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Shafi J, Virk MK, Kalk E, Carlucci JG, Chepkemoi A, Bernard C, McHenry MS, Were E, Humphrey J, Davies MA, Mehta UC, Patel RC. Pharmacovigilance in Pregnancy Studies, Exposures and Outcomes Ascertainment, and Findings from Low- and Middle-Income Countries: A Scoping Review. Drug Saf 2024:10.1007/s40264-024-01445-1. [PMID: 38907172 DOI: 10.1007/s40264-024-01445-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 06/23/2024]
Abstract
INTRODUCTION Pharmacovigilance (PV), or the ongoing safety monitoring after a medication has been licensed, plays a crucial role in pregnancy, as clinical trials often exclude pregnant people. It is important to understand how pregnancy PV projects operate in low- and middle-income countries (LMICs), where there is a disproportionate lack of PV data yet a high burden of adverse pregnancy outcomes. We conducted a scoping review to assess how exposures and outcomes were measured in recently published pregnancy PV projects in LMICs. METHODS We utilized a search string, secondary review, and team knowledge to review publications focusing on therapeutic or vaccine exposures among pregnant people in LMICs. We screened abstracts for relevance before conducting a full text review, and documented measurements of exposures and outcomes (categorized as maternal, birth, or neonatal/infant) among other factors, including study topic, setting, and design, comparator groups, and funding sources. RESULTS We identified 31 PV publications spanning at least 24 LMICs, all focusing on therapeutics or vaccines for infectious diseases, including HIV (n = 17), tuberculosis (TB; n = 9), malaria (n = 7), pertussis, tetanus, and diphtheria (n = 1), and influenza (n = 3). As for outcomes, n = 15, n = 31, and n = 20 of the publications covered maternal, birth, and neonatal/infant outcomes, respectively. Among HIV-specific publications, the primary exposure-outcome relationship of focus was exposure to maternal antiretroviral therapy and adverse outcomes. For TB-specific publications, the main exposures of interest were second-line drug-resistant TB and isoniazid-based prevention therapeutics for pregnant people living with HIV. For malaria-specific publications, the primary exposure-outcome relationship of interest was antimalarial medication exposure during pregnancy and adverse outcomes. Among vaccine-focused publications, the exposure was assessed during a specific time during pregnancy, with an overall interest in vaccine safety and/or efficacy. The study settings were frequently from Africa, designs varied from cohort or cross-sectional studies to clinical trials, and funding sources were largely from high-income countries. CONCLUSION The published pregnancy PV projects were largely centered in Africa and concerned with infectious diseases. This may reflect the disease burden in LMICs but also funding priorities from high-income countries. As the prevalence of non-communicable diseases increases in LMICs, PV projects will have to broaden their scope. Birth and neonatal/infant outcomes were most reported, with fewer reporting on maternal outcomes and none on longer-term child outcomes; additionally, heterogeneity existed in definitions and ascertainment of specific measures. Notably, almost all projects covered a single therapeutic exposure, missing an opportunity to leverage their projects to cover additional exposures, add scientific rigor, create uniformity across health services, and bolster existing health systems. For many publications, the timing of exposure, specifically by trimester, was crucial to maternal and neonatal safety. While currently published pregnancy PV literature offer insights into the PV landscape in LMICs, further work is needed to standardize definitions and measurements, integrate PV projects across health services, and establish longer-term monitoring.
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Affiliation(s)
| | | | - Emma Kalk
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | | | | | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Ushma C Mehta
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Rena C Patel
- University of Washington, Seattle, WA, USA.
- University of Alabama at Birmingham, Birmingham, AL, USA.
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Menon S, Benova L, Mabeya H. Epilepsy management in pregnant HIV+ women in sub-Saharan Africa, clinical aspects to consider: a scoping review. BMC Med 2020; 18:341. [PMID: 33198766 PMCID: PMC7670685 DOI: 10.1186/s12916-020-01799-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/25/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Since the introduction of highly active antiretroviral therapy (HAART), acquired immune deficiency syndrome (AIDS) related mortality has markedly declined. As HAART is becoming increasingly available, the infection with human immunodeficiency virus (HIV+) in sub-Saharan Africa (SSA) is becoming a chronic condition. While pregnancy in HIV+ women in SSA has always been considered a challenging event for the mother and the fetus, for pregnant HIV+ women also diagnosed with epilepsy (WWE), there are additional risks as HIV increases the odds of developing seizures due to the vulnerability of the central nervous system to other infections, immune dysfunction, and overall metabolic disturbances. In light of a growing proportion of HIV+ WWE on HAART and an increasing number of pregnant women accessing mother-to-child transmission of HIV programs through provision of HAART in SSA, there is a need to develop contextualized and evidenced-based clinical strategies for the management of epilepsy in this population. In this study, we conduct a literature scoping review to identify issues that warrant consideration for clinical management. RESULT Twenty-three articles were retained after screening, which covered six overarching clinical aspects: status epilepticus (SE), Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), dyslipidemia, congenital malformation (CM), chronic kidney disease (CKD), and neurological development. No studies for our population of interest were identified, highlighting the need for a cautionary approach to be employed when extrapolating findings. CONCLUSION High risks of CM and drug interactions with first-line antiepileptic drugs (AEDs) warrant measures to increase the accessibility and choices of safer second-line AEDs. To ensure evidence-based management of epilepsy within this population, the potential high prevalence of SE, CKD, dyslipidemia, and SJS/TEN and the cumulative effect of drug-drug interactions should be considered. Further understanding of the intersections between pregnancy and drug-drug interactions in SSA is needed to ensure evidenced-based management of epilepsy in pregnant HIV+ WWE. To prevent SE, the barriers for AED treatment adherence in pregnant HIV+ women should be explored. Our review underscores the need to conduct cohort studies of HIV+ WWE in reproductive age over time and across pregnancies to capture the cumulative effect of HAART and AED to inform clinical management.
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Affiliation(s)
- Sonia Menon
- Instiute of Tropical Medicine Antwerp, Antwerp, Belgium.
| | - Lenka Benova
- Instiute of Tropical Medicine Antwerp, Antwerp, Belgium
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Adane F, Afework M, Seyoum G, Gebrie A. Prevalence and associated factors of birth defects among newborns in sub-Saharan African countries: a systematic review and meta-analysis. Pan Afr Med J 2020; 36:19. [PMID: 32774596 PMCID: PMC7388615 DOI: 10.11604/pamj.2020.36.19.19411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 02/20/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Birth defects are the most serious causes of infant mortality and disability in sub-Saharan African countries with variable magnitude. Hence, this study was aimed to determine the pooled prevalence of birth defects and its associated risk factors among newborn infants in sub-Saharan African countries. Methods A total of 43 eligible studies were identified through literature search from Medline (PubMed), EMBASE, HINARI, Google scholar, Science Direct, Cochrane Library and other sources. Extracted data were analyzed using STATA 15.0 statistical software. A random effect meta-analysis model was used. Results Twenty-five studies in 9 countries showed that the pooled prevalence of birth defects was 20.40 per 1,000 births (95% CI: 17.04, 23.77). In the sub-group analysis, the highest prevalence was observed in southern Africa region with a prevalence of 43 per 1000 (95% CI: 14.89, 71.10). The most prevalent types of birth defects were musculo-skeletal system defects with a pooled prevalence of 3.90 per 1000 (95% CI: 3.11, 4.70) while the least was Down syndrome 0.62 per 1000 (95% CI: 0.40, 0.84). Lack of folic acid supplementation (95% CI: 1.95, 7.88), presence of chronic disease (95% CI: 2.00, 6.07) and intake of drugs (95% CI: 3.88, 14.66) during pregnancy were significantly associated with the birth defects. Conclusion The prevalence of birth defects is relatively high with high degree of regional variabilities. The most common types of birth defects were musculoskeletal defects. Lack of folic acid supplementation, presence of chronic disease and intake of drugs during pregnancy were significantly associated with birth defects.
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Affiliation(s)
- Fentahun Adane
- Department of Anatomy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mekbeb Afework
- Department of Anatomy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Girma Seyoum
- Department of Anatomy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemu Gebrie
- Department of Biomedical Science, School of Medicine, Debre Markos University, Debre Markos, Ethiopia
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Ao RF, Liang YX, Liu XQ, Tan K, Wang X, Liu D, Zhang T, Sun G, Xie J. Stavudine exposure results in developmental abnormalities by causing DNA damage, inhibiting cell proliferation and inducing apoptosis in mouse embryos. Toxicology 2020; 439:152443. [PMID: 32278789 DOI: 10.1016/j.tox.2020.152443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/17/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022]
Abstract
Stavudine is an anti-AIDS drug widely used to prevent HIV transmission from pregnant mothers to the fetuses in underdeveloped countries for its low price. However, there is still a controversy on whether stavudine affects embryo development. In the current study, embryotoxicity of stavudine was evaluated using cultured mouse embryos with the concentrations: 5, 10, 15 μM and vehicle control. The data indicated that the effect of stavudine was dose-dependent at early neurogenesis. Stavudine exposure reduced somite numbers, yolk sac diameter, crown-rump length, and increased the rate of embryonic degeneration compared with the control. We chose the lowest but clearly toxic concentration: 5 μM to investigate the molecular mechanisms of the damage. At the molecular level, stavudine produced DNA damage, increased the levels of the phospho-CHK1 and cleaved-caspase-3, and decreased the expression level of proliferating cell nuclear antigen. These changes indicated that stavudine caused a coordinated DNA damage response, inhibited cell proliferation, and induced apoptosis in the embryos. Collectively these results suggest that stavudine exposure disturbs the embryonic development, and its use in pregnant mothers should be re-examined.
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Affiliation(s)
- Rui-Fang Ao
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Yu-Xiang Liang
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Xiao-Qing Liu
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Kui Tan
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Xiaoling Wang
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Dan Liu
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Ting Zhang
- Capital Institute of Pediatrics, Beijing 100020, China.
| | - Gongqin Sun
- Department of Cell & Molecular Biology, University of Rhode Island, 389 CBLS Building, 120 Flagg Road, Kingston, RI, 02881, USA
| | - Jun Xie
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China.
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Hoffman RM, Brummel SS, Britto P, Pilotto JH, Masheto G, Aurpibul L, Joao E, Purswani MU, Buschur S, Pierre MF, Coletti A, Chakhtoura N, Klingman KL, Currier JS. Adverse Pregnancy Outcomes Among Women Who Conceive on Antiretroviral Therapy. Clin Infect Dis 2020; 68:273-279. [PMID: 29868833 DOI: 10.1093/cid/ciy471] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 05/29/2018] [Indexed: 11/12/2022] Open
Abstract
Background Adverse pregnancy outcomes for women who conceive on antiretroviral therapy (ART) may be increased, but data are conflicting. Methods Human immunodeficiency virus-infected, nonbreastfeeding women with pre-ART CD4 counts ≥400 cells/μL who started ART during pregnancy were randomized after delivery to continue ART (CTART) or discontinue ART (DCART). Women randomized to DCART were recommended to restart if a subsequent pregnancy occurred or for clinical indications. Using both intent-to-treat and as-treated approaches, we performed Fisher exact tests to compare subsequent pregnancy outcomes by randomized arm. Results Subsequent pregnancies occurred in 277 of 1652 (17%) women (CTART: 144/827; DCART: 133/825). A pregnancy outcome was recorded for 266 (96%) women with a median age of 27 years (interquartile range [IQR], 24-31 years) and median CD4+ T-cell count 638 cells/μL (IQR, 492-833 cells/μL). When spontaneous abortions and stillbirths were combined, there was a significant difference in events, with 33 of 140 (23.6%) in the CTART arm and 15 of 126 (11.9%) in the DCART arm (relative risk [RR], 2.0 [95% confidence interval {CI}, 1.1-3.5]; P = .02). In the as-treated analysis, the RR was reduced and no longer statistically significant (RR, 1.4 [95% CI, .8-2.4]). Conclusions Women randomized to continue ART who subsequently conceived were more likely to have spontaneous abortion or stillbirth, compared with women randomized to stop ART; however, the findings did not remain significant in the as-treated analysis. More data are needed on pregnancy outcomes among women conceiving on ART, particularly with newer regimens.
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Affiliation(s)
- Risa M Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles
| | - Sean S Brummel
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Paula Britto
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jose H Pilotto
- Oswaldo Cruz Foundation/Fiocruz and Hospital Geral de Nova Iguacu, Rio de Janeiro, Brazil
| | | | - Linda Aurpibul
- Research Institute for Health Sciences, Chiang Mai University, Thailand
| | - Esau Joao
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | - Murli U Purswani
- Division of Pediatric Infectious Diseases, Bronx-Lebanon Hospital Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Marie Flore Pierre
- Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections Centers, Port-au-Prince
| | - Anne Coletti
- Family Health International 360, Durham, North Carolina
| | | | - Karin L Klingman
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Judith S Currier
- Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles
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Mehta UC, van Schalkwyk C, Naidoo P, Ramkissoon A, Mhlongo O, Maharaj NR, Naidoo N, Fieggen K, Urban MF, Krog S, Welte A, Dheda M, Pillay Y, Moran NF. Birth outcomes following antiretroviral exposure during pregnancy: Initial results from a pregnancy exposure registry in South Africa. South Afr J HIV Med 2019; 20:971. [PMID: 31616571 PMCID: PMC6779987 DOI: 10.4102/sajhivmed.v20i1.971] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/04/2019] [Indexed: 11/29/2022] Open
Abstract
Background In 2013, a pregnancy exposure registry and birth defects surveillance (PER/BDS) system was initiated in eThekwini District, KwaZulu-Natal (KZN), to assess the impact of antiretroviral treatment (ART) on birth outcomes. Objectives At the end of the first year, we assessed the risk of major congenital malformations (CM) and other adverse birth outcomes (ABOs) detected at birth, in children born to women exposed to ART during pregnancy. Method Data were collected from women who delivered at Prince Mshiyeni Memorial Hospital, Durban, from 07 October 2013 to 06 October 2014, using medicine exposure histories and birth outcomes from maternal interviews, clinical records and neonatal surface examination. Singleton births exposed to only one ART regimen were included in bivariable analysis for CM risk and multivariate risk analysis for ABO risk. Results Data were collected from 10 417 women with 10 517 birth outcomes (4013 [38.5%] HIV-infected). Congenital malformations rates in births exposed to Efavirenz during the first trimester (T1) (RR 0.87 [95% CI 0.12–6.4; p = 0.895]) were similar to births not exposed to ART during T1. However, T1 exposure to Nevirapine was associated with the increased risk of CM (RR 9.28 [95% CI 2.3–37.9; p = 0.002]) when compared to the same group. Other ABOs were more frequent in the combination of HIV/ART-exposed births compared to HIV-unexposed births (29.9% vs. 26.0%, adjusted RR 1.23 [1.14–1.31; p < 0.001]). Conclusion No association between T1 use of EFV-based ART regimens and CM was observed. Associations between T1 NVP-based ART regimen and CM need further investigation. HIV- and ART-exposed infants had more ABOs compared to HIV-unexposed infants.
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Affiliation(s)
- Ushma C Mehta
- Centre for Infectious Disease Epidemiology and Research (CIDER), School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Cari van Schalkwyk
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch, South Africa
| | - Prineetha Naidoo
- Maternal and Adolescent Child Health Systems (MatCH), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Arthi Ramkissoon
- Maternal and Adolescent Child Health Systems (MatCH), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Otty Mhlongo
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | | | - Niree Naidoo
- Prince Mshiyeni Memorial Hospital, Durban, South Africa
| | - Karen Fieggen
- Division of Human Genetics, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael F Urban
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Shaun Krog
- VP Health Systems, KwaZulu-Natal, Durban, South Africa
| | - Alex Welte
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch, South Africa
| | - Mukesh Dheda
- Programmatic Pharmacovigilance Unit, National Department of Health, Pretoria, South Africa
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | - Neil F Moran
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
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Abdi F, Alimoradi Z, Alidost F. Pregnancy outcomes and effects of antiretroviral drugs in HIV-positive pregnant women: a systematic review. Future Virol 2019. [DOI: 10.2217/fvl-2018-0213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: Despite the clear morbidity, mortality and vertical transmission rates in women infected with HIV, there is still controversy surrounding the relationship between maternal infection and adverse neonatal outcomes. Antiretroviral therapy during pregnancy is considered the main and most effective method for reducing the vertical transmission of infection. However, there is no consensus over potential associations between antiretroviral therapy and adverse pregnancy outcomes. This systematic review focuses on the effects of antiretroviral drugs on pregnancy outcomes in HIV-positive women. Methods: After searching MEDLINE, the Cochrane Database of Systematic Reviews, the ISI Web of Sciences and EMBASE, 570 potentially eligible papers were identified. Only 32 papers were selected based on the inclusion criteria. Results: The most prevalent adverse pregnancy outcomes were low birth weight, preterm birth and stillbirth. Conclusion: Considering the higher prevalence of adverse pregnancy outcomes in HIV-infected women, HIV screening methods should be administered in all pregnant women. Appropriate treatment modalities should also be selected to minimize adverse pregnancy outcomes.
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Affiliation(s)
- Fatemeh Abdi
- Student Research Committee, Nursing & Midwifery Faculty, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zainab Alimoradi
- Department of Midwifery, Nursing & Midwifery Faculty, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Farzane Alidost
- Department of Reproductive Health, Nursing & Midwifery Faculty, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Hill A, Clayden P, Thorne C, Christie R, Zash R. Safety and pharmacokinetics of dolutegravir in HIV-positive pregnant women: a systematic review. J Virus Erad 2018; 4:66-71. [PMID: 29682297 PMCID: PMC5892677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The integrase strand transfer inhibitor dolutegravir (DTG) is being introduced into low- and middle-income countries (LMICs) as an alternative to first-line treatment with non-nucleoside reverse transcriptase inhibitors. However, DTG is not yet widely recommended for use in pregnant women. The aim of this systematic review was to analyse all available data on birth outcomes and congenital anomalies in the infants of pregnant women treated with DTG. METHODS A PubMed and Embase search was conducted using the terms "dolutegravir" or "DTG" and "pregnancy" or "pregnant" from the earliest available date on the database to 26 July 2017. Any reports involving women who were pregnant, HIV positive and taking DTG were included. The percentage of pregnant women with adverse birth outcomes or congenital anomalies in their infants after taking dolutegravir was compared with five historical control databases. RESULTS There were six databases included in the main analysis of birth outcomes and congenital anomalies, with a total of 1200 pregnant women. The percentage of pregnant women taking DTG with adverse birth outcomes and congenital abnormalities was similar to results from historical control studies of HIV-positive women. However, there was significant heterogeneity among the six databases - the percentage of infants with congenital anomalies ranged from 0.0% in Botswana (0/116 infants) to 13.3% in IMPAACT P1026S (2/15 infants). CONCLUSIONS Up to 15 million people could be on treatment with DTG in LMICs within the next 5 years, of whom a substantial percentage is likely to be women of child-bearing potential. In many countries with large HIV epidemics, unplanned pregnancies are common and access to antenatal clinic facilities may be limited. Continued pharmacovigilance is essential, but it is reassuring that no clear safety signals have been detected, to date, for pregnant women treated with DTG in terms of birth outcomes or congenital anomalies.
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Affiliation(s)
- Andrew Hill
- Department of Translational Medicine, University of Liverpool,
UK
| | | | - Claire Thorne
- University College London Great Ormond Street Institute of Child Health,
UK
| | | | - Rebecca Zash
- Beth Israel Deaconess Medical Center, Division of Infectious Diseases,
Boston,
USA
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Hill A, Clayden P, Thorne C, Christie R, Zash R. Safety and pharmacokinetics of dolutegravir in HIV-positive pregnant women: a systematic review. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30247-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Health and survival of HIV perinatally exposed but uninfected children born to HIV-infected mothers. Curr Opin HIV AIDS 2017; 11:465-476. [PMID: 27716731 DOI: 10.1097/coh.0000000000000300] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The number of HIV-exposed but uninfected (HEU) infants exposed to both HIV and multiple antiretroviral drugs in utero and during prolonged breastfeeding is increasing in low-income countries where HIV prevalence is the highest. We review recent evidence on the effects of perinatal/postnatal exposure to maternal HIV and combined antiretroviral therapy (cART) on health outcomes of HEU children (mitochondrial and metabolic toxicity, adverse pregnancy outcomes, neurodevelopment, growth, infectious morbidity, and mortality). RECENT FINDINGS Several studies have reported ART-associated mitochondrial toxicity and metabolic disorders with conflicting results on adverse pregnancy outcomes, underscoring the need to conduct further investigations on these questions. Studies about congenital abnormalities report no significant differences between HEU exposed to ART and HIV-unexposed (HUU) children. Updated French data showed no significant difference in cancer incidence between HEU cART-exposed children and the general paediatric population. Furthermore, HEU children exposed to maternal cART have modest but significant impairment of development and a higher risk of growth impairment. Finally, HEU have higher risks of infections (mainly low respiratory tract infections and diarrhoea) and malaria than HUU children, particularly in children not breastfed or after early weaning. Higher mortality risk from infectious disease is reported in HEU compared to HUU children. SUMMARY As we move toward the elimination of mother-to-child transmission of HIV, HEU children are an emerging population whose health outcomes remain to be fully described. Future large cohorts of HEU children using careful comparison groups of HUU in the post-ART era are needed to better understand their long-term health outcomes.
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Disclosing in utero HIV/ARV exposure to the HIV-exposed uninfected adolescent: is it necessary? J Int AIDS Soc 2016; 19:21099. [PMID: 27741954 PMCID: PMC5065689 DOI: 10.7448/ias.19.1.21099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 09/06/2016] [Accepted: 09/14/2016] [Indexed: 01/04/2023] Open
Abstract
Introduction The tremendous success of antiretroviral therapy has resulted in a diminishing population of perinatally HIV-infected children on the one hand and a mounting number of HIV-exposed uninfected (HEU) children on the other. As the oldest of these HEU children are reaching adolescence, questions have emerged surrounding the implications of HEU status disclosure to these adolescents. This article outlines the arguments for and against disclosure of a child's HEU status. Discussion Disclosure of a child's HEU status, by definition, requires disclosure of maternal HIV status. It is necessary to weigh the benefits and harms which could occur with disclosure in each of the following domains: psychosocial impact, long-term physical health of the HEU individual and the public health impact. Does disclosure improve or worsen the psychological health of the HEU individual and extended family unit? Do present data on the long-term safety of in utero HIV/ARV exposure reveal potential health risks which merit disclosure to the HEU adolescent? What research and public health programmes or systems need to be in place to afford monitoring of HEU individuals and which, if any, of these require disclosure? Conclusions At present, it is not clear that there is sufficient evidence on whether long-term adverse effects are associated with in utero HIV/ARV exposures, making it difficult to mandate universal disclosure. However, as more countries adopt electronic medical record systems, the HEU status of an individual should be an important piece of the health record which follows the infant not only through childhood and adolescence but also adulthood. Clinicians and researchers should continue to approach the dialogue around mother–child disclosure with sensitivity and a cogent consideration of the evolving risks and benefits as new information becomes available while also working to maintain documentation of an individual's perinatal HIV/ARV exposures as a vital part of his/her medical records. As more long-term adult safety data on in utero HIV/ARV exposures become available these decisions may become clearer, but at this time, they remain complex and multi-faceted.
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Poda A, Hema A, Konaté A, Kaboré F, Zoungrana J, Kamboulé E, Soré I, Bado G, Ouédraogo AS, Ouédraogo M, Meda N, Sawadogo AB. Pregnancy rate and birth outcomes among women receiving antiretroviral therapy in Burkina Faso: a retrospective cohort study. Pan Afr Med J 2016; 23:105. [PMID: 27222692 PMCID: PMC4867182 DOI: 10.11604/pamj.2016.23.105.7372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 02/10/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION In Sub-Saharan Africa, few studies reported pregnancy incidence and outcomes in women taking antiretroviral therapy (ART). This survey aims to estimate the incidence and outcomes of pregnancy in a cohort of HIV positive women initiating ART in Bobo-Dioulasso, Burkina Faso. METHODS We carried out a retrospective cohort study. We selected women in childbearing age initiating ART and followed up in Bobo-Dioulasso teaching hospital between January 2005 and June 2011. The incidence of pregnancies during follow-up was calculated. Childbirth was defined by the expulsion of a fetus after 22 weeks of amenorrhea. Before this term, it is an abortion. Childbirth is said premature if it occurs before 37 weeks of gestation, to term if it occurs between the 38th and the 42nd week. The annual age-standardized fertility rates were calculated using the baseline population from the 2010 demographic and health survey (DHS) in Burkina Faso. RESULTS A total of 1,763 women of childbearing age under ART were included in the study. They ranged between 18 and 48 years old with a median of 35 years old. A total of 222 pregnancies were observed during 4639 women-years of follow-up, corresponding to an incidence density of 5 pregnancies for 100 women-years (95% CI: 4.2-5.5). Among the 222 pregnancies recorded, 9(4.0%) ended with abortion, 205(92.4%) with childbirth (including 15 premature childbirths); the outcome of 8(3.6%) pregnancies were unknown abortion. Live birth and stillborn rates were 94.0% (193/205) and 6.0% respectively. The standard fertility rate in our cohort was 45 live births for 1,000 women-years. The general decrease in fertility rates was 66.0% among women infected with HIV compared to the overall population. CONCLUSION This study shows a low pregnancy incidence among women initiating ART as compared to their peers from the general population. Pregnancies that occurred during ART generally end with live births. Care packages for HIV infected women of childbearing age must include reproductive health services to better address this issue.
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Affiliation(s)
- Armel Poda
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Souro Sanou, Bobo Dioulasso, Burkina Faso; Institut Supérieur des Sciences de la Santé (INSSA), Université Polytechnique de Bobo Dioulasso (UPB), Bobo Dioulasso, Burkina Faso
| | - Arsène Hema
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Souro Sanou, Bobo Dioulasso, Burkina Faso
| | - Aina Konaté
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Souro Sanou, Bobo Dioulasso, Burkina Faso
| | - Firmin Kaboré
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Souro Sanou, Bobo Dioulasso, Burkina Faso
| | - Jacques Zoungrana
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Souro Sanou, Bobo Dioulasso, Burkina Faso
| | - Euloges Kamboulé
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Souro Sanou, Bobo Dioulasso, Burkina Faso
| | - Ibrahim Soré
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Souro Sanou, Bobo Dioulasso, Burkina Faso
| | - Guillaume Bado
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Souro Sanou, Bobo Dioulasso, Burkina Faso
| | - Abdoul-Salam Ouédraogo
- Institut Supérieur des Sciences de la Santé (INSSA), Université Polytechnique de Bobo Dioulasso (UPB), Bobo Dioulasso, Burkina Faso; Service de Bactériologie Virologie, CHU Souro Sanou, Bobo Dioulasso, Burkina Faso
| | - Macaire Ouédraogo
- Institut Supérieur des Sciences de la Santé (INSSA), Université Polytechnique de Bobo Dioulasso (UPB), Bobo Dioulasso, Burkina Faso; Service de Médecine Interne, CHU Souro Sanou, Bobo Dioulasso, Burkina Faso
| | - Nicolas Meda
- Unité de Formation et de Recherche en Sciences de la Santé, Université de Ouagadougou, Ouagadougou, Burkina Faso; Centre Muraz, Bobo Dioulasso, Burkina Faso
| | - Adrien Bruno Sawadogo
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Souro Sanou, Bobo Dioulasso, Burkina Faso; Unité de Formation et de Recherche en Sciences de la Santé, Université de Ouagadougou, Ouagadougou, Burkina Faso
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Sibiude J, Warszawski J, Blanche S. Tolerance of the newborn to antiretroviral drug exposure in utero. Expert Opin Drug Saf 2015; 14:643-54. [PMID: 25727366 DOI: 10.1517/14740338.2015.1019462] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The prevention of mother-to-child HIV-1 transmission by antiretroviral drug treatment is remarkably effective. The risk of transmission to the child is now almost zero for women optimally treated during pregnancy. The rapid expansion of this prophylactic treatment has led the World Health Organization to aspire to the virtual elimination of mother-to-child transmission and pediatric AIDS over the next few years. In 2014, more than 900,000 women worldwide were treated with antiretroviral drugs during pregnancy. The issue of fetal and neonatal antiretroviral drug tolerance is therefore extremely important. AREAS COVERED This review focuses on the possible impact of in utero exposure to antiretroviral drug on newborn health. To restrict analysis to this period is justified by the specificities of transplacental drug exposure and fetal vulnerability. Relevant data are available from trials and observational cohorts. The significance of various bio-markers detectable at birth is still unresolved, but merits a careful evaluation. Long-term assessment is associated with various logistical difficulties. EXPERT OPINION The health of 'exposed but not infected' children poses no major problem in the immense majority of cases, but a series of biological, clinical and imaging-based warning signs have emerged indicating the need for careful attention to be paid to this issue. Some effects that are straightforward to manage in industrialized countries may have more severe consequences in countries in which access to effective healthcare is limited. Nucleoside/nucleotide analogs are potentially genotoxic to mitochondrial and nuclear DNA, and the principal question to be addressed concerns their potential long-term effects.
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Affiliation(s)
- Jeanne Sibiude
- Hôpital Louis Mourier, Service de Gynécologie et d'Obstétrique, Assistance Publique -Hôpitaux de Paris (APHP) , Colombes , France
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