRISA), Durban, South Africa
| | | | - Bangani Kusakara
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Avy Violari
- Perinatal HIV Research Unit, Johannesburg, South Africa
| | - Tapiwa Mbengeranwa
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Boniface Njau
- Kilimanjaro Christian Medical Center, Moshi, United Republic of Tanzania
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Gerard Theron
- Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa
| | | | - Sandhya Khadse
- Department of Obstetrics and Gynaecology, BJ Government Medical College, Pune, India
| | - Renee Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, United States of America
| | - Mary Glenn Fowler
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - George K. Siberry
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, United States of America
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Drug Exposure in Newborns: Effect of Selected Drugs Prescribed to Mothers During Pregnancy and Lactation. Ther Drug Monit 2021; 42:255-263. [PMID: 32068668 DOI: 10.1097/ftd.0000000000000747] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The number of newborns exposed to therapeutic drugs during pregnancy is growing because of the increased use of drugs during pregnancy. In recent years, advances in our understanding of drug placental transfer have augmented the likelihood of a healthy baby in mothers with chronic diseases needing drug therapy. Globally, for example, more than 1.4 million pregnancies in 2015 have been burdened with antiretroviral drugs due to an increasing number of HIV-positive women treated with these drugs, particularly in low- and middle-income countries. In most cases, the fetus is exposed to much higher drug doses in utero than the newborn nursed by the mother. Drug transfer through the placenta takes place by passive diffusion, active transport, or facilitated transport, and drug concentrations in the fetal circulation may be comparable to that in the mother's blood concentration. The excretion of drugs into breastmilk predominantly occurs by passive diffusion, allowing only the non-protein-bound fraction of the blood drug concentration to penetrate. Drug agencies in the United States and Europe highly recommend performing clinical trials in pregnant or breastfeeding women. However, only a few drugs have reported statistically sound data in these patient groups. Most available results concerning pregnancy are obtained from observational studies after birth, assessing outcomes in the newborn or by measuring drug concentrations in the mother and umbilical cord blood. In the case of the lactation period, some studies have evaluated drug concentrations in breastmilk and blood of the mother and/or infant. In this review, exposure to antiretrovirals, immunosuppressants used after solid organ transplantation, and antiepileptics during pregnancy and lactation has been discussed in detail.
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Pintye J, Huo Y, Kacanek D, Zhang K, Kuncze K, Okochi H, Gandhi M. Extent of In Utero Transfer of Tenofovir From Mother to Fetus: A Paired Analysis of Hair Specimens Collected at Birth From a Cohort in the United States. J Infect Dis 2020; 223:638-644. [PMID: 32620015 PMCID: PMC7904286 DOI: 10.1093/infdis/jiaa398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/26/2020] [Indexed: 11/15/2022] Open
Abstract
Understanding in utero transfer of antiretrovirals is critical for interpreting safety. Hair levels measure cumulative exposure. We measured tenofovir (TFV) concentrations in hair at delivery among women living with human immunodeficiency virus receiving TFV disoproxil fumarate-based treatment and their infants, using liquid chromatography-tandem mass spectrometry. Among 103 mother-infant pairs, the mean log10 ratio of infant-to-maternal TFV levels was 1.08 (95% confidence interval, .97-1.20). TFV transfer was 60% lower from mothers who had preterm compared with term deliveries and 42% lower from mothers who had cesarean compared with vaginal deliveries. Like prior studies assessing transfer via short-term measures (plasma, cord blood, amniotic fluid), we found high cumulative transfer using hair.
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Affiliation(s)
- Jillian Pintye
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - Yanling Huo
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Deborah Kacanek
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kevin Zhang
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Karen Kuncze
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Hideaki Okochi
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Monica Gandhi
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Wen WH, Chen HL, Shih TTF, Wu JF, Ni YH, Lee CN, Zhao LL, Lai MW, Mu SC, Tung YC, Hsu HY, Chang MH. Long-term growth and bone development in children of HBV-infected mothers with and without fetal exposure to tenofovir disoproxil fumarate. J Hepatol 2020; 72:1082-1087. [PMID: 32044401 DOI: 10.1016/j.jhep.2020.01.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/08/2019] [Accepted: 01/09/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS Tenofovir disoproxil fumarate (TDF) is the preferred treatment to prevent maternal transmission of HBV, owing to its efficacy and safety. However, data are lacking on the long-term safety outcomes in children following fetal exposure to TDF. METHODS Children participating in a prospective, multisite trial of maternal TDF treatment during late pregnancy were recruited for follow-up visits once a year. Growth parameters, serum biochemistry, HBV serology, and bone mineral density (BMD) by dual-energy x-ray absorptiometery scan were measured. RESULTS One hundred and twenty-eight children, 71 in the TDF and 57 in the control group, completed 255 follow-up visits at the age of 2 to 7 (median, 4.08) years. No differences in z-scores for weight-for-age (0.26 ± 0.90 vs. 0.22 ± 0.99, p = 0.481), z-scores for height-for-age (0.20 ± 1.02 vs. 0.25 ± 0.98, p = 0.812), and estimated glomerular filtration rate (169.12 ± 50.48 vs. 169.06 ± 34.46 ml/min/1.73m2, p = 0.479) were detected. After adjustment for age, sex and HBV status by multiple linear regression, children in the TDF and control group had comparable levels of serum calcium, phosphorus, bone-specific alkaline phosphatase, calcidiol and BMD of lumbar spines (0.55 ± 0.01 vs. 0.57 ± 0.01 g/cm2, p = 0.159) and left hip (0.56 ± 0.01 vs. 0.56 ± 0.01 g/cm2, p = 0.926). CONCLUSIONS Children of HBV-infected mothers who did or did not receive tenofovir disoproxil fumarate treatment during late pregnancy had comparable long-term growth, renal function, and bone development up to 6-7 years after delivery. CLINICAL TRIAL NUMBER NCT01312012 (ClinicalTrials.gov) LAY SUMMARY: Currently there are insufficient long-term safety data in children born to mothers who took antiviral agents during pregnancy to prevent mother-to-infant transmission of hepatitis B virus (HBV). In this study, we found that children of HBV-infected mothers who did or did not receive tenofovir disoproxil fumarate treatment during late pregnancy had comparable long-term growth, renal function, and bone development up to 6-7 years after delivery.
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Affiliation(s)
- Wan-Hsin Wen
- Department of Pediatrics, Cardinal Tien Hospital, New Taipei City, Taiwan; School of Medicine, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Huey-Ling Chen
- Department of Pediatrics, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Department and Graduate Institute of Medical Education and Bioethics, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tiffany Ting-Fang Shih
- Department of Radiology, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Chien-Nan Lee
- Department of Obstetrics and Gynecology, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Lu-Lu Zhao
- Department of Pediatrics, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Ming-Wei Lai
- Division of Pediatric Gastroenterology, Department of Pediatrics; Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taiwan
| | - Shu-Chi Mu
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Yi-Ching Tung
- Department of Pediatrics, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Hong-Yuan Hsu
- Department of Pediatrics, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Department and Graduate Institute of Medical Education and Bioethics, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Mei-Hwei Chang
- Department of Pediatrics, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
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Seidel V, Weizsäcker K, Henrich W, Rancourt RC, Bührer C, Krüger R, Feiterna-Sperling C. Safety of tenofovir during pregnancy: early growth outcomes and hematologic side effects in HIV-exposed uninfected infants. Eur J Pediatr 2020; 179:99-109. [PMID: 31659467 DOI: 10.1007/s00431-019-03481-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 08/27/2019] [Accepted: 09/23/2019] [Indexed: 11/25/2022]
Abstract
Intrauterine exposure to zidovudine-based combination antiretroviral therapy (cART) can cause severe anemia within the first weeks of life. Tenofovir disoproxil fumarate (TDF)-based regimens may have less hematologic side effects but may affect growth parameters. This study aimed to assess the safety of TDF for prevention of mother-to-child transmission (PMTCT) in HIV-exposed uninfected infants regarding early growth outcomes and hematologic side effects. Our retrospective observational cohort study included children born (n = 232) to HIV-infected mothers (n = 228) on cART. Blood counts were compared at birth, 4-6 weeks, and 3, 12 and 18 months of age. Growth parameters were measured at birth and 12 and 18 months of age. Data were analyzed according to treatment group (TDF and non-TDF cART regimes). The median hemoglobin (Hgb) was significantly lower in the non-TDF-based group at birth (15.4 g/dl vs. 16.9 g/dl; **p = 0.002) and at 4-6 weeks of age (9.9 g/dl vs. 10.4 g/dl; **p = 0.004). The mean corpuscular volume was higher in the non-TDF-based group (109 fl vs. 105 fl; ***p < 0.001) as well at 4-6 weeks (102 fl vs. 95 fl; ***p < 0.001). In the TDF-based group, a higher proportion of neutropenia (grade 2 and higher) compared to the non-TDF-group (21.4% vs. 11%; *p = 0.015) was observed at three months of age. This effect was transient. There was no difference in growth.Conclusions: TDF appears to have no major side effects in our cohort. Transient anemia was observed more commonly with non-TDF regimens. However, our research suggests a potential delayed effect of TDF on neutrophils at 3 months of age.What is Known:• TDF is suspected to affect the growth of HIV-exposed uninfected infants.• Non-TDF-based cART regimes for prevention of mother-to-child transmission of HIV often result in transient anemia in the infant.What is New:• TDF appears to have no major side effects regarding the growth of HIV-exposed uninfected infants.• Our research suggests a potential delayed effect of TDF on neutrophils at 3 months of age in these infants.
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Affiliation(s)
- Vera Seidel
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178, Berlin, Germany.
| | - Katharina Weizsäcker
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Rebecca C Rancourt
- Division of 'Experimental Obstetrics', Clinic of Obstetrics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Renate Krüger
- Department of Pediatric Pneumology, Immunology and Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Cornelia Feiterna-Sperling
- Department of Pediatric Pneumology, Immunology and Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Joseph Davey DL, Pintye J, Baeten JM, Aldrovandi G, Baggaley R, Bekker L, Celum C, Chi BH, Coates TJ, Haberer JE, Heffron R, Kinuthia J, Matthews LT, McIntyre J, Moodley D, Mofenson LM, Mugo N, Myer L, Mujugira A, Shoptaw S, Stranix‐Chibanda L, John‐Stewart G. Emerging evidence from a systematic review of safety of pre-exposure prophylaxis for pregnant and postpartum women: where are we now and where are we heading? J Int AIDS Soc 2020; 23:e25426. [PMID: 31912985 PMCID: PMC6948023 DOI: 10.1002/jia2.25426] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 11/20/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION HIV incidence is high during pregnancy and breastfeeding with HIV acquisition risk more than doubling during pregnancy and the postpartum period compared to when women are not pregnant. The World Health Organization recommends offering pre-exposure prophylaxis (PrEP) to pregnant and postpartum women at substantial risk of HIV infection. However, maternal PrEP national guidelines differ and most countries with high maternal HIV incidence are not offering PrEP. We conducted a systematic review of recent research on PrEP safety in pregnancy to inform national policy and rollout. METHODS We used a standard Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) approach to conduct a systematic review by searching for completed, ongoing, or planned PrEP in pregnancy projects or studies from clinicaltrials.gov, PubMed and NIH RePORTER from 2014 to March 2019. We performed a systematic review of studies that assess tenofovir disoproxil fumarate (TDF)-based oral PrEP safety in pregnant and breastfeeding HIV-uninfected women. RESULTS AND DISCUSSION We identified 14 completed (n = 5) and ongoing/planned (n = 9) studies that evaluate maternal and/or infant outcomes following PrEP exposure during pregnancy or breastfeeding. None of the completed studies found differences in pregnancy or perinatal outcomes associated with PrEP exposure. Nine ongoing studies, to be completed by 2022, will provide data on >6200 additional PrEP-exposed pregnancies and assess perinatal, infant growth and bone health outcomes, expanding by sixfold the data on PrEP safety in pregnancy. Research gaps include limited data on (1) accurately measured PrEP exposure within maternal and infant populations including drug levels needed for maternal protection; (2) uncommon perinatal outcomes (e.g. congenital anomalies); (3) infant outcomes such as bone growth beyond one year following PrEP exposure; (4) outcomes in HIV-uninfected women who use PrEP during pregnancy and/or lactation. CONCLUSIONS Expanding delivery of PrEP is an essential strategy to reduce HIV incidence in pregnancy and breastfeeding women. Early safety studies of PrEP among pregnant women without HIV infection are reassuring and ongoing/planned studies will contribute extensive new data to bolster the safety profile of PrEP use in pregnancy. However, addressing research gaps is essential to expanding PrEP delivery for women in the context of pregnancy.
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Affiliation(s)
- Dvora L Joseph Davey
- Department of EpidemiologyFielding School of Public HealthUniversity of CaliforniaLos AngelesCAUSA
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jillian Pintye
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Grace Aldrovandi
- Geffen School of MedicineUniversity of CaliforniaLos AngelesCAUSA
| | | | - Linda‐Gail Bekker
- Faculty of Health SciencesDesmond Tutu HIV CentreInstitute of Infectious Disease and Molecular MedicineUniversity of Cape TownCape TownNCSouth Africa
| | - Connie Celum
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Benjamin H Chi
- Department of Obstetrics and GynecologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Thomas J Coates
- Geffen School of MedicineUniversity of CaliforniaLos AngelesCAUSA
| | | | - Renee Heffron
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - John Kinuthia
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | | | - James McIntyre
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- ANOVAJohannesburgSouth Africa
| | - Dhayendre Moodley
- Department of Obstetrics and GynaecologyUniversity of KwaZulu‐NatalDurbanSouth Africa
- Centre for AIDS Research in South AfricaDurbanSouth Africa
| | | | - Nelly Mugo
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Center for Clinical ResearchKenya Medical Research Institute (KEMRI)NairobiKenya
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Andrew Mujugira
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Steven Shoptaw
- Geffen School of MedicineUniversity of CaliforniaLos AngelesCAUSA
- Department of Family MedicineUniversity of CaliforniaLos AngelesCAUSA
| | | | - Grace John‐Stewart
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
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Li B, Tang LY, Wang ZQ, Gao S, Wu YT, Xu HL, Ma YZ. Growth of HIV-uninfected children born to HIV-infected mothers in Guangdong, China: an 18-month longitudinal follow-up study. BMC Pediatr 2019; 19:374. [PMID: 31647006 PMCID: PMC6806490 DOI: 10.1186/s12887-019-1771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/07/2019] [Indexed: 11/11/2022] Open
Abstract
Background To evaluate the early growth (weight and length) of HIV-exposed uninfected (HEU) children from the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) program in Guangdong Province, China. Methods A total of 731 HEU children were longitudinally followed up at 7 time points, with anthropometric measurement conducted of weight and length (supine) in the first 18 months. Z scores were calculated, with and without adjustment for gestational age. Results A total of 708 HEU children were included in the final follow-up cohort, and 105 (14.83%) children completed all 7 follow-up visits. The mean of adjusted weight-for-age Z scores in these children was above zero and showed a decreasing trend in 18 months. The mean of adjusted length-for-age Z scores showed a decreasing trend and was above zero in the first 12 months; this declined to under zero at age 18 months. The proportion of underweight was 0.28–2.19% and that of stunting was 0.71–4.63% at each follow-up month-age. Slower growth in HEU children was associated with no sustained food subside after 6 month, mothers’ hemoglobin content less than 100 g/L during pregnancy, preterm birth, and low birth weight (p < 0.05). Conclusions HEU children could catch up to WHO growth standards in first 18 months in Guangdong; however, growth declined after 12 months, and these children need sustained nutritional support.
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Affiliation(s)
- Bing Li
- Department of Healthcare, Guangdong Women and Children Hospital, No. 521, XingNan Road, Guangzhou, 511442, Guangdong, China.
| | - Liu-Ying Tang
- Department of Healthcare, Guangdong Women and Children Hospital, No. 521, XingNan Road, Guangzhou, 511442, Guangdong, China
| | - Zhi-Qiang Wang
- Department of Healthcare, Guangdong Women and Children Hospital, No. 521, XingNan Road, Guangzhou, 511442, Guangdong, China
| | - Shuang Gao
- Department of Healthcare, Guangdong Women and Children Hospital, No. 521, XingNan Road, Guangzhou, 511442, Guangdong, China
| | - Yun-Tao Wu
- Department of Healthcare, Guangdong Women and Children Hospital, No. 521, XingNan Road, Guangzhou, 511442, Guangdong, China
| | - Hao-Li Xu
- Department of Healthcare, Guangdong Women and Children Hospital, No. 521, XingNan Road, Guangzhou, 511442, Guangdong, China
| | - Yuan-Zhu Ma
- Department of Healthcare, Guangdong Women and Children Hospital, No. 521, XingNan Road, Guangzhou, 511442, Guangdong, China
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Heffron R, Pintye J, Matthews LT, Weber S, Mugo N. PrEP as Peri-conception HIV Prevention for Women and Men. Curr HIV/AIDS Rep 2017; 13:131-9. [PMID: 26993627 DOI: 10.1007/s11904-016-0312-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Daily oral tenofovir (TDF)-based pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy and recommended for men and women with substantial risk of HIV acquisition. The peri-conception period, the stage prior to pregnancy when condom use is necessarily reduced, has elevated HIV risk that can be mitigated by PrEP use. Data from a randomized trial suggest that peri-conception PrEP use by HIV-seronegative women does not increase the risk of pregnancy loss, birth defects or congenital anomalies, preterm birth, or infant growth faltering. Women considering PrEP use throughout pregnancy must weigh the known increased risk of HIV acquisition with unknown risks of drug effects on infant growth. PrEP has been used safely by HIV-seronegative men with HIV-seropositive female partners who have become pregnant. As an effective user-controlled HIV prevention strategy, PrEP offers autonomy and empowerment for HIV prevention and can be recommended alongside antiretroviral therapy, fertility screening, vaginal self-insemination, intercourse timed to peak fertility, medically assisted reproduction, and other safer conception strategies to provide multiple options. The integration of PrEP into safer conception programs is warranted and will safely reduce HIV transmission to women, men, and children during the peri-conception period.
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Affiliation(s)
- Renee Heffron
- Departments of Global Health and Epidemiology, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA.
| | - Jillian Pintye
- School of Nursing, University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA, 98104, USA
| | - Lynn T Matthews
- Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, 125 Nashua Street, Suite 722, Boston, MA, 02114, USA
| | - Shannon Weber
- University of California San Francisco, 1001 Potrero Ave, 6D-33, San Francisco, CA, 94110, USA
| | - Nelly Mugo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
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Tenofovir disoproxil fumarate safety for women and their infants during pregnancy and breastfeeding. AIDS 2017; 31:213-232. [PMID: 27831952 DOI: 10.1097/qad.0000000000001313] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Pregnant/lactating women in some sub-Saharan Africa settings are at substantial risk of HIV acquisition and could benefit from preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate (TDF), but safety data in pregnancy/lactation are limited. DESIGN Systematic data review through August 2016. METHODS We reviewed research reports/conference abstracts with maternal/child adverse outcome data in HIV-infected and HIV-uninfected pregnant/lactating women receiving TDF alone or in combination with other drugs compared with non-TDF regimens. RESULTS In total, 26 articles in HIV-infected and seven in HIV-uninfected women were identified. No statistically significant differences were observed between TDF and comparison non-TDF regimens in pregnancy incidence, stillbirth/pregnancy loss, preterm delivery less than 37 weeks, low birth weight <2500/<1500 g, small for gestational age, birth defects, or infant (>14 days) or maternal mortality. One study reported significantly higher very preterm delivery (<34 weeks) and neonatal mortality with TDF versus non-TDF antiretroviral therapy (ART), but no significant difference between TDF ART and zidovudine/single-dose nevirapine. Most studies report normal infant linear growth; one study showed slightly lower, and one higher 1-year length-for-age z-score in TDF ART-exposed infants. No significant differences were reported in abnormal laboratory values or bone markers between TDF and non-TDF-exposed infants in four studies. Lower maternal bone mineral density was observed at 74 weeks postpartum in breastfeeding women on TDF ART compared with no ART in one study. CONCLUSION Given available safety data, there does not appear to be a safety-related rationale for prohibiting PrEP during pregnancy/lactation or for discontinuing PrEP in HIV-uninfected women receiving PrEP who become pregnant and are at continuing risk of HIV acquisition.
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Abstract
PURPOSE OF REVIEW Chronic HIV infection and exposure to antiretroviral therapy compromises bone health in children and adolescents, potentially impacting their long-term quality of life. Thus, the purpose of this article is to review the most recent literature on this topic in HIV-infected children and adolescents. RECENT FINDINGS Recent studies continue to demonstrate bone abnormalities in HIV-infected children and adolescents, whether HIV is acquired perinatally or during adolescence. Researchers have employed new modalities, both high tech and those that can be utilized in resource-limited settings, to better assess bone health. New data suggest that this population may also be experiencing an increase incidence of fractures, and they may not acquire the same peak bone mass as their HIV-uninfected counterparts. Reassuringly, however, in-utero tenofovir exposure does not appear to have a significant impact on bone health in HIV-exposed, uninfected infants. SUMMARY HIV-infected children and adolescents are exposed to HIV and antiretroviral therapy for many decades starting early in life and during the most critical time for skeletal growth and bone mass accrual. Recent findings underscore the need for further research on bone in this population. Longitudinal studies are especially needed to evaluate long-term risk of osteoporosis and fracture.
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Seidman DL, Weber S, Timoney MT, Oza KK, Mullins E, Cohan DL, Wright RL. Use of HIV pre-exposure prophylaxis during the preconception, antepartum and postpartum periods at two United States medical centers. Am J Obstet Gynecol 2016; 215:632.e1-632.e7. [PMID: 27448959 DOI: 10.1016/j.ajog.2016.06.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/09/2016] [Accepted: 06/13/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Pregnancy may increase a woman's susceptibility to HIV. Maternal HIV acquisition during pregnancy and lactation is associated with increased perinatal and lactational HIV transmission. There are no published reports of preexposure prophylaxis use after the first trimester of pregnancy or during lactation. OBJECTIVE The purpose of this study was to report the use of preexposure prophylaxis and to identify gaps in HIV prevention services for women who were at substantial risk of HIV preconception and during pregnancy and lactation at 2 United States medical centers. STUDY DESIGN Chart review was performed on women who were identified as "at significant risk" for HIV acquisition preconception (women desiring pregnancy) and during pregnancy and lactation at 2 medical centers in San Francisco and New York from 2010-2015. Women were referred to specialty clinics for women who were living with or were at substantial risk of HIV. RESULTS Twenty-seven women who were identified had a median age of 27 years. One-half of the women had unstable housing, 22% of the women had ongoing intimate partner violence, and 22% of the women had active substance use. Twenty-six women had a male partner living with HIV, and 1 woman had a male partner who had sex with men. Of the partners who were living with HIV, 73% (19/26) were receiving antiretroviral therapy, and 42% (11/26) had documented viral suppression. Thirty-nine percent (10/26) of partners had known detectable virus, and 19% (5/26) had unknown viral loads. Women were identified by clinicians, health educators, and health departments. Approximately one-third of the women were identified preconception (8/27); the majority of the women were identified during pregnancy (18/27) with a median gestational age of 20 weeks (interquartile range, 11-23), and 1 woman was identified in the postpartum period. None of the pregnant referrals had received safer conception counseling to reduce HIV transmission. Twenty-six percent of all women (7/27) were eligible for postexposure prophylaxis at referral, of whom 57% (4/7) were offered postexposure prophylaxis. In 30% (8/27), the last HIV exposure was not assessed and postexposure prophylaxis was not offered. The median time from identification as "at substantial risk" to consultation was 30 days (interquartile range, 2-62). Two women were lost to follow up before consultation. One woman who was identified as "at significant risk" was not referred because of multiple pregnancy complications. She remained in obstetrics care and was HIV-negative at delivery but was lost to follow up until 10 months after delivery when she was diagnosed with HIV. No other seroconversions were identified. Of referrals who presented and were offered preexposure prophylaxis, 67% women (16/24) chose to take it, which was relatively consistent whether the women were preconception (5/8), pregnant (10/15), or after delivery (1/1). Median length of time on preexposure prophylaxis was 30 weeks (interquartile range, 20-53). One-half of women (10/20) who were in care at delivery did not attend a postpartum visit. CONCLUSION Women at 2 United States centers frequently chose to use preexposure prophylaxis for HIV prevention when it was offered preconception and during pregnancy and lactation. Further research and education are needed to close critical gaps in screening for women who are at risk of HIV for pre- and postexposure prophylaxis eligibility and gaps in care linkage before and during pregnancy and lactation. Postpartum women are particularly vulnerable to loss-to-follow-up and miss opportunities for safe and effective HIV prevention.
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Floridia M, Liotta G, Andreotti M, Galluzzo CM, Amici R, Jere H, Sagno JB, Marazzi MC, Buonomo E, Scarcella P, Mancinelli S, Vella S, Giuliano M, Palombi L. Levels of bone markers in a population of infants exposedin uteroand during breastfeeding to tenofovir within an Option B+ programme in Malawi. J Antimicrob Chemother 2016; 71:3206-3211. [DOI: 10.1093/jac/dkw268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/04/2016] [Accepted: 06/02/2016] [Indexed: 01/11/2023] Open
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Jao J, Abrams EJ, Phillips T, Petro G, Zerbe A, Myer L. In Utero Tenofovir Exposure Is not Associated With Fetal Long Bone Growth. Clin Infect Dis 2016; 62:1604-1609. [PMID: 27009251 DOI: 10.1093/cid/ciw159] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/11/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite widespread use of tenofovir disoproxil fumarate (TDF) in pregnant and breastfeeding women, few data exist on fetal bone development after in utero TDF exposure. We evaluated fetal long bone growth in human immunodeficiency virus (HIV)-infected pregnant woman/fetus dyads in Cape Town, South Africa. METHODS Women were recruited from primary care antenatal services and underwent ultrasonography to determine femur (FLZ) and humerus (HLZ) length z scores. The duration of in utero TDF exposure was calculated in weeks. Linear regression models were applied to assess the associations between the duration of in utero TDF exposure and change in FLZ and HLZ. RESULTS A total of 646 woman/fetus dyads contributed 1376 ultrasonographic scans to this analysis: 132 dyads with ≥25 weeks, 326 with 10-24 weeks, and 188 with <10 weeks of TDF exposure. Women receiving TDF for ≥25 weeks were older than those receiving TDF for 10-24 or <10 weeks (median age, 31 vs 28 and 28 years, respectively; P < .01), and had lower HIV RNA levels (median log10 HIV RNA level, 1.59 vs 4.08 and 3.83, respectively; P < .01). Throughout gestation, overall median FLZ and HLZ were 0.30 (interquartile range, -0.03 to 0.63) and 0.22 (-0.26 to 0.59) respectively. In multivariate analysis, there was no association between duration of in utero TDF exposure per 1-week increment and change in FLZ (ß = .00; P = .51) or change in HLZ (ß = .00; P = .40). Results were similar using mixed-effects models. CONCLUSIONS Although longer follow-up is needed, these in utero data are reassuring and support the continued use of TDF in pregnancy.
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Affiliation(s)
- Jennifer Jao
- Department of Medicine and Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai
| | - Elaine J Abrams
- ICAP, Mailman School of Public Health.,College of Physicians and Surgeons, Columbia University, New York, New York
| | | | - Greg Petro
- Division of Epidemiology and Biostatistics.,Division of Obstetrics & Gynaecology
| | | | - Landon Myer
- Division of Epidemiology and Biostatistics.,Division of Desmond Tutu HIV Centre, University of Cape Town, South Africa
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