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Espinal M, Yee LM, Fisher SA. Advances in HIV Management During Pregnancy and Infant Feeding. Infect Dis Clin North Am 2024; 38:423-452. [PMID: 38969531 DOI: 10.1016/j.idc.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
Recent advances in human immunodeficiency virus (HIV) management during pregnancy and infant feeding encompass several key elements: expanded HIV testing guidance; growing evidence of safety, efficacy, and pharmacokinetic data favoring the use of preferred antiretroviral therapy (ART) during pregnancy and breastfeeding; increasing advocacy for the inclusion of pregnant individuals with HIV in clinical trials to expedite access to new ART; and updated guidelines supporting shared decision-making for choice of infant feeding methods in people with HIV.
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Affiliation(s)
- Mariana Espinal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA.
| | - Stephanie A Fisher
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA
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Powell A, Agwu A. In Support of Breast-/Chestfeeding by People With HIV in High-Income Settings. Clin Infect Dis 2024; 79:202-207. [PMID: 38270916 DOI: 10.1093/cid/ciae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 01/26/2024] Open
Abstract
Given that HIV can be transmitted through breastfeeding, historically, breastfeeding among women with HIV in the US and other resource-rich settings was discouraged. Formula feeding was the mandated feeding option out of concern for breast-milk transmission of HIV, which occurred in 16-24% of cases pre-antiretroviral therapy (pre-ART) use. In January 2023, the US Department of Health and Human Services' Perinatal Guidelines were revised to support shared decision-making for infant feeding choices. Updated clinical trials' data from resource-limited settings suggest the actual breastmilk HIV transmission rate in the context of maternal ART or neonatal postexposure prophylaxis is 0.3-1%. High-income countries are reporting more people with HIV breastfeeding their infants without cases of HIV transmission. We present the reasons for fully embracing breast-/chestfeeding as a viable, safe infant feeding option for HIV-exposed infants in high-income settings, while acknowledging unanswered questions and the need to continually craft more nuanced clinical guidance.
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Affiliation(s)
- Anna Powell
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allison Agwu
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Boisson-Walsh A, Ravelomanana NLR, Tabala M, Malongo F, Kawende B, Babakazo P, Yotebieng M. Association of comprehensiveness of antiretroviral care and detectable HIV viral load suppression among pregnant and postpartum women in the Democratic Republic of the Congo: a cross-sectional study. Front Glob Womens Health 2024; 5:1308019. [PMID: 38903153 PMCID: PMC11188341 DOI: 10.3389/fgwh.2024.1308019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 05/21/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction Worldwide, over two-thirds of people living with HIV are on antiretroviral therapy (ART). Despite increased ART access, high virological suppression prevalence remains out of reach. Few studies consider the quality of ART services and their impact on recipients' viral suppression. We assessed the association between ART service readiness and HIV viral load suppression among pregnant and breastfeeding women living with HIV (WLH) receiving ART in maternal and child health (MCH) clinics in Kinshasa, Democratic Republic of Congo. Methods We performed a cross-sectional analysis leveraging data from a continuous quality improvement intervention on WLH's long-term ART outcomes. From November 2016 to May 2020, we enrolled WLH from the three largest clinics in each of Kinshasa'Łs 35 health zones. We measured clinic's readiness using three WHO-identified ART care quality indicators: relevant guidelines in ART service area, stocks of essential ART medicines, and relevant staff training in ≥24 months, scoring clinics 0-3 based on observed indicators. We defined viral load suppression as ≤1,000 cp/ml. Multilevel mixed-effect logistic models were used to estimate prevalence odds ratios (ORs) measuring the strength of the association between ART service readiness and viral suppression. Results Of 2,295 WLH, only 1.9% received care from a clinic with a score of 3, 24.1% received care from a 0-scoring clinic, and overall, 66.5% achieved virologically suppression. Suppression increased from 65% among WLH receiving care in 0-scoring clinics to 66.9% in 1-scoring clinics, 65.8% in 2-scoring clinics, and 76.1% in 3-scoring clinics. We did not observe a statistically significant association between ART service readiness score and increased viral suppression prevalence, however we did find associations between other factors, such as the location of the health center and pharmacist availability with suppressed viral load. Discussion A lack of comprehensive ART care underscores the need for enhanced structural and organizational support to improve virological suppression and overall health outcomes for women living with HIV..
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Affiliation(s)
- Alix Boisson-Walsh
- Department of Health Policy and Management, University of Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Martine Tabala
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Fathy Malongo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Bienvenu Kawende
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Pélagie Babakazo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, United States
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Goulding AN, Meeks K, Shay L, Casey S, Applegarth C, McKinney J. Antiretroviral Therapy in Pregnancy: A 2023 Review of the Literature. Curr HIV/AIDS Rep 2024; 21:1-10. [PMID: 38277098 PMCID: PMC11095844 DOI: 10.1007/s11904-024-00688-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE OF REVIEW Selection of antiretroviral therapy during pregnancy must consider maternal physiology and resulting pharmacokinetic changes in pregnancy, resistance and efficacy profiles, tolerability and frequency of adverse effects, teratogenicity, and maternal, neonatal, and pregnancy outcomes. The objective of this review is to summarize the underlying data that informs the current clinical perinatal guidelines in the USA. RECENT FINDINGS Data now supports the use of dolutegravir at all stages of pregnancy with no significant increase in neural tube defects. Safety and pharmacokinetic data on newer antiretroviral medications in pregnancy continue to lag behind the general population. While there are multiple safety and tolerability concerns with older regimens, there are now multiple options of regimens that are highly efficacious and have good safety data in pregnancy. Most pregnant patients who are virally suppressed on a well-tolerated regimen are able to safely continue those medications during pregnancy.
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Affiliation(s)
- Alison N Goulding
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Kasey Meeks
- School of Medicine, Saint Louis University, Saint Louis, MO, USA
| | - Lena Shay
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Sarah Casey
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Colton Applegarth
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jennifer McKinney
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA.
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Chinula L, Ziemba L, Brummel S, McCarthy K, Coletti A, Krotje C, Johnston B, Knowles K, Moyo S, Stranix-Chibanda L, Hoffman R, Sax PE, Stringer J, Chakhtoura N, Jean-Philippe P, Korutaro V, Cassim H, Fairlie L, Masheto G, Boyce C, Frenkel LM, Amico KR, Purdue L, Shapiro R, Mmbaga BT, Patel F, van Wyk J, Rooney JF, Currier JS, Lockman S. Efficacy and safety of three antiretroviral therapy regimens started in pregnancy up to 50 weeks post partum: a multicentre, open-label, randomised, controlled, phase 3 trial. Lancet HIV 2023; 10:e363-e374. [PMID: 37167996 PMCID: PMC10280394 DOI: 10.1016/s2352-3018(23)00061-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Drugs taken during pregnancy can affect maternal and child health outcomes, but few studies have compared the safety and virological efficacy of different antiretroviral therapy (ART) regimens. We report the primary safety outcomes from enrolment up to 50 weeks post partum and a secondary virological efficacy outcome at 50 weeks post partum of three commonly used ART regimens for HIV-1. METHODS In this multicentre, open-label, randomised, controlled, phase 3 trial, we enrolled pregnant women aged 18 years or older with confirmed HIV-1 infection at 14-28 weeks of gestation. Women were enrolled at 22 clinical research sites in nine countries (Botswana, Brazil, India, South Africa, Tanzania, Thailand, Uganda, the USA, and Zimbabwe). Participants were randomly assigned (1:1:1) to one of three oral regimens: dolutegravir, emtricitabine, and tenofovir alafenamide; dolutegravir, emtricitabine, and tenofovir disoproxil fumarate; or efavirenz, emtricitabine, and tenofovir disoproxil fumarate. Up to 14 days of antepartum ART before enrolment was permitted. Women with known multiple gestation, fetal anomalies, acute significant illness, transaminases more than 2·5 times the upper limit of normal, or estimated creatinine clearance of less than 60 mL/min were excluded. Primary safety analyses were pairwise comparisons between ART regimens of the proportion of maternal and infant adverse events of grade 3 or higher up to 50 weeks post partum. Secondary efficacy analyses at 50 weeks post partum included a comparison of the proportion of women with plasma HIV-1 RNA of less than 200 copies per mL in the combined dolutegravir-containing groups versus the efavirenz-containing group. Analyses were done in the intention-to-treat population, which included all randomly assigned participants with available data. This trial was registered with ClinicalTrials.gov, NCT03048422. FINDINGS Between Jan 19, 2018, and Feb 8, 2019, we randomly assigned 643 pregnant women to the dolutegravir, emtricitabine, and tenofovir alafenamide group (n=217), the dolutegravir, emtricitabine, and tenofovir disoproxil fumarate group (n=215), and the efavirenz, emtricitabine, and tenofovir disoproxil fumarate group (n=211). At enrolment, median gestational age was 21·9 weeks (IQR 18·3-25·3), median CD4 count was 466 cells per μL (308-624), and median HIV-1 RNA was 903 copies per mL (152-5183). 607 (94%) women and 566 (92%) of 617 liveborn infants completed the study. Up to the week 50 post-partum visit, the estimated probability of experiencing an adverse event of grade 3 or higher was 25% in the dolutegravir, emtricitabine, and tenofovir alafenamide group; 31% in the dolutegravir, emtricitabine, and tenofovir disoproxil fumarate group; and 28% in the efavirenz, emtricitabine, and tenofovir disoproxil fumarate group (no significant difference between groups). Among infants, the estimated probability of experiencing at least one adverse event of grade 3 or higher by postnatal week 50 was 28% overall, with small and non-statistically significant differences between groups. By postnatal week 50, 14 infants whose mothers were in the efavirenz-containing group (7%) died, compared with six in the combined dolutegravir groups (1%). 573 (89%) women had HIV-1 RNA data available at 50 weeks post partum: 366 (96%) in the dolutegravir-containing groups and 186 (96%) in the efavirenz-containing group had HIV-1 RNA less than 200 copies per mL, with no significant difference between groups. INTERPRETATION Safety and efficacy data during pregnancy and up to 50 weeks post partum support the current recommendation of dolutegravir-based ART (particularly in combination with emtricitabine and tenofovir alafenamide) rather than efavirenz, emtricitabine, and tenofovir disoproxil fumarate, when started in pregnancy. FUNDING National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute of Mental Health.
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Affiliation(s)
- Lameck Chinula
- University of North Carolina Project-Malawi, Lilongwe, Malawi; Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Lauren Ziemba
- Department of Immunology and Infectious Diseases and Center for Biostatistics in AIDS Research, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Sean Brummel
- Department of Immunology and Infectious Diseases and Center for Biostatistics in AIDS Research, Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | | | - Chelsea Krotje
- Frontier Science & Technology Research Foundation, Amherst, NY, USA
| | | | - Kevin Knowles
- Frontier Science & Technology Research Foundation, Amherst, NY, USA
| | - Sikhulile Moyo
- Department of Immunology and Infectious Diseases and Center for Biostatistics in AIDS Research, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Risa Hoffman
- University of California Los Angeles, Los Angeles, CA, USA
| | - Paul E Sax
- Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Jeffrey Stringer
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nahida Chakhtoura
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD, USA
| | | | - Violet Korutaro
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Haseena Cassim
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Lee Fairlie
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Gaerolwe Masheto
- Department of Immunology and Infectious Diseases and Center for Biostatistics in AIDS Research, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Ceejay Boyce
- Seattle Children's Research Center and University of Washington, Seattle, WA, USA
| | - Lisa M Frenkel
- Seattle Children's Research Center and University of Washington, Seattle, WA, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Lynette Purdue
- Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Roger Shapiro
- Department of Immunology and Infectious Diseases and Center for Biostatistics in AIDS Research, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Blandina Theophil Mmbaga
- Kilimanjaro Christian Medical Centre and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Faeezah Patel
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Shahin Lockman
- Department of Immunology and Infectious Diseases and Center for Biostatistics in AIDS Research, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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Wu Y, Liu S, Chu L, Zhang Q, Yang J, Qiao S, Li X, Zhou Y, Deng H, Shen Z. Hair Zidovudine Concentrations Predict Virologic Outcomes Among People Living with HIV/AIDS in China. Patient Prefer Adherence 2022; 16:1885-1896. [PMID: 35945983 PMCID: PMC9357394 DOI: 10.2147/ppa.s371623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/26/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Hair antiretroviral concentrations are an objective and non-invasive measure of adherence to long-term antiretroviral therapy (ART) and can further predict virologic outcomes among people living with HIV/AIDS (PLWH). Zidovudine, one of the mainstream antiretrovirals in China, has been verified to have high reliability in adherence assessment, especially for its hair concentrations. However, data are limited in its predicting virologic outcomes. Therefore, this study aimed to characterize whether hair zidovudine concentrations can predict virologic suppression among Chinese PLWH compared with hair lamivudine concentrations and two self-reported measures, the overall frequency of adherence behaviors and percentage adherence. METHODS This cross-sectional study randomly recruited 564 PLWH currently treated with zidovudine, lamivudine, and other ART agents (efavirenz, nevirapine, or lopinavir/ritonavir) in Guangxi, China. Hair antiretroviral concentrations were determined using the LC-ESI+-MS/MS method. Receiver operating characteristic (ROC) curves were used to estimate the optimal classification thresholds of hair concentrations of zidovudine and lamivudine, and the two self-reported measures. Based on those optimal classification thresholds, logistic regression was used to examine whether those four adherence measures can predict virologic suppression (HIV-1 RNA <200 copies/mL). RESULTS ROC curves demonstrated good classification performance for association with virologic suppression of zidovudine with the optimal threshold at 58 pg/mg and lamivudine at 255 pg/mg but no self-reported measures. PLWH with hair zidovudine concentrations >58 pg/mg had an adjusted odds ratio (aOR) of 43.191 (95% confidence interval (CI) = 10.171‒183.418, p < 0.001) for virologic suppression. Hair lamivudine concentrations were also associated with virologic suppression (aOR = 10.656, 95% CI = 3.670‒30.943, p < 0.001). However, two self-reported measures did not predict virologic suppression (aORs = 1.157 and 2.488, ps >0.149). CONCLUSION Hair zidovudine concentrations can be served as an alternative tool for clinically predicting virologic suppression among PLWH in China.
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Affiliation(s)
- Yan Wu
- Department of Brain and Learning Science, School of Biological Science & Medical Engineering, Southeast University, Nanjing, People’s Republic of China
- Key Laboratory of Child Development and Learning Science (Southeast University), Ministry of Education, Nanjing, People’s Republic of China
- Institute of Child Development and Education, Research Center for Learning Science, Southeast University, Nanjing, People’s Republic of China
| | - Shuaifeng Liu
- Unit of AIDS Prevention and Control, Guangxi Zhuang Autonomous Region Center for Disease Prevention and Control, Nanning, People’s Republic of China
| | - Liuxi Chu
- Department of Brain and Learning Science, School of Biological Science & Medical Engineering, Southeast University, Nanjing, People’s Republic of China
- Key Laboratory of Child Development and Learning Science (Southeast University), Ministry of Education, Nanjing, People’s Republic of China
- Institute of Child Development and Education, Research Center for Learning Science, Southeast University, Nanjing, People’s Republic of China
| | - Quan Zhang
- Department of Health Promotion, Education and Behavior, South Carolina SmartState Center for Healthcare Quality (CHQ), Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
- College of Graduate Health Sciences, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jin Yang
- Institute of Child Development and Education, Research Center for Learning Science, Southeast University, Nanjing, People’s Republic of China
- Department of Preventive Medicine, School of Public Health, Southeast University, Nanjing, People’s Republic of China
| | - Shan Qiao
- Department of Health Promotion, Education and Behavior, South Carolina SmartState Center for Healthcare Quality (CHQ), Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Xiaoming Li
- Department of Health Promotion, Education and Behavior, South Carolina SmartState Center for Healthcare Quality (CHQ), Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Yuejiao Zhou
- Unit of AIDS Prevention and Control, Guangxi Zhuang Autonomous Region Center for Disease Prevention and Control, Nanning, People’s Republic of China
| | - Huihua Deng
- Department of Brain and Learning Science, School of Biological Science & Medical Engineering, Southeast University, Nanjing, People’s Republic of China
- Key Laboratory of Child Development and Learning Science (Southeast University), Ministry of Education, Nanjing, People’s Republic of China
- Institute of Child Development and Education, Research Center for Learning Science, Southeast University, Nanjing, People’s Republic of China
- Correspondence: Huihua Deng, Department of Brain and Learning Science, School of Biological Science & Medical Engineering, Southeast University, No. 2 Sipailou, Nanjing, 210096, People’s Republic of China, Tel +86 25 8379 5664, Fax +86 25 8379 3779, Email
| | - Zhiyong Shen
- Unit of AIDS Prevention and Control, Guangxi Zhuang Autonomous Region Center for Disease Prevention and Control, Nanning, People’s Republic of China
- Zhiyong Shen, Unit of AIDS Prevention and Control, Guangxi Zhuang Autonomous Region Center for Disease Prevention and Control, No. 18 Jinzhou Road, Nanning, 530028, People’s Republic of China, Tel +86 771 251 8838, Email
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Dapar MP, Joseph BN, Okunlola RC, Mutihir J, Chingle MP, Banwat ME. Pregnancy and Birth Outcomes Among Women on Antiretroviral Therapy: A Long-term Retrospective Analysis of Data from a Major Tertiary Hospital in North Central Nigeria. Int J MCH AIDS 2021; 10:183-190. [PMID: 34754614 PMCID: PMC8564061 DOI: 10.21106/ijma.511] [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] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Antiretroviral therapy (ART) has transformed human immune deficiency virus (HIV) infection from a death sentence to a chronic syndrome, allowing infected individuals to lead near-normal lives, including achieving pregnancy and bearing children. Notwithstanding, concerns remain about the effects of ART in pregnancy. Previous studies suggested contradictory associations between ART and pregnancy. This study determined birth outcomes in pregnant women who accessed ART between 2004 and 2017 at a major tertiary hospital in North Central Nigeria. METHODS This was a retrospective study of 5,080 participants. Ethical clearance was obtained from the Institutional Review Board of the Harvard T. H. Chan School of Public Health Boston. A pro forma for data abstraction was designed and used to collect data. Abstracted data were sorted and managed using SPSS® version 22. The Chi-square test was used to calculate the proportions of pregnancy outcomes. One-way analysis of variance was used to test the effect of antiretroviral drug regimens on mean birth weight and gestational age at delivery. All levels of significance were set at p 0.05. RESULTS Pregnancy outcomes were recorded as live birth (99.8%), stillbirth (0.2%), preterm delivery (6.6%), and low birth weight (23%). There was a statistically significant association between ART in pregnancy and low birth weight {χ2 [(5, n = 3439) = 11.99, p = 0.04]}. The highest mean birth weights were recorded in participants who received drug combinations with protease inhibitors or efavirenz, in contrast to participants who received Nevirapine, stavudine and Emtricitabine/Tenofovirbased regimens. However, there was no significant difference in the gestational age of babies at birth for the six ART regimens in the study. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS Findings support the benefits of ART in pregnancy, which is in line with the testing and treatment policies of the 90-90-90 targets for ending HIV by the year 2030.
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Affiliation(s)
- Maxwell P. Dapar
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, University of Jos, Nigeria
| | - Benjamin N. Joseph
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, University of Jos, Nigeria
| | - Rotkangmwa C. Okunlola
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, University of Jos, Nigeria
| | - Josiah Mutihir
- Department of Obstetrics and Gynecology, College of Health Sciences, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - Moses P. Chingle
- Department of Community Medicine, College of Health Sciences, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - Mathilda E. Banwat
- Department of Community Medicine, College of Health Sciences, University of Jos and Jos University Teaching Hospital, Jos Nigeria
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8
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Apornpong T, Grinsztejn B, Hughes M, Ritz J, Kerr SJ, Fletcher CV, Ruxrungtham K, Godfrey C, Gross R, Hogg E, Wallis CL, Badal-Faesen S, Hosseinipour MC, Mngqbisa R, Santos BR, Shah S, Hovind LJ, Mawlana S, Van Schalkwyk M, Chotirosniramit N, Kanyama C, Kumarasamy N, Salata R, Collier AC, Gandhi M. Antiretroviral hair levels, self-reported adherence, and virologic failure in second-line regimen patients in resource-limited settings. AIDS 2021; 35:1439-1449. [PMID: 33831905 PMCID: PMC8243835 DOI: 10.1097/qad.0000000000002901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate associations between hair antiretroviral hair concentrations as an objective, cumulative adherence metric, with self-reported adherence and virologic outcomes. DESIGN Analysis of cohort A of the ACTG-A5288 study. These patients in resource-limited settings were failing second-line protease inhibitor-based antiretroviral therapy (ART) but were susceptible to at least one nucleoside reverse transcriptase inhibitor (NRTI) and their protease inhibitor, and continued taking their protease inhibitor-based regimen. METHODS Antiretroviral hair concentrations in participants taking two NRTIs with boosted atazanavir (n = 69) or lopinavir (n = 112) were analyzed at weeks 12, 24, 36 and 48 using liquid-chromatography--tandem-mass-spectrometry assays. Participants' self-reported percentage of doses taken in the previous month; virologic failure was confirmed HIV-1 RNA at least 1000 copies/ml at week 24 or 48. RESULTS From 181 participants with hair samples (61% women, median age: 39 years; CD4+ cell count: 167 cells/μl; HIV-1 RNA: 18 648 copies/ml), 91 (50%) experienced virologic failure at either visit. At 24 weeks, median hair concentrations were 2.95 [interquartile range (IQR) 0.49-4.60] ng/mg for atazanavir, 2.64 (IQR 0.73--7.16) for lopinavir, and 0.44 (IQR 0.11--0.76) for ritonavir. Plasma HIV-1 RNA demonstrated inverse correlations with hair levels (rs -0.46 to -0.74) at weeks 24 and 48. Weaker associations were seen with self-reported adherence (rs -0.03 to -0.24). Decreasing hair concentrations were significantly associated with virologic failure, the hazard ratio (95% CI) for ATV, LPV, and RTV were 0.69 (0.56-0.86), 0.77 (0.68-0.87), and 0.12 (0.06-0.27), respectively. CONCLUSION Protease inhibitor hair concentrations showed stronger associations with subsequent virologic outcomes than self-reported adherence in this cohort. Hair adherence measures could identify individuals at risk of second-line treatment failure in need of interventions.
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Affiliation(s)
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Michael Hughes
- Harvard T.H. Chan School of Public Health, Boston, Maryland, USA
| | - Justin Ritz
- Harvard T.H. Chan School of Public Health, Boston, Maryland, USA
| | - Stephen J Kerr
- HIV-NAT, TRCARC, Bangkok, Thailand
- Biostatistics Excellence Centre, Bangkok, Thailand
- The Kirby Institute, UNSW, Sydney, Australia
| | | | - Kiat Ruxrungtham
- HIV-NAT, TRCARC, Bangkok, Thailand
- Chulalongkorn University, Bangkok, Thailand
| | | | | | - Evelyn Hogg
- Social & Scientific Systems, Silver Spring, Maryland, USA
| | | | - Sharlaa Badal-Faesen
- Clinical HIV Research Unit, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Breno R Santos
- Hospital Nossa Senhora da Conceicao CRS, Rio Grande do Sul, Brazil
| | | | - Laura J Hovind
- Frontier Science & Technology Research Foundation, Inc., Amherst, Massachusetts, USA
| | - Sajeeda Mawlana
- Hospital Nossa Senhora da Conceicao CRS, Rio Grande do Sul, Brazil
| | - Marije Van Schalkwyk
- Family Centre for Research with Ubuntu (FAMCRU), Stellenbosch University, Cape Town, South Africa
| | | | | | | | | | | | - Monica Gandhi
- University of California, San Francisco, California, USA
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9
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Okochi H, Louie A, Phung N, Zhang K, Tallerico RM, Kuncze K, Spinelli MA, Koss CA, Benet LZ, Gandhi M. Tenofovir and emtricitabine concentrations in hair are comparable between individuals on tenofovir disoproxil fumarate versus tenofovir alafenamide-based ART. Drug Test Anal 2021; 13:1354-1370. [PMID: 33742745 PMCID: PMC9131373 DOI: 10.1002/dta.3033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 12/15/2022]
Abstract
Tenofovir disoproxil fumarate (TDF) in combination with emtricitabine (FTC) is the backbone for both human immunodeficiency virus (HIV) treatment and pre-exposure prophylaxis (PrEP) worldwide. Tenofovir alafenamide (TAF) with FTC is increasingly used in HIV treatment and was recently approved for PrEP among men-who-have-sex-with-men. TDF and TAF are both metabolized into tenofovir (TFV). Antiretrovirals in plasma are taken up into hair over time, with hair levels providing a long-term measure of adherence. Here, we report a simple, robust, highly sensitive, and validated high-performance liquid chromatography coupled with tandem mass spectrometry (LC/MS/MS)-based analytical method for analyzing TFV and FTC from individuals on either TDF/FTC or TAF/FTC in small hair samples. TFV/FTC are extracted from ~5 mg hair and separated on a column using a gradient elution. The lower quantification limits are 0.00200 (TFV) and 0.0200 (FTC) ng/mg hair; the assay is linear up to 0.400 (TFV) and 4.00 (FTC) ng/mg hair. The intra-day and inter-day coefficients of variance (CVs) are 5.39-12.6% and 6.40-13.5% for TFV and 0.571-2.45% and 2.45-5.16% for FTC. TFV concentrations from participants on TDF/FTC-based regimens with undetectable plasma HIV RNA were 0.0525 ± 0.0295 ng/mg, whereas those from individuals on TAF/FTC-based regimens were 0.0426 ± 0.0246 ng/mg. Despite the dose of TFV in TDF being 10 times that of TAF, hair concentrations of TFV were not significantly different for those on TDF versus TAF regimens. Pharmacological enhancers (ritonavir and cobicistat) did not boost TFV concentrations in hair. In summary, we developed and validated a sensitive analytical method to analyze TFV and FTC in hair and found that hair concentrations of TFV were essentially equivalent among those on TDF and TAF.
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Affiliation(s)
- Hideaki Okochi
- Division of HIV, Infection Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- UCSF-Hair Analytical Laboratory, University of California San Francisco, San Francisco, California, USA
| | - Alexander Louie
- Division of HIV, Infection Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- UCSF-Hair Analytical Laboratory, University of California San Francisco, San Francisco, California, USA
| | - Nhi Phung
- Division of HIV, Infection Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- UCSF-Hair Analytical Laboratory, University of California San Francisco, San Francisco, California, USA
| | - Kevin Zhang
- Division of HIV, Infection Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- UCSF-Hair Analytical Laboratory, University of California San Francisco, San Francisco, California, USA
| | - Regina M. Tallerico
- Division of HIV, Infection Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- UCSF-Hair Analytical Laboratory, University of California San Francisco, San Francisco, California, USA
| | - Karen Kuncze
- Division of HIV, Infection Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- UCSF-Hair Analytical Laboratory, University of California San Francisco, San Francisco, California, USA
| | - Matthew A. Spinelli
- Division of HIV, Infection Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Catherine A. Koss
- Division of HIV, Infection Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Leslie Z. Benet
- UCSF-Hair Analytical Laboratory, University of California San Francisco, San Francisco, California, USA
- Department of Bioengineering and Therapeutic Sciences, Schools of Pharmacy and Medicine, University of California San Francisco, San Francisco, California, USA
| | - Monica Gandhi
- Division of HIV, Infection Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- UCSF-Hair Analytical Laboratory, University of California San Francisco, San Francisco, California, USA
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10
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Pascom ARP, Fonseca FF, Pinho RGG, Perini FB, Pereira G, Avelino-Silva VI. Impact of antiretroviral regimen on viral suppression among pregnant women living with HIV in Brazil. Int J STD AIDS 2021; 31:903-910. [PMID: 32702281 DOI: 10.1177/0956462420932688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Human immunodeficiency virus (HIV) viral load (VL) during pregnancy is a critical determinant of the risk of HIV mother-to-child transmission (MTCT). Prior studies suggest that VL suppression is influenced by antiretroviral regimen. In this study, using secondary real-life data from the Ministry of Health of Brazil, we compared VL suppression at 60-180 days after the first antiretroviral therapy (ART) prescription during pregnancy and time to undetectable VL among pregnant women under treatment with double nucleoside/nucleotide regimens combined with efavirenz, boosted lopinavir, boosted atazanavir, or raltegravir, with adjustment for potential confounders in multivariable models. A total of 18,997 pregnant women living with HIV were included in the study. Compared to regimens containing lopinavir, we found that atazanavir-, efavirenz-, and raltegravir-based regimens were superior in achieving both outcomes after adjustment for age, social vulnerability index, time under ART, baseline CD4+ cell count, and baseline HIV VL. Raltegravir-containing regimens had the highest adjusted odds/rates of VL suppression compared to patients with other regimens. Elimination of HIV MTCT is still a critical public health issue in many countries. Our findings suggest that raltegravir-based regimens were superior when compared to efavirenz-, lopinavir-, and atazanavir-based antiretroviral regimens in achieving suppression of HIV VL.
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Affiliation(s)
- Ana R Pati Pascom
- Department of Chronic Conditions and Sexually Transmitted Infections, Ministry of Health of Brazil, Brasilia, Brazil
| | - Fernanda F Fonseca
- Department of Chronic Conditions and Sexually Transmitted Infections, Ministry of Health of Brazil, Brasilia, Brazil
| | | | - Filipe Barros Perini
- Department of Chronic Conditions and Sexually Transmitted Infections, Ministry of Health of Brazil, Brasilia, Brazil
| | - Gerson Pereira
- Department of Chronic Conditions and Sexually Transmitted Infections, Ministry of Health of Brazil, Brasilia, Brazil
| | - Vivian I Avelino-Silva
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina da Universidade de Sao Paulo, Brazil
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11
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Zhang Q, Li X, Qiao S, Liu S, Shen Z, Zhou Y. Association of Hair Concentrations of Antiretrovirals with Virologic Outcomes Among People Living with HIV in Guangxi, China. Patient Prefer Adherence 2021; 15:853-861. [PMID: 33935495 PMCID: PMC8080155 DOI: 10.2147/ppa.s277965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/23/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Hair concentrations of antiretrovirals are an innovative and non-invasive method for measuring cumulative antiretroviral exposure and assessing long-term antiretroviral adherence. This study aimed to examine hair concentrations of antiretrovirals in relation to virologic outcomes among PLHIV in Guangxi, China. METHODS Cross-sectional data of hair concentrations of antiretrovirals and HIV viral load were collected from 215 PLHIV in Guangxi, China. Multivariate logistic regression analyses were used to examine the association of hair concentrations of antiretrovirals with virologic outcomes. RESULTS Of the 215 participants, 215, 67, and 163 PLHIV are receiving lamivudine, zidovudine, and efavirenz, respectively. Multivariate analysis revealed that hair concentrations of lamivudine [odds ratio = 16.52, 95% CI 2.51-108.60, p = 0.004] and efavirenz [odds ratio = 14.26, 95% CI 1.18-172.01, p = 0.036], but not zidovudine [odds ratio = 1.77, 95% CI 0.06-56.14, p = 0.747], were the strongest independent predictor of virologic suppression when controlling for sociodemographic and other HIV-related characteristics. CONCLUSION Hair concentrations of lamivudine and efavirenz were the strongest independent predictor of virologic suppression among Chinese PLHIV. Hair analysis of antiretrovirals may provide a non-invasive, cost-effective tool that predicts virologic suppression among PLHIV in China.
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Affiliation(s)
- Quan Zhang
- South Carolina SmartState Center for Healthcare Quality (CHQ), Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
- Institute of Pedagogy and Applied Psychology, School of Public Administration, Hohai University, Nanjing, Jiangsu, People’s Republic of China
| | - Xiaoming Li
- South Carolina SmartState Center for Healthcare Quality (CHQ), Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Shan Qiao
- South Carolina SmartState Center for Healthcare Quality (CHQ), Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Shuaifeng Liu
- Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, Guangxi, People’s Republic of China
| | - Zhiyong Shen
- Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, Guangxi, People’s Republic of China
| | - Yuejiao Zhou
- Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, Guangxi, People’s Republic of China
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12
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Approaches to Objectively Measure Antiretroviral Medication Adherence and Drive Adherence Interventions. Curr HIV/AIDS Rep 2020; 17:301-314. [PMID: 32424549 PMCID: PMC7363551 DOI: 10.1007/s11904-020-00502-5] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Traditional methods to assess antiretroviral adherence, such as self-report, pill counts, and pharmacy refill data, may be inaccurate in determining actual pill-taking to both antiretroviral therapy (ART) or pre-exposure prophylaxis (PrEP). HIV viral loads serve as surrogates of adherence on ART, but loss of virologic control may occur well after decreases in adherence and viral loads are not relevant to PrEP. RECENT FINDINGS Pharmacologic measures of adherence, electronic adherence monitors, and ingestible electronic pills all serve as more objective metrics of adherence, surpassing self-report in predicting outcomes. Pharmacologic metrics can identify either recent adherence or cumulative adherence. Recent dosing measures include antiretroviral levels in plasma or urine, as well as emtricitabine-triphosphate in dried blood spots (DBS) for those on tenofovir-emtricitabine-based therapy. A urine tenofovir test has recently been developed into a point-of-care test for bedside adherence monitoring. Cumulative adherence metrics assess adherence over weeks to months and include measurement of tenofovir-diphosphate in peripheral blood mononuclear cells or DBS, as well as ART levels in hair. Electronic adherence monitors and ingestible electronic pills can track pill bottle openings or medication ingestion, respectively. New and objective approaches in adherence monitoring can be used to detect nonadherence prior to loss of prevention efficacy or virologic control with PrEP or ART, respectively.
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13
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McDonald CR, Weckman AM, Wright JK, Conroy AL, Kain KC. Pregnant Women in Low- and Middle-Income Countries Require a Special Focus During the COVID-19 Pandemic. Front Glob Womens Health 2020; 1:564560. [PMID: 34816152 PMCID: PMC8594030 DOI: 10.3389/fgwh.2020.564560] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/24/2020] [Indexed: 01/22/2023] Open
Affiliation(s)
- Chloe R McDonald
- University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Andrea M Weckman
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Julie K Wright
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrea L Conroy
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Kevin C Kain
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
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14
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Adverse perinatal outcomes associated with antiretroviral therapy regimens: systematic review and network meta-analysis. AIDS 2020; 34:1643-1656. [PMID: 32701581 DOI: 10.1097/qad.0000000000002593] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Assess adverse perinatal outcomes associated with antenatal antiretroviral therapy (ART) regimens. DESIGN Systematic review and network meta-analysis of randomized controlled trials (RCTS). METHODS We conducted a systematic literature review by searching PubMed, CINAHL, Global Health, EMBASE, and the Cochrane Central Register of Controlled Trials and four clinical trial databases from 1 January 1980 to 28 April 2018. We included RCTs of antenatal ART regimens in HIV-positive pregnant women, which assessed preterm birth (PTB), spontaneous preterm birth (sPTB), very preterm birth (VPTB), low birthweight (LBW), very low birthweight (VLBW), small-for-gestational-age (SGA), neonatal death (NND), and mother-to-child-transmission. We used random-effects network meta-analysis models to calculate relative risks for treatment comparisons and the hierarchy of treatments. RESULTS Of 83 260 citations identified, 10 manuscripts were included, assessing 6285 women. Compared with zidovudine (ZDV) monotherapy, we found a higher risk of LBW after exposure to zidovudine/lamivudine/efavirenz (ZDV/3TC/EFV; relative risk 1.61; 95% CI 1.03-2.51), tenofovir disoproxil fumarate/emtricitabine/ritonavir-boosted lopinavir (TDF/FTC/LPV/r; 1.64; 1.18-2.29), or zidovudine/lamivudine/ritonavir-boosted lopinavir (ZDV/3TC/LPV/r; 1.87; 1.58-2.20). TDF/FTC/LPV/r carried an increased risk of VLBW, compared with ZDV monotherapy (5.40; 1.08-27.08). ZDV/3TC/LPV/r posed a higher risk of PTB than ZDV monotherapy (1.43; 1.08-1.91) and a higher risk of sPTB than zidovudine/lamivudine/abacavir (ZDV/3TC/ABC) (1.81; 1.21-2.71). LPV/r-containing regimens also carried the highest risks of VPTB, SGA and NND, although the limited data showed no significant differences. CONCLUSION Of the ART regimens assessed in RCTs in pregnancy, LPV/r-containing regimens were associated with the highest risks of adverse perinatal outcomes.
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15
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Perinatal Antiretroviral Intensification to Prevent Intrapartum HIV Transmission When Antenatal Antiretroviral Therapy Is Initiated Less Than 8 Weeks Before Delivery. J Acquir Immune Defic Syndr 2020; 84:313-322. [PMID: 32205720 PMCID: PMC9741956 DOI: 10.1097/qai.0000000000002350] [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] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Infants born to women living with HIV initiating combination antiretroviral therapy (cART) late in pregnancy are at high risk of intrapartum infection. Mother/infant perinatal antiretroviral intensification may substantially reduce this risk. METHODS In this single-arm Bayesian trial, pregnant women with HIV receiving standard of care antiretroviral prophylaxis in Thailand (maternal antenatal lopinavir-based cART; nonbreastfed infants 4 weeks' postnatal zidovudine) were offered "antiretroviral intensification" (labor single-dose nevirapine plus infant zidovudine-lamivudine-nevirapine for 2 weeks followed by zidovudine-lamivudine for 2 weeks) if their antenatal cART was initiated ≤8 weeks before delivery. A negative birth HIV-DNA polymerase chain reaction (PCR) followed by a confirmed positive PCR defined intrapartum transmission. Before study initiation, we modeled intrapartum transmission probabilities using data from 3738 mother/infant pairs enrolled in our previous trials in Thailand using a logistic model, with perinatal maternal/infant antiretroviral regimen and predicted viral load at delivery as main covariates. Using the characteristics of the women enrolled who received intensification, prior intrapartum transmission probabilities (credibility intervals) with/without intensification were estimated. After including the transmission data observed in the current study, the corresponding Bayesian posterior transmission probability was derived. RESULTS No intrapartum transmission of HIV was observed among the 88 mother/infant pairs receiving intensification. The estimated intrapartum transmission probability was 2·2% (95% credibility interval 0·5-6·1) without intensification versus 0·3% (0·0-1·6) with intensification. The probability of superiority of intensification over standard of care was 94·4%. Antiretroviral intensification appeared safe. CONCLUSION Mother/infant antiretroviral intensification was effective in preventing intrapartum transmission of HIV in pregnant women receiving ≤8 weeks antepartum cART.
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16
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Mei Y, Luo D, Wei S, Liao X, Pan Y, Yang X, Lin Y. Obstetric Management of COVID-19 in Pregnant Women. Front Microbiol 2020; 11:1186. [PMID: 32574255 PMCID: PMC7264107 DOI: 10.3389/fmicb.2020.01186] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/11/2020] [Indexed: 12/11/2022] Open
Abstract
The 2019 novel coronavirus disease (COVID-19), which is caused by the novel beta coronavirus, SARS-CoV-2, is currently prevalent all over the world, causing thousands of deaths with relatively high virulence. Like two other notable beta coronaviruses, severe acute respiratory syndrome coronavirus-1 (SARS-CoV-1) and Middle East respiratory syndrome coronavirus (MERS-CoV), SARS-CoV-2 can lead to severe contagious respiratory disease. Due to impaired cellular immunity and physiological changes, pregnant women are susceptible to respiratory disease and are more likely to develop severe pneumonia. Given the prevalence of COVID-19, it is speculated that some pregnant women have already been infected. However, limited data are available for the clinical course and management of COVID-19 in pregnancy. Therefore, we conducted this review to identify strategies for the obstetric management of COVID-19. We compared the clinical course and outcomes of COVID-19, SARS, and MERS in pregnancy and discussed several drugs for the treatment of COVID-19 in pregnancy.
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Affiliation(s)
| | | | | | | | | | | | - Yonghong Lin
- Department of Obstetrics and Gynecology, Chengdu Women and Children's Central Hospital Affiliated to University of Electronic Science and Technology of China, Chengdu, China
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17
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Finkelstein JL, Herman HS, Plenty A, Mehta S, Natureeba P, Clark TD, Kamya MR, Ruel T, Charlebois ED, Cohan D, Havlir D, Young SL. Anemia and Micronutrient Status during Pregnancy, and Their Associations with Obstetric and Infant Outcomes among HIV-Infected Ugandan Women Receiving Antiretroviral Therapy. Curr Dev Nutr 2020; 4:nzaa075. [PMID: 32440638 PMCID: PMC7229869 DOI: 10.1093/cdn/nzaa075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/18/2020] [Accepted: 04/09/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Women living with HIV (WLHIV) are at higher risk of micronutrient deficiencies and adverse health outcomes. There are limited data on the burden or sequelae of micronutrient deficiencies among pregnant WLHIV receiving antiretroviral therapy (ART). OBJECTIVES We aimed to examine anemia and vitamin B-12, folate, and vitamin D deficiencies, and their associations with obstetric and infant outcomes, among pregnant WLHIV initiating combination antiretroviral therapy (cART) in rural Uganda. METHODS This was a prospective analysis among pregnant WLHIV (12-28 weeks of gestation) in PROMOTE-Pregnant Women and Infants (PIs), a randomized trial comparing the effects of protease inhibitor (PI)-based ART with those of a non-PI-based ART on placental malaria risk. We conducted a substudy on the burden of anemia [trimester 1/3: hemoglobin (Hb) <11.0 g/dL; trimester 2: Hb <10.5 g/dL; n = 367] and micronutrient deficiencies (n = 127) in pregnant WLHIV and their associations with obstetric and infant outcomes. Hb was measured by cyanmethemoglobin, vitamin B-12 and folate were measured via electrochemiluminescence, and vitamin D was measured by ELISA. Linear and binomial regression were used to evaluate associations between micronutrient status during pregnancy and perinatal outcomes. RESULTS 26.8% women were anemic, 30.2% were vitamin B-12 insufficient (<221.0 pmol/L), 66.1% were folate insufficient (<13.5 nmol/L), and 65.4% were vitamin D insufficient (<30.0 ng/mL) at enrollment. Anemia during pregnancy was associated with a greater risk of small for gestational age (SGA) (RR: 1.88; 95% CI: 1.28, 2.77; P = 0.001); each 1-g/dL decrease in Hb was associated with greater risk of SGA (RR: 0.76; 95% CI: 0.65, 0.90; P = 0.001). Multivariate models showed that increased vitamin D concentrations predicted lower risk of infant wasting (WLZ < -2; RR: 0.94; 95% CI: 0.89, 0.99; P = 0.04). Multivariate models also indicated that maternal vitamin B-12 and folate concentrations at enrollment predicted maternal (P < 0.001) and infant (P = 0.02) concentrations postpartum. CONCLUSIONS Anemia and micronutrient deficiencies are associated with a variety of adverse obstetric and infant outcomes and are an important public health concern in perinatal WLHIV on cART and their children.This trial was registered at clinicaltrials.gov as NCT00993031.
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Affiliation(s)
| | - Heather S Herman
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Albert Plenty
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
| | - Saurabh Mehta
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Paul Natureeba
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Tamara D Clark
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Theodore Ruel
- Division of Infectious Disease, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Deborah Cohan
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA, USA
| | - Diane Havlir
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sera L Young
- Department of Anthropology and Global Health Studies, Northwestern University, Evanston, IL, USA
- Institute for Policy Research, Northwestern University, Evanston, IL, USA
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18
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Comparison of guidelines for HIV viral load monitoring among pregnant and breastfeeding women in sub-Saharan Africa. AIDS 2020; 34:311-315. [PMID: 31634186 DOI: 10.1097/qad.0000000000002400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intensified viral load monitoring for pregnant and breastfeeding women has been proposed to help address concerns around antiretroviral therapy (ART) adherence, viraemia and transmission risk, but there have been no systematic evaluations of existing policies. METHODS We used an individual Monte Carlo simulation to describe longitudinal ART adherence and viral load from conception until 2 years' postpartum. We applied national and international guidelines for viral load monitoring to the simulated data. We compared guidelines on the percentage of women receiving viral load monitoring and the percentage of women monitored at the time of elevated viral load. RESULTS Coverage of viral load monitoring in pregnancy and breastfeeding varied markedly, with between 14% and 100% of women monitored antenatally and 38-98% monitored during breastfeeding. Specific recommendations for testing at either a fixed gestation or a short, fixed period after ART initiation achieved more than 95% testing in pregnancy but this was much lower (14-83%) among guidelines with no special stipulations. By the end of breastfeeding, only a small proportion of simulated episodes of elevated viral load more than 1000 copies/ml were successfully detected by monitoring (range, 20-50%). DISCUSSION Although further research is needed to understand optimal viral load frequency and timing in this population, these results suggest that current policies yield suboptimal detection of elevated viral load in pregnant and breastfeeding women.
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19
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Zhang Q, Qiao S, Yang X, Li X. Antiretroviral Concentration in Hair as a Measure for Antiretroviral Medication Adherence: A Systematic Review of Global Literature. AIDS Behav 2020; 24:311-330. [PMID: 30877582 DOI: 10.1007/s10461-019-02460-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This review aims to validate hair antiretroviral concentration (HAC) as a measure for antiretroviral medication adherence. This review included 31 studies that analyzed a total of 11 ARV drugs in four different drug classes. The associations between HAC and non-pharmacokinetic measures were generally lower than the association between HAC and other pharmacokinetic measures: the correlation coefficients (r) ranged from - 0.20 to 0.38 for self-report or pill counts and 0.20 to 0.85 for electronic drug monitoring; HAC and other pharmacokinetic measures were positively correlated with the correlation coefficients (r) ranging from 0.20 to 0.72, 0.34 to 0.86, 0.50 to 0.85 for antiretroviral concentration in plasma, peripheral blood mononuclear cells, and dried blood spots, respectively. HAC was one of the strongest independent predictors of virologic responses. HAC of tenofovir was significantly associated with renal toxicity in large sample studies. This review suggests that HAC is a valid biomarker of antiretroviral medication adherence.
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Affiliation(s)
- Quan Zhang
- South Carolina SmartState Center for Healthcare Quality (CHQ), University of South Carolina Arnold School of Public Health, Discovery I, 915 Greene Street, Columbia, SC, 29028, USA.
- Institute of Pedagogy and Applied Psychology, School of Public Administration, Hohai University, Nanjing, China.
| | - Shan Qiao
- South Carolina SmartState Center for Healthcare Quality (CHQ), University of South Carolina Arnold School of Public Health, Discovery I, 915 Greene Street, Columbia, SC, 29028, USA
| | - Xueying Yang
- South Carolina SmartState Center for Healthcare Quality (CHQ), University of South Carolina Arnold School of Public Health, Discovery I, 915 Greene Street, Columbia, SC, 29028, USA
| | - Xiaoming Li
- South Carolina SmartState Center for Healthcare Quality (CHQ), University of South Carolina Arnold School of Public Health, Discovery I, 915 Greene Street, Columbia, SC, 29028, USA
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20
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Su B, Wang Y, Zhou R, Jiang T, Zhang H, Li Z, Liu A, Shao Y, Hua W, Zhang T, Wu H, He S, Dai L, Sun L. Efficacy and Tolerability of Lopinavir/Ritonavir- and Efavirenz-Based Initial Antiretroviral Therapy in HIV-1-Infected Patients in a Tertiary Care Hospital in Beijing, China. Front Pharmacol 2019; 10:1472. [PMID: 31920659 PMCID: PMC6920196 DOI: 10.3389/fphar.2019.01472] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/13/2019] [Indexed: 01/26/2023] Open
Abstract
Background: Lopinavir/ritonavir (LPV/r) is a major antiretroviral treatment in China, but little is known about the performance of first-line LPV/r-based regimen in treatment-naïve patients with human immunodeficiency virus type 1 (HIV-1) infection. This study aims to assess the efficacy and adverse effect events of LPV/r plus lamivudine and tenofovir or zidovudine as an initial antiretroviral treatment in HIV-1-infected individuals for whom cannot take efavirenz (EFV) or is allergic to EFV. Methods: We performed a retrospective study of patients registering with the China's National Free Antiretroviral Treatment Program from July 2012 to January 2017, followed at a tertiary care hospital in Beijing, China. The primary outcome was the proportion of subjects with HIV-1 RNA ≤40 copies/ml at 6 and 24 months of treatment. We assessed the immunological response and adverse events. Results: In total, 4,862 patients were enrolled in the study and 237 were eligible for analysis in each study arm. During the first six months, virological suppression was better with the LPV/r-based regimen than with the EFV-based regimen (93.80 vs 87.80% for P < 0.05). Viral suppression rates continued to increase until 12 months, remain steady thereafter until 24 months, for both groups. The multilevel analysis revealed that patients in the LPV/r group were more likely to display improvements in CD4 T-cell count over time than those in the EFV group (P < 0.001). Grade 3 or 4 laboratory adverse events were observed in 14 patients (5.91%) from the LPV/r group and three patients (1.20%) in EFV group. Conclusion: Our findings demonstrate that LPV/r-containing regimens are effective and well-tolerated in Chinese treatment-naïve patients with HIV-1 infection.
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Affiliation(s)
- Bin Su
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
| | - Yin Wang
- Center for Infectious Diseases, Public Health Clinic Center of Chengdu, Chengdu, China
| | - Ruifeng Zhou
- Center for Infectious Diseases, Public Health Clinic Center of Chengdu, Chengdu, China
| | - Taiyi Jiang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
| | - Hongwei Zhang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Zaicun Li
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - An Liu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Ying Shao
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Wei Hua
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Tong Zhang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
| | - Shenghua He
- Center for Infectious Diseases, Public Health Clinic Center of Chengdu, Chengdu, China
| | - Lili Dai
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Lijun Sun
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
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21
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Dugdale CM, Phillips TK, Myer L, Hyle EP, Brittain K, Freedberg KA, Cunnama L, Walensky RP, Zerbe A, Weinstein MC, Abrams EJ, Ciaranello AL. Cost-effectiveness of integrating postpartum antiretroviral therapy and infant care into maternal & child health services in South Africa. PLoS One 2019; 14:e0225104. [PMID: 31730630 PMCID: PMC6857940 DOI: 10.1371/journal.pone.0225104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 10/29/2019] [Indexed: 11/29/2022] Open
Abstract
Background Poor engagement in postpartum maternal HIV care is a challenge worldwide and contributes to adverse maternal outcomes and vertical transmission. Our objective was to project the clinical and economic impact of integrated postpartum maternal antiretroviral therapy (ART) and pediatric care in South Africa. Methods Using the CEPAC computer simulation models, parameterized with data from the Maternal and Child Health–Antiretroviral Therapy (MCH-ART) randomized controlled trial, we evaluated the cost-effectiveness of integrated postpartum care for women initiating ART in pregnancy and their children. We compared two strategies: 1) standard of care (SOC) referral to local clinics after delivery for separate standard ART services for women and pediatric care for infants, and 2) the MCH-ART intervention (MCH-ART) of co-located maternal/pediatric care integrated in Maternal and Child Health (MCH) services throughout breastfeeding. Trial-derived inputs included: 12-month maternal retention in care and virologic suppression (SOC: 49%, MCH-ART: 67%), breastfeeding duration (SOC: 6 months, MCH-ART: 8 months), and postpartum healthcare costs for mother-infant pairs (SOC: $50, MCH-ART: $69). Outcomes included pediatric HIV infections, maternal and infant life expectancy (LE), lifetime HIV-related per-person costs, and incremental cost-effectiveness ratios (ICERs; ICER <US$903/YLS considered “cost-effective”). Results Compared to SOC, MCH-ART increased maternal LE (SOC: 25.26 years, MCH-ART: 26.20 years) and lifetime costs (SOC: $9,912, MCH-ART: $10,207; discounted). Projected pediatric outcomes for all HIV-exposed children were similar between arms, although undiscounted LE for HIV-infected children was shorter in SOC (SOC: 23.13 years, MCH-ART: 23.40 years). Combining discounted maternal and pediatric outcomes, the ICER was $599/YLS. Conclusion Co-located maternal HIV and pediatric care, integrated in MCH services throughout breastfeeding, is a cost-effective strategy to improve maternal and pediatric outcomes and should be implemented in South Africa.
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Affiliation(s)
- Caitlin M. Dugdale
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- * E-mail:
| | - Tamsin K. Phillips
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Emily P. Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Kirsty Brittain
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Lucy Cunnama
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, South Africa
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Allison Zerbe
- ICAP at Columbia and the Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Milton C. Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Elaine J. Abrams
- ICAP at Columbia and the Mailman School of Public Health, Columbia University, New York, NY, United States of America
- College of Physicians & Surgeons, Columbia University, New York, NY, United States of America
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
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22
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McDonald CR, Conroy AL, Gamble JL, Papp E, Hawkes M, Olwoch P, Natureeba P, Kamya M, Silverman M, Cohan D, Koss CA, Dorsey G, Kain KC, Serghides L. Estradiol Levels Are Altered in Human Immunodeficiency Virus-Infected Pregnant Women Randomized to Efavirenz-Versus Lopinavir/Ritonavir-Based Antiretroviral Therapy. Clin Infect Dis 2019; 66:428-436. [PMID: 29136115 DOI: 10.1093/cid/cix772] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/23/2017] [Indexed: 11/13/2022] Open
Abstract
Background Combination antiretroviral therapy (cART) use in pregnancy has been associated with hormonal dysregulation. We performed a secondary retrospective analysis of longitudinal progesterone and estradiol levels in pregnancy using specimens from the Protease Inhibitors to Reduce Malaria Morbidity in HIV-infected Pregnant Women study, which randomized Ugandan human immunodeficiency virus (HIV)-infected ART-naive women to initiate either lopinavir/ritonavir (LPV/r)-based or efavirenz (EFV)-based cART. Methods Three hundred twenty-six women (160 randomized to the EFV arm and 166 women to the LPV/r arm) with at least 1 plasma sample collected during pregnancy were included. Enrollment samples collected prior to cART initiation were used as a cART-naive comparator group. Hormone levels were quantified by enzyme-linked immunosorbent assay. Results Estradiol levels were differentially affected by the 2 cART regimens. Exposure to LPV/r was associated with an increase in estradiol (P < .0001), whereas exposure to EFV was associated with a decrease in estradiol (P < .0001), relative to the cART-naive gestationally matched comparator group. Lower estradiol levels correlated with small for gestational age (SGA) (P = .0019) and low birth weight (P = .019) in the EFV arm, while higher estradiol levels correlated with SGA in the LPV/r arm (P = .027). Although progesterone levels were similar between treatment arms, we observed an association between SGA and lower progesterone in the LPV/r arm (P = .04). No association was observed between hormone levels and preterm birth in either arm. Levels of progesterone and estradiol were lower in cases of stillbirth, and levels of both hormones declined immediately prior to stillbirth in 5 of 8 cases. Conclusions Combination ART regimens differentially affect estradiol levels in pregnancy, a hormone critical to the maintenance of a healthy pregnancy. Identifying cART regimens that minimize perinatal HIV transmission without contributing to hormonal dysregulation represents an urgent public health priority. Clinical Trials Registration NCT00993031.
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Affiliation(s)
- Chloe R McDonald
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Canada.,Institute of Medical Science, University of Toronto, Canada
| | - Andrea L Conroy
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Canada.,Institute of Medical Science, University of Toronto, Canada
| | - Joel L Gamble
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Canada
| | - Eszter Papp
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Canada.,Institute of Medical Science, University of Toronto, Canada
| | - Michael Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Peter Olwoch
- Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda
| | - Paul Natureeba
- Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda
| | - Moses Kamya
- Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda
| | | | - Deborah Cohan
- Department of Obstetrics and Gynecology, University of California, San Francisco
| | | | - Grant Dorsey
- Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda.,Department of Medicine, University of California, San Francisco
| | - Kevin C Kain
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Canada.,Institute of Medical Science, University of Toronto, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto
| | - Lena Serghides
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Canada.,Toronto General Research Institute, Toronto General Hospital, Canada.,Department of Immunology, University of Toronto, Canada
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23
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Protease Inhibitors or NNRTIs as First-Line HIV-1 Treatment in West Africa (PIONA): A Randomized Controlled Trial. J Acquir Immune Defic Syndr 2019; 79:386-393. [PMID: 30044302 DOI: 10.1097/qai.0000000000001820] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nonnucleoside reverse transcriptase inhibitors (NNRTIs) are recommended as part of first-line treatment for HIV-1 in Africa. However, NNRTI-based regimens are more prone to resistance development than protease inhibitors (PIs) in a context in which drug interruptions are frequent. The aim of this study was to compare the efficacy and tolerability of NNRTIs with PIs in HIV-1-infected patients in Guinea-Bissau. METHODS This open-label randomized, 2-arm superiority trial compared the use of 2 NRTIs plus either one NNRTI (efavirenz or nevirapine) or one PI (lopinavir/ritonavir) in treatment-naive HIV-1-infected adults in the Bissau HIV Cohort (ClinicalTrials.gov, NCT0019235). The primary endpoint was HIV-1 RNA <400 copies per milliliter after 12 months of treatment. RESULTS Between May 5, 2011, and April 26, 2013, 400 patients were included in the study. In an intention-to-treat analysis, the proportions of patients with viral suppression were similar in the NNRTI [65/197 (33.0%)] and PI [68/203 (33.5%)] arms (P = 0.92). No PI resistance was detected, but high-level NNRTI resistance was seen in 17/30 (56.7%) of NNRTI vs. 3/26 (11.5%) of PI-treated patients, P < 0.01. After 1 year of follow-up, 65 patients died (16.3%) and 93 were lost to follow-up (23.3%). There was no difference in mortality (hazard ratio 0.84, 95% confidence interval: 0.51 to 1.36) or frequency of clinical adverse events between treatment arms [NNRTI: 73/197 (37.1%); and PI: 69/203 (34.0%); P = 0.52]. CONCLUSIONS In patients at an HIV clinic in Guinea-Bissau, treatment with PIs led to less development of resistance compared with NNRTIs but was not superior in terms of viral suppression, CD4 cell increment, mortality, or severe adverse events.
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24
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Weinberg A, Huo Y, Kacanek D, Patel K, Watts DH, Wara D, Hoffman RM, Klawitter J, Christians U. Brief Report: Markers of Spontaneous Preterm Delivery in Women Living With HIV: Relationship With Protease Inhibitors and Vitamin D. J Acquir Immune Defic Syndr 2019; 82:181-187. [PMID: 31513074 PMCID: PMC6760328 DOI: 10.1097/qai.0000000000002111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Women living with HIV (WLHIV) have increased risk of spontaneous preterm delivery (SPTD). We sought to identify plasma predictors of SPTD and their correlations with factors that increase the risk of SPTD, such as vitamin D deficiency and use of protease inhibitors. DESIGN Plasma was obtained from 103 WLHIV with SPTD (≤35 weeks gestation) and 205 controls with term deliveries (TDs; ≥37 weeds) matched to cases 2:1 by race and gestational age at blood draw. TNFα, IFNγ, IL6, IL8, IL1β, IL18, IL17, granulocyte colony stimulating factor (GCSF), MCP1, IP10, sIL2Rα, sCD14, vascular endothelial factor a, monocyte colony stimulation factor, GROα, MMP9, IL10, TGFβ, sCTLA4, and eicosanoids were compared between cases adjusting for known SPTD risk factors. RESULTS Participants had similar demographic characteristics, but cases had higher plasma HIV RNA, lower CD4 cells, and more advanced HIV disease compared with controls. High sIL2Rα was associated with increased risk of SPTD. High sCD14, GCSF, PGF2α, and 5-HEPE were marginally associated with increased risk of SPTD. Women who initiated protease inhibitors-containing antiretroviral treatment before or during the first trimester had higher levels of GCSF and 5-HEPE compared with women without such exposure before plasma collection. Vitamin D insufficiency was associated with higher inflammatory sCD14 and PGF2α, and lower anti-inflammatory 5-HEPE. CONCLUSIONS The best plasma predictor of SPTD in WLHIV was sIL2Rα, a marker of T-cell activation. Markers of monocyte activation and eicosanoids were marginally increased in WLHIV and SPTD, suggesting that they may also play a role in the pathogenesis of this disorder.
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Affiliation(s)
- Adriana Weinberg
- Department of Pediatrics, Medicine and Pathology, Anschutz Medical Center, University of Colorado Denver, Aurora, CO 80045
| | - Yanling Huo
- Center for Biostatistics in AIDS Research (CBAR), Harvard T.H. Chan School of Public Health, Boston, MA 02115
| | - Deborah Kacanek
- Center for Biostatistics in AIDS Research (CBAR), Harvard T.H. Chan School of Public Health, Boston, MA 02115
| | - Kunjal Patel
- Center for Biostatistics in AIDS Research (CBAR), Harvard T.H. Chan School of Public Health, Boston, MA 02115
| | - D. Heather Watts
- National Institute of Child Health and Human Development, Bethesda, MD
| | | | - Risa M. Hoffman
- University of California San Francisco, San Francisco, CA
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles. Los Angeles, CA
| | - Jelena Klawitter
- iC42 Clinical Research and Development, Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045
| | - Uwe Christians
- iC42 Clinical Research and Development, Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045
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25
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Harrington BJ, DiPrete BL, Jumbe AN, Ngongondo M, Limarzi L, Wallie SD, Chagomerana MB, Hosseinipour MC. Safety and efficacy of Option B+ ART in Malawi: few severe maternal toxicity events or infant HIV infections among pregnant women initiating tenofovir/lamivudine/efavirenz. Trop Med Int Health 2019; 24:1221-1228. [PMID: 31381233 DOI: 10.1111/tmi.13296] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Malawi's Option B+ universal antiretroviral therapy (ART) program for pregnant and breastfeeding women does not include routine laboratory monitoring. We report safety outcomes of pregnant women who initiated ART through Option B+. METHODS We analysed 12-month data from an observational cohort study on Option B+ among women newly initiating tenofovir/lamivudine/efavirenz (TDF/3TC/EFV) at a government antenatal clinic in Lilongwe, Malawi. Proportions of women engaged in care, incidence of DAIDS grade ≥ 2 laboratory toxicity, grade ≥ 3 adverse events (AEs), viral suppression (<1000 copies/mL), birth outcomes and infant HIV infections are reported. RESULTS At ART initiation, participants (n = 299) had a median age of 26 years (IQR 22-30), median CD4 count of 352 cells/μl (IQR 231-520) and 94% were in WHO Stage 1. We noted 76 incident DAIDS Grade ≥ 2 laboratory results among 58 women, most commonly elevated liver function tests (n = 30 events) and low haemoglobin (n = 27). No women had elevated creatinine. Clinical AEs (n = 45) were predominantly infectious diseases and Grade 3. Five participants (2%) discontinued TDF/3TC/EFV due to virologic failure (3) or toxicity (2). Twelve months after ART initiation, most women were engaged in care (89%) and had HIV RNA < 1000 copies/ml (90%). 8% of pregnancies resulted in preterm birth, 9% were low birthweight (<2500 g), and 2% resulted in infant HIV infection at 6 weeks post-delivery. CONCLUSION Most women remained on ART and were virally suppressed 12 months after starting Option B+. Few infants contracted HIV perinatally. While some women experienced adverse laboratory events, clinical symptom monitoring is likely reasonable.
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Affiliation(s)
- Bryna J Harrington
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bethany L DiPrete
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allan N Jumbe
- UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Laura Limarzi
- UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | | | - Mina C Hosseinipour
- UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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26
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Ejigu Y, Magnus JH, Sundby J, Magnus MC. Pregnancy outcome among HIV-infected women on different antiretroviral therapies in Ethiopia: a cohort study. BMJ Open 2019; 9:e027344. [PMID: 31383698 PMCID: PMC6687026 DOI: 10.1136/bmjopen-2018-027344] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/19/2019] [Accepted: 06/21/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The objective of the study was to compare pregnancy outcomes according to maternal antiretroviral treatment (ART) regimens. DESIGN A retrospective cohort study. PARTICIPANTS AND SETTINGS Clinical data was extracted from ART exposed pregnancies of HIV-infected Ethiopian women attending antenatal care follow-up in public health facilities in Addis Ababa between February 2010 and October 2016. OUTCOMES The primary outcomes evaluated were preterm birth, low birth weight and small-for-gestational-age. RESULTS A total 1663 of pregnancies exposed to ART were included in the analyses. Of these pregnancies, 17% resulted in a preterm birth, 19% in low birth weight and 32% in a small-for-gestational-age baby. Compared with highly active antiretroviral therapy (HAART) initiated during pregnancy, zidovudine monotherapy was less likely to result in preterm birth (adjusted OR 0.35, 95% CI 0.19 to 0.64) and low birth weight (adjusted OR 0.48, 95% CI 0.24 to 0.94). We observed no differential risk of preterm birth, low birth weight and small-for-gestational-age, when comparing women who initiated HAART during pregnancy to women who initiated HAART before conception. The risk for preterm birth was higher in pregnancies exposed to nevirapine-based HAART (adjusted OR 1.44, 95% CI 1.06 to 1.96) compared with pregnancies exposed to efavirenz-based HAART. Comparing nevirapine-based HAART with efavirenz-based HAART indicated no strong evidence of increased risk of low birth weight or small-for-gestational-age. CONCLUSIONS We observed a higher risk of preterm birth among women who initiated HAART during pregnancy compared with zidovudine monotherapy. Pregnancies exposed to nevirapine-based HAART also had a greater risk of preterm births compared with efavirenz-based HAART.
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Affiliation(s)
- Yohannes Ejigu
- Health Metrics and Evaluation, Jimma University College of Public Health and Medical Sciences, Jimma, Ethiopia
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jeanette H Magnus
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Johanne Sundby
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Maria C Magnus
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Department of Population Health Sciences, University of Bristol Medical School, Bristol, UK
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
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27
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Gandhi M, Devi S, Bacchetti P, Chandy S, Heylen E, Phung N, Kuncze K, Okochi H, Ravi KB, Kurpad AV, Ekstrand ML. Measuring Adherence to Antiretroviral Therapy via Hair Concentrations in India. J Acquir Immune Defic Syndr 2019; 81:202-206. [PMID: 30865182 PMCID: PMC6522327 DOI: 10.1097/qai.0000000000001993] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Objective adherence measures are of increasing interest in antiretroviral treatment (ART) monitoring. Hair ART levels predict virologic suppression, and hair is easy to collect and store. No previous study has examined hair levels in an India-based cohort or laboratory. METHODS Small hair samples were collected from HIV-positive participants on either efavirenz (EFV)-based or nevirapine (NVP)-based ART in a South India-based study. Hair samples were split and analyzed for EFV or NVP in the University of California, San Francisco -based Hair Analytical Laboratory and the analytic laboratory of the Division of Nutrition at St. John's Research Institute, Bangalore, India, using liquid chromatography/tandem mass spectrometry. Agreement (using Bland-Altman methods) and rank correlation between the 2 laboratories' hair levels were calculated. Rank correlation between self-reported adherence (SRA) over the previous month using a visual analog scale and hair ART levels was calculated. RESULTS Among 75 participants (38 on NVP; 37 on EFV), the correlation between NVP levels generated by the 2 laboratories was 0.66 (P < 0.0001) and between EFV levels was 0.87 (P < 0.0001). Measurements from St. John's Research Institute were usually within 20% of those from the University of California, San Francisco Hair Analytical Laboratory. SRA was essentially uncorrelated with hair antiretroviral levels for either drug (all correlations < 0.04). Hair levels showed variability in adherence although SRA was >85% in all participants. CONCLUSIONS Hair ART levels measured by both an India-based laboratory and the standard U.S.-based laboratory showed generally high agreement and correlation, demonstrating local capacity. As in many other cohorts, hair ART levels and SRA were not well-correlated, likely indicating limitations in self-report and the need for objective adherence monitoring in resource-limited settings.
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Affiliation(s)
- Monica Gandhi
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco (UCSF)
| | - Sarita Devi
- Division of Nutrition, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bengaluru (Bangalore), India
| | | | - Sara Chandy
- Department of Medicine, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, India
| | - Elsa Heylen
- Center for AIDS Prevention Studies, Department of Medicine, UCSF
| | - Nhi Phung
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco (UCSF)
| | - Karen Kuncze
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco (UCSF)
| | - Hideaki Okochi
- Department of Bioengineering and Therapeutic Sciences, UCSF
| | | | - Anura V. Kurpad
- Department of Physiology, St. John’s Medical College, St. John’s National Academy of Health Sciences, Bangalore, India
| | - Maria L. Ekstrand
- Department of Medicine, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, India
- Center for AIDS Prevention Studies, Department of Medicine, UCSF
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28
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Prevention of HIV-1 Transmission Through Breastfeeding: Efficacy and Safety of Maternal Antiretroviral Therapy Versus Infant Nevirapine Prophylaxis for Duration of Breastfeeding in HIV-1-Infected Women With High CD4 Cell Count (IMPAACT PROMISE): A Randomized, Open-Label, Clinical Trial. J Acquir Immune Defic Syndr 2019; 77:383-392. [PMID: 29239901 DOI: 10.1097/qai.0000000000001612] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND No randomized trial has directly compared the efficacy of prolonged infant antiretroviral prophylaxis versus maternal antiretroviral therapy (mART) for prevention of mother-to-child transmission throughout the breastfeeding period. SETTING Fourteen sites in Sub-Saharan Africa and India. METHODS A randomized, open-label strategy trial was conducted in HIV-1-infected women with CD4 counts ≥350 cells/mm (or ≥country-specific ART threshold if higher) and their breastfeeding HIV-1-uninfected newborns. Randomization at 6-14 days postpartum was to mART or infant nevirapine (iNVP) prophylaxis continued until 18 months after delivery or breastfeeding cessation, infant HIV-1 infection, or toxicity, whichever occurred first. The primary efficacy outcome was confirmed infant HIV-1 infection. Efficacy analyses included all randomized mother-infant pairs except those with infant HIV-1 infection at entry. RESULTS Between June 2011 and October 2014, 2431 mother-infant pairs were enrolled; 97% of women were World Health Organization Clinical Stage I, median screening CD4 count 686 cells/mm. Median infant gestational age/birth weight was 39 weeks/2.9 kilograms. Seven of 1219 (0.57%) and 7 of 1211 (0.58%) analyzed infants in the mART and iNVP arms, respectively, were HIV-infected (hazard ratio 1.0, 96% repeated confidence interval 0.3-3.1); infant HIV-free survival was high (97.1%, mART and 97.7%, iNVP, at 24 months). There were no significant differences between arms in median time to breastfeeding cessation (16 months) or incidence of severe, life-threatening, or fatal adverse events for mothers or infants (14 and 42 per 100 person-years, respectively). CONCLUSIONS Both mART and iNVP prophylaxis strategies were safe and associated with very low breastfeeding HIV-1 transmission and high infant HIV-1-free survival at 24 months.
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Dadabhai S, Gadama L, Chamanga R, Kawalazira R, Katumbi C, Makanani B, Dula D, Hua N, Lau B, Mallewa M, Taha TE. Pregnancy Outcomes in the Era of Universal Antiretroviral Treatment in Sub-Saharan Africa (POISE Study). J Acquir Immune Defic Syndr 2019; 80:7-14. [PMID: 30272628 PMCID: PMC6289692 DOI: 10.1097/qai.0000000000001875] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adverse pregnancy outcomes such as preterm birth (PTB), low birth weight (LBW), and small for gestational age (SGA) remain major global problems. We compared pregnancy outcomes among HIV-infected women receiving antiretroviral treatment (ART) and with CD4 ≥350 cells, and HIV-uninfected women to assess whether disparities associated with HIV infection have been eliminated through use of ART. SETTING Observational study conducted at 5 health facilities in Blantyre, Malawi, during 2016-2017. METHODS HIV-infected women receiving the national ART regimen (efavirenz + lamivudine + tenofovir) and HIV-uninfected women were consented and enrolled at delivery. Data collected included sociodemographic and clinical; gestational age; BW; infant/maternal anthropometry; and laboratory results. We defined PTB as GA <37 weeks; LBW as BW <2·5 kg; and SGA as BW <10th percentile of GA. SGA infants were classified into proportionate and disproportionate based on ponderal index. Descriptive, stratified, and multivariate logistic and linear regression analyses were used. RESULTS Of 5423 women approached, 614 HIV-infected and 685 HIV-uninfected women were enrolled. Rates of PTB, LBW, and SGA were 10.6%, 7.2%, and 17.1% among HIV-infected women on ART and 9.5%, 5.0%, and 18.4% among HIV-uninfected women, respectively. None of these differences were statistically significant in univariate- or multivariate-adjusted analyses (P > 0.05). Of 231 SGA infants, 78.8% were proportionate and 21% were disproportionate. Of the 614 HIV-infected women on ART, 75% had undetectable virus at delivery. CONCLUSIONS ART use has reduced the high rates of adverse pregnancy outcomes among HIV-infected women. However, the rates remain high irrespective of HIV infection and require appropriate interventions.
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Affiliation(s)
- Sufia Dadabhai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Luis Gadama
- Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Rachel Chamanga
- Johns Hopkins-College of Medicine Research Project, Blantyre, Malawi
| | - Rachel Kawalazira
- Johns Hopkins-College of Medicine Research Project, Blantyre, Malawi
| | - Chaplain Katumbi
- Johns Hopkins-College of Medicine Research Project, Blantyre, Malawi
| | - Bonus Makanani
- Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Dingase Dula
- Johns Hopkins-College of Medicine Research Project, Blantyre, Malawi
| | - Nan Hua
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Macpherson Mallewa
- Department of Pediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Taha E. Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
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Abuogi LL, Humphrey JM, Mpody C, Yotebieng M, Murnane PM, Clouse K, Otieno L, Cohen CR, Wools-Kaloustian K. Achieving UNAIDS 90-90-90 targets for pregnant and postpartum women in sub-Saharan Africa: progress, gaps and research needs. J Virus Erad 2018; 4:33-39. [PMID: 30515312 PMCID: PMC6248851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The implementation of the 2013 World Health Organization Option B+ recommendations for HIV treatment during pregnancy has helped drive significant progress in achieving universal treatment for pregnant and postpartum women in sub-Saharan Africa (SSA). Yet, critical research and implementation gaps exist in achieving the UNAIDS 90-90-90 targets. To help guide researchers, programmers and policymakers in prioritising these areas, we undertook a comprehensive review of the progress, gaps and research needs to achieve the 90-90-90 targets for this population in the Option B+ era, including early infant HIV diagnosis (EID) for HIV-exposed infants. Salient areas where progress has been achieved or where gaps remain include: (1) knowledge of HIV status is higher among people with HIV in southern and eastern Africa compared to western and central Africa (81% versus 48%, UNAIDS); (2) access to antiretroviral therapy (ART) for pregnant women has doubled in 22 of 42 SSA countries, but only six have achieved the second 90, and nearly a quarter of pregnant women initiating ART become lost to follow-up; (3) viral suppression data for this population are sparse (estimates range from 30% to 98% peripartum), with only half of women maintaining suppression through 12 months postpartum; and (4) EID rates range from 15% to 62%, with only three of 21 high-burden SSA countries testing >50% HIV-exposed infants within the first 2 months of life. We have identified and outlined promising innovations and research designed to address these gaps and improve the health of pregnant and postpartum women living with HIV and their infants.
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Affiliation(s)
- Lisa L Abuogi
- Department of Pediatrics, University of Colorado,
Denver, Aurora, CO,
USA,Corresponding author:
Lisa Abuogi, Department of Pediatrics, University of Colorado,
Denver, Aurora,
CO,
USA
| | - John M Humphrey
- Department of Medicine, Indiana University School of Medicine,
Indianapolis, IN,
USA
| | - Christian Mpody
- Division of Epidemiology, Ohio State University,
Columbus, OH,
USA
| | - Marcel Yotebieng
- Division of Epidemiology, Ohio State University,
Columbus, OH,
USA
| | - Pamela M Murnane
- Center for AIDS Prevention Studies, University of California San Francisco,
San Francisco, CA,
USA
| | - Kate Clouse
- Vanderbilt Institute for Global Health, Vanderbilt University,
Nashville, TN,
USA
| | - Lindah Otieno
- Center for Microbial Research, Research Care and Training Program, Kenya Medical Research Institute,
Nairobi,
Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences,
University of California San Francisco, CA,
USA
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine,
Indianapolis, IN,
USA
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Achieving UNAIDS 90-90-90 targets for pregnant and postpartum women in sub-Saharan Africa: progress, gaps and research needs. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30343-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Delicio AM, Lajos GJ, Amaral E, Lopes F, Cavichiolli F, Myioshi I, Milanez H. Adverse effects of antiretroviral therapy in pregnant women infected with HIV in Brazil from 2000 to 2015: a cohort study. BMC Infect Dis 2018; 18:485. [PMID: 30261855 PMCID: PMC6161436 DOI: 10.1186/s12879-018-3397-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 09/19/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) use in pregnancy presents unquestionable benefits in preventing mother-to-child transmission (MTCT) of HIV although it is associated with maternal adverse effects. The aim of this study was to evaluate the adverse effects of antiretroviral therapy in pregnant women infected with HIV. METHODS Cohort study of pregnant women infected with HIV followed at the CAISM/UNICAMP Obstetric Clinic from 2000 to 2015. The following maternal adverse effects were observed: anemia, thrombocytopenia, allergy, liver function test abnormalities, dyslipidemia and diabetes. Data collected from patients' files was added to a specific database. Descriptive analysis was shown in terms of absolute (n) and relative (%) frequencies and mean, median and standard deviation calculations. Chi-square or Fisher exact test (n < 5) and relative risk (RR) with its respective p values were used for categorical variables and Student t-test (parametric data) or Mann-Whitney (non-parametric data) for the quantitative ones. A 95% confidence interval (CI) and a significant level of 0.05 were used. A multivariate Cox Logistic Regression was also done. Data analysis was conducted using SAS version 9.4. RESULTS Data from 793 pregnancies were included. MTCT rate was 2.3%, with 0.8% in the last 5 years. Maternal adverse effects were: dyslipidemia (82%), anemia (56%), liver function test abnormalities (54.5%), including hyperbilirubinemia (11.6%), fasting glycemia alteration (19.2%), thrombocytopenia (14.1%), and allergic reaction (2.7%). The majority of adverse effects deemed related to ART in this study were mild according to DAIDS scale. In the multivariate analysis, co-infections and starting ART during pregnancy were risk factors for maternal anemia, while CD4 count higher than 200 cells/mm3 was protective. Nevirapine, nelfinavir and atazanavir regimens increased the risk for liver function tests abnormalities. Lopinavir use during pregnancy increased the risk for fasting glycemia alteration. CONCLUSION The evolution of the national guidelines of antiretroviral therapy for pregnant women improved adherence to the treatment and resulted in a significant reduction of MTCT. Despite the high frequency of maternal adverse effects, they are mostly of low severity. Newer ART medications with improved efficacy and significantly more favorable tolerability profiles should reduce the incidence of ART-related adverse effects.
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Affiliation(s)
- Adriane M. Delicio
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
- Department of Clinics, School of Medical Sciences, University of Campinas, Campinas, Brazil
- Referral Center for STIs and AIDS of Campinas, Campinas, Brazil
| | - Giuliane J. Lajos
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Eliana Amaral
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Fabia Lopes
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Fernanda Cavichiolli
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Isabeli Myioshi
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Helaine Milanez
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
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Phung N, Kuncze K, Okochi H, Louie A, Benet LZ, Ofokotun I, Haas DW, Currier JS, Chawana TD, Sheth AN, Bacchetti P, Gandhi M, Horng H. Development and validation of an assay to analyze atazanavir in human hair via liquid chromatography/tandem mass spectrometry. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2018; 32:431-441. [PMID: 29315954 PMCID: PMC5848502 DOI: 10.1002/rcm.8058] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 12/24/2017] [Accepted: 01/01/2018] [Indexed: 06/07/2023]
Abstract
RATIONALE Assays to quantify antiretrovirals in hair samples are increasingly used to monitor adherence and exposure in both HIV prevention and treatment studies. Atazanavir (ATV) is a protease inhibitor used in combination antiretroviral therapy (ART). We developed and validated a liquid chromatography/tandem mass spectrometry (LC/MS/MS)-based method to quantify ATV in human hair, per the NIH Division of AIDS Clinical Pharmacology Quality Assurance (CPQA) program and the FDA bioanalytical method validation guidelines. METHODS ATV was extracted from hair using optimized methods and the extracts were injected onto a BDS C-18 column (5 μm, 4.6 × 100 mm), followed by isocratic elution via a mobile phase composed of 55% acetonitrile, 45% water, 0.15% acetic acid, and 4 mM ammonium acetate, at a flow rate of 0.8 mL/min prior to analysis by MS/MS. Levels were quantified using positive electrospray ionization by multiple reaction monitoring (MRM) for the transitions MH+ m/z 705.3 to m/z 168.0 and MH+ m/z 710.2 to m/z 168.0 for ATV and ATV-d5 (internal standard), respectively. RESULTS Our assay demonstrated a linear standard curve (r = 0.99) over the concentration range of 0.0500 ng ATV/mg hair to 20.0 ng/mg hair. The inter- and intraday accuracy of ATV quality control (QC) samples was -1.33 to 4.00% and precision (% coefficient of variation (%CV)) was 1.75 to 6.31%. The %CV for ATV levels in hair samples from highly adherent patients (incurred samples) was less than 10%. No significant endogenous peaks or crosstalk were observed in the specificity test with other HIV drugs. The overall extraction efficiency of ATV from incurred hair samples was greater than 95%. CONCLUSIONS This highly sensitive, highly specific and validated assay can be considered for therapeutic drug monitoring for HIV-infected patients on ATV-based ART.
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Affiliation(s)
- Nhi Phung
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Karen Kuncze
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Hideaki Okochi
- Department of Bioengineering and Therapeutic Sciences and Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Alexander Louie
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Leslie Z Benet
- Department of Bioengineering and Therapeutic Sciences and Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Igho Ofokotun
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia GA, USA; and Grady Healthcare System, Atlanta, Georgia GA, USA
| | - David W Haas
- Division of Infectious Diseases, Department of Medicine, Vanderbilt School of Medicine and Department of Internal Medicine, Meharry Medical College, Nashville, TN, USA
| | - Judith S Currier
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, CA, USA
| | - Tariro D Chawana
- Department of Clinical Pharmacology, University of Zimbabwe, Harare, Zimbabwe
| | - Anandi N Sheth
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia GA, USA; and Grady Healthcare System, Atlanta, Georgia GA, USA
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, University of California, San Francisco (UCSF), San Francisco, CA, 94143, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Howard Horng
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe recent clinical trial, laboratory and observational findings that highlight both the progress that can be achieved in elimination of new pediatric infections in international clinical trial settings among HIV-infected breastfeeding women while also describing recent safety concerns related to currently used antiretroviral regimens. The article will also address the ongoing adherence challenges for HIV-infected mothers in taking their antiretroviral drugs. This information is timely and relevant as new regimens are being considered for both prevention of mother-to-child transmission (PMTCT) of HIV and HIV treatment options worldwide. RECENT FINDINGS The main themes described in this article include both efficacy of different antiretroviral therapy (ART) regimens currently being rolled out internationally for PMTCT as well as safety findings from recent research including a large multisite international trial, PROMISE. SUMMARY The findings from the IMPAACT PROMISE trial as well as other recent trial and observational findings suggest that while progress has been steady in reducing PMTCT worldwide, the goal of virtual elimination of pediatric HIV worldwide will require careful attention to optimizing safety of new regimens which are less dependent on maternal daily ART adherence and safer in preventing certain toxicities.
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Affiliation(s)
- Mary G Fowler
- Department of Pathology, Johns Hopkins U. School of Medicine, Baltimore, Maryland
| | - Patricia Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins U. Bloomberg School of Public Health, Baltimore, Maryland, USA
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Saberi P, Ming K, Legnitto D, Neilands TB, Gandhi M, Johnson MO. Novel methods to estimate antiretroviral adherence: protocol for a longitudinal study. Patient Prefer Adherence 2018; 12:1033-1042. [PMID: 29950816 PMCID: PMC6014386 DOI: 10.2147/ppa.s166380] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is currently no gold standard for assessing antiretroviral (ARV) adherence, so researchers often resort to the most feasible and cost-effective methods possible (eg, self-report), which may be biased or inaccurate. The goal of our study was to evaluate the feasibility and acceptability of innovative and remote methods to estimate ARV adherence, which can potentially be conducted with less time and financial resources in a wide range of clinic and research settings. Here, we describe the research protocol for studying these novel methods and some lessons learned. METHODS The 6-month pilot study aimed to examine the feasibility and acceptability of a remotely conducted study to evaluate the correlation between: 1) text-messaged photographs of pharmacy refill dates for refill-based adherence; 2) text-messaged photographs of pills for pill count-based adherence; and 3) home-collected hair sample measures of ARV concentration for pharmacologic-based adherence. Participants were sent monthly automated text messages to collect refill dates and pill counts that were taken and sent via mobile telephone photographs, and hair collection kits every 2 months by mail. At the study end, feasibility was calculated by specific metrics, such as the receipt of hair samples and responses to text messages. Participants completed a quantitative survey and qualitative exit interviews to examine the acceptability of these adherence evaluation methods. The relationship between the 3 novel metrics of adherence and self-reported adherence will be assessed. DISCUSSION Investigators conducting adherence research are often limited to using either self-reported adherence, which is subjective, biased, and often overestimated, or other more complex methods. Here, we describe the protocol for evaluating the feasibility and acceptability of 3 novel and remote methods of estimating adherence, with the aim of evaluating the relationships between them. Additionally, we note the lessons learned from the protocol implementation to date. We expect that these novel measures will be feasible and acceptable. The implications of this research will be the identification and evaluation of innovative and accurate metrics of ARV adherence for future implementation.
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Affiliation(s)
- Parya Saberi
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Correspondence: Parya Saberi, Department of Medicine, University of California San Francisco, UCSF Box 0886, San Francisco, CA 94143, USA, Tel +1 415 476 6357, Fax +1 415 476 5348, Email
| | - Kristin Ming
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Dominique Legnitto
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Torsten B Neilands
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Monica Gandhi
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mallory O Johnson
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Viral Suppression and Retention in Care up to 5 Years After Initiation of Lifelong ART During Pregnancy (Option B+) in Rural Uganda. J Acquir Immune Defic Syndr 2017; 74:279-284. [PMID: 27828878 DOI: 10.1097/qai.0000000000001228] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Lifelong antiretroviral therapy (ART) is recommended for all HIV-infected pregnant women, but early studies suggest that women often drop out of care postpartum and data are limited on virologic outcomes. METHODS We evaluated viral suppression (primary outcome) and retention in care up to 5 years after ART initiation among HIV-infected women who started lifelong ART during pregnancy, irrespective of CD4 count, in a study in rural Uganda (NCT00993031). Participants were followed in the study for up to 1 year postpartum, then referred to clinics in surrounding communities. A random sample (N = 200) was invited to participate in a cross-sectional follow-up study after completing the trial, involving one visit for a questionnaire and pregnancy and HIV-1 RNA testing. Retention in care was defined as having attended an HIV clinic in the last 90 days. Logistic regression models were used to examine factors associated with viral suppression (HIV-1 RNA <400 copies/ml) at follow-up. RESULTS One hundred fifty women (75%) were successfully contacted for follow-up at a median of 4.2 years after starting ART; 135 were retained in care [90%, 95% confidence interval (CI): 84.0% to 94.3%] and 121 demonstrated viral suppression (80.7%, 95% CI: 73.4% to 86.7%). Women who had disclosed their HIV status to their primary partner had greater odds of viral suppression (adjusted odds ratio: 4.51, 95% CI: 1.02 to 19.8). CONCLUSIONS High rates of viral suppression can be achieved up to 5 years after initiating ART during pregnancy among women retained in care. Interventions to facilitate disclosure may improve long-term outcomes among women who initiate ART during pregnancy under universal treatment.
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Currier JS, Britto P, Hoffman RM, Brummel S, Masheto G, Joao E, Santos B, Aurpibul L, Losso M, Pierre MF, Weinberg A, Gnanashanmugam D, Chakhtoura N, Klingman K, Browning R, Coletti A, Mofenson L, Shapiro D, Pilotto J. Randomized trial of stopping or continuing ART among postpartum women with pre-ART CD4 ≥ 400 cells/mm3. PLoS One 2017; 12:e0176009. [PMID: 28489856 PMCID: PMC5425014 DOI: 10.1371/journal.pone.0176009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 04/03/2017] [Indexed: 11/24/2022] Open
Abstract
Background Health benefits of postpartum antiretroviral therapy (ART) for human immunodeficiency virus (HIV) positive women with high CD4+ T-counts have not been assessed in randomized trials. Methods Asymptomatic, HIV-positive, non-breastfeeding women with pre-ART CD4+ T-cell counts ≥ 400 cells/mm3 started on ART during pregnancy were randomized up to 42 days after delivery to continue or discontinue ART. Lopinavir/ritonavir plus tenofovir/emtricitabine was the preferred ART regimen. The sample size was selected to provide 88% power to detect a 50% reduction from an annualized primary event rate of 2.07%. A post-hoc analysis evaluated HIV/AIDS-related and World Health Organization (WHO) Stage 2 and 3 events. All analyses were intent to treat. Results 1652 women from 52 sites in Argentina, Botswana, Brazil, China, Haiti, Peru, Thailand and the US were enrolled (1/2010-11/2014). Median age was 28 years and major racial categories were Black African (28%), Asian (25%) White (15%). Median entry CD4 count was 696 cells/mm3 (IQR 575–869), median ART exposure prior to delivery was 19 weeks (IQR 13–24) and 94% had entry HIV-1 RNA < 1000 copies/ml. After a median follow-up of 2.3 years, the primary composite endpoint rate was significantly lower than expected, and not significantly different between arms (continue arm 0.21 /100 person years(py); discontinue 0.31/100 py, Hazard ratio (HR) 0.68, 95% CI: 0.19, 2.40). WHO Stage 2 and 3 events were significantly reduced with continued ART (2.08/100 py vs. 4.36/100 py in the discontinue arm; HR 0.48, 95%CI: 0.33, 0.70). Toxicity rates did not differ significantly between arms. Among women randomized to continue ART, 189/827 (23%) had virologic failure; of the 155 with resistance testing, 103 (66%) failed without resistance to their current regimen, suggesting non-adherence. Conclusions Overall, serious clinical events were rare among young HIV-positive post-partum women with high CD4 cell counts. Continued ART was safe and was associated with a halving of the rate of WHO 2/3 conditions. Virologic failure rates were high, underscoring the urgent need to improve adherence in this population. Trial registration ClinicalTrials.gov NCT00955968
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Affiliation(s)
- Judith S. Currier
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States of America
- * E-mail:
| | - Paula Britto
- Center for Biostatistics in AIDS Research, T.H. Chan School of Public Health, Harvard University, Cambridge, Massachusettes, United States of America
| | - Risa M. Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Sean Brummel
- Center for Biostatistics in AIDS Research, T.H. Chan School of Public Health, Harvard University, Cambridge, Massachusettes, United States of America
| | | | - Esau Joao
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | | | - Linda Aurpibul
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Marcelo Losso
- HIV Unit, Hospital J.M. Ramos Meija, Buenos Aires, Argentina
| | | | - Adriana Weinberg
- University of Colorado Denver, Aurora, Colorado, United States of America
| | | | | | | | | | - Anne Coletti
- Science Facilitation, FHI360, Durham, North Carolina, United States
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, D.C., United States of America
| | - David Shapiro
- Center for Biostatistics in AIDS Research, T.H. Chan School of Public Health, Harvard University, Cambridge, Massachusettes, United States of America
| | - Jose Pilotto
- Laboratório de AIDS & Imunologia Molecular, Instituto Oswaldo Cruz-FIOCRUZ, Rio de Janeiro, Brazil
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Moretton MA, Bertera F, Lagomarsino E, Riedel J, Chiappetta DA, Höcht C. Advances in therapy for the prevention of HIV transmission from mother to child. Expert Opin Pharmacother 2017; 18:657-666. [PMID: 28398096 DOI: 10.1080/14656566.2017.1316369] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Actually, ~17.8 million women and 1.8 million children (<15 years) are currently infected with the Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS). Particularly, the majority of pediatric infections (>90%) resulted from 'HIV mother-to-child transmission' (MTCT), both in pregnancy, labour, delivery and later by breastfeeding. Due to its high pediatric incidence, MTCT represents a public health concern. Areas covered: In this review, we focus on available treatments and antiretroviral drugs recommended by the World Health Organization, and the main clinical investigations in antiretroviral pharmacotherapy to prevent the MTCT. Expert opinion: The MTCT has been improved dramatically in the last few years mainly due to prophylactic perinatal antiretroviral therapy for pregnant women living with HIV. However, there is still a milestone to reach since HIV MTCT remains as a public health challenge associated with MTCT though breastfeeding (post-natal transmission). In this context, different strategies could be employed as an attempt to reduce pediatric HIV infections. One of them involves the improvement of patient adherence to the HIV therapy. One possible solution is the development of novel long-acting formulations for prophylaxis of mothers and children, and a second possible solution is increase the inclusion of mothers and infants in care programs to more effectively prevent the vertical transmission.
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Affiliation(s)
- Marcela A Moretton
- a Departamento de Tecnología Farmacéutica, Facultad de Farmacia y Bioquímica, Cátedra de Tecnología Farmacéutica I ., Universidad de Buenos Aires , Buenos Aires , Argentina.,b Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET) , Buenos Aires , Argentina
| | - Facundo Bertera
- c Departamento de Farmacología , Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Cátedra de Farmacología , Buenos Aires , Argentina
| | - Eduardo Lagomarsino
- d Departamento de Farmacología, Universidad de Buenos Aires , Facultad de Farmacia y Bioquímica, Cátedra de Farmacia Clínica , Buenos Aires , Argentina
| | - Jennifer Riedel
- a Departamento de Tecnología Farmacéutica, Facultad de Farmacia y Bioquímica, Cátedra de Tecnología Farmacéutica I ., Universidad de Buenos Aires , Buenos Aires , Argentina
| | - Diego A Chiappetta
- a Departamento de Tecnología Farmacéutica, Facultad de Farmacia y Bioquímica, Cátedra de Tecnología Farmacéutica I ., Universidad de Buenos Aires , Buenos Aires , Argentina.,b Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET) , Buenos Aires , Argentina
| | - Christian Höcht
- c Departamento de Farmacología , Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Cátedra de Farmacología , Buenos Aires , Argentina
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Phillips T, Cois A, Remien RH, Mellins CA, McIntyre JA, Petro G, Abrams EJ, Myer L. Self-Reported Side Effects and Adherence to Antiretroviral Therapy in HIV-Infected Pregnant Women under Option B+: A Prospective Study. PLoS One 2016; 11:e0163079. [PMID: 27760126 PMCID: PMC5070813 DOI: 10.1371/journal.pone.0163079] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 09/02/2016] [Indexed: 11/24/2022] Open
Abstract
Background Antiretroviral therapy (ART) regimens containing efavirenz (EFV) are recommended as part of universal ART for pregnant and breastfeeding women. EFV may have appreciable side effects (SE), and ART adherence in pregnancy is a major concern, but little is known about ART SE and associations with adherence in pregnancy. Methods We investigated the distribution of patient-reported SE (based on Division of AIDS categories) and the association of SE with missed ART doses in a cohort of 517 women starting EFV+3TC/FTC+TDF during pregnancy. In analysis, SE were considered in terms of their overall frequency, by systems category, and by latent classes. Results Overall 97% of women reported experiencing at least one SE after ART initiation, with 48% experiencing more than five SE. Gastrointestinal, central nervous system, systemic and skin SE were reported by 81%, 85%, 79% and 31% of women, respectively, with considerable overlap across groups. At least one missed dose was reported by 32% of women. In multivariable models, ART non-adherence was associated with systemic SE compared to other systems categories, and measures of the overall burden of SE experienced were most strongly associated with missed ART doses. Conclusion These data demonstrate very high levels of SE in pregnant women initiating EFV-based ART and a strong association between SE burden and ART adherence. ART regimens with reduced SE profiles may enhance adherence, and as countries expand universal ART for all adult patients, counseling must include preparation for ART SE.
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Affiliation(s)
- Tamsin Phillips
- Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Annibale Cois
- Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, University of Cape Town, Cape Town, South Africa
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, United States of America
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, United States of America
| | - James A. McIntyre
- Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa
- Anova Health Institute, Johannesburg, South Africa
| | - Greg Petro
- Department of Obstetrics & Gynaecology, University of Cape Town, Cape Town, South Africa
- New Somerset Hospital, Cape Town, South Africa
| | - Elaine J. Abrams
- ICAP, Columbia University, Mailman School of Public Health, New York, NY, United States of America
- College of Physicians & Surgeons, Columbia University, New York, NY, United States of America
| | - Landon Myer
- Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, University of Cape Town, Cape Town, South Africa
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Kanters S, Vitoria M, Doherty M, Socias ME, Ford N, Forrest JI, Popoff E, Bansback N, Nsanzimana S, Thorlund K, Mills EJ. Comparative efficacy and safety of first-line antiretroviral therapy for the treatment of HIV infection: a systematic review and network meta-analysis. Lancet HIV 2016; 3:e510-e520. [PMID: 27658869 DOI: 10.1016/s2352-3018(16)30091-1] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/24/2016] [Accepted: 06/30/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND New antiretroviral therapy (ART) regimens for HIV could improve clinical outcomes for patients. To inform global guidelines, we aimed to assess the comparative effectiveness of recommended ART regimens for HIV in ART-naive patients. METHODS For this systematic review and network meta-analysis, we searched for randomised clinical trials published up to July 5, 2015, comparing recommended antiretroviral regimens in treatment-naive adults and adolescents (aged 12 years or older) with HIV. We extracted data on trial and patient characteristics, and the following primary outcomes: viral suppression, mortality, AIDS defining illnesses, discontinuations, discontinuations due to adverse events, and serious adverse events. We synthesised data using network meta-analyses in a Bayesian framework and included older treatments, such as indinavir, to serve as connecting nodes. We defined network nodes in terms of specific antivirals rather than specific ART regimens. We categorised backbone regimens and adjusted for them through group-specific meta-regression. We used the GRADE framework to interpret the strength of inference. FINDINGS We identified 5865 citations through database searches and other sources, of which, 126 articles related to 71 unique trials were included in the network analysis, including 34 032 patients randomly assigned to 161 treatment groups. For viral suppression at 48 weeks, compared with efavirenz, the odds ratio (OR) for viral suppression was 1·87 (95% credible interval [CrI] 1·34-2·64) with dolutegravir and 1·40 (1·02-1·96) with raltegravir; with respect to viral suppression, low-dose efavirenz was similar to all other treatments. Both low-dose efavirenz and integrase strand transfer inhibitors tended to be protective of discontinuations due to adverse events relative to normal-dose efavirenz. The most protective effect relative to efavirenz in network meta-analyses was that of dolutegravir (OR 0·26, 95% CrI 0·14-0·47), followed by low-dose efavirenz (0·39, 0·16-0·92). Owing to insufficient data, we could make no conclusions about serious adverse events. Low event rates also limited the quality of evidence with regard to mortality and AIDS defining illnesses. INTERPRETATION The efficacy and safety of ART has substantially improved with the introduction of newer drug classes of antiretrovirals that are now available to patients and HIV care providers. Their improved tolerance could be part of a larger solution to improve retention, which is a challenge, particularly in low-income and middle-income country settings. FUNDING The World Health Organization.
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Affiliation(s)
- Steve Kanters
- Precision Global Health, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Meg Doherty
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | | | - Nathan Ford
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - Jamie I Forrest
- Precision Global Health, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Evan Popoff
- Precision Global Health, Vancouver, BC, Canada
| | - Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Edward J Mills
- Precision Global Health, Vancouver, BC, Canada; School of Public Health, University of Rwanda, Kigali, Rwanda.
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Brief Report: Food Insufficiency Is Associated With Lack of Sustained Viral Suppression Among HIV-Infected Pregnant and Breastfeeding Ugandan Women. J Acquir Immune Defic Syndr 2016; 71:310-5. [PMID: 26397935 PMCID: PMC4752388 DOI: 10.1097/qai.0000000000000860] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is Available in the Text. Food insecurity is associated with poor virologic outcomes, but this has not been studied during pregnancy and breastfeeding. We assessed sustained viral suppression from 8 weeks on antiretroviral therapy to 48 weeks postpartum among 171 pregnant and breastfeeding Ugandan women; 74.9% experienced food insufficiency. In multivariable analysis, food insufficiency [adjusted odds ratio (aOR) 0.38, 95% confidence interval (CI): 0.16 to 0.91], higher pretreatment HIV-1 RNA (aOR 0.55 per 10-fold increase, 95% CI: 0.37 to 0.82), and lopinavir/ritonavir versus efavirenz (aOR 0.49, 95% CI: 0.24 to 0.96) were associated with lower odds of sustained viral suppression. Interventions to address food security may improve virologic outcomes among HIV-infected women.
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Chikhungu LC, Bispo S, Rollins N, Siegfried N, Newell ML. HIV-free survival at 12-24 months in breastfed infants of HIV-infected women on antiretroviral treatment. Trop Med Int Health 2016; 21:820-8. [PMID: 27120500 PMCID: PMC5096069 DOI: 10.1111/tmi.12710] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objective To provide estimates of HIV‐free survival at 12–24 months in breastfed children by maternal ART (6 months or lifelong) to inform WHO HIV and Infant Feeding guidelines. Methods Eighteen studies published 2005–2015 were included in a systematic literature review (1295 papers identified, 156 abstracts screened, 55 full texts); papers were analysed by narrative synthesis and meta‐analysis of HIV‐free survival by maternal ART regimen in a random effects model. We also grouped studies by feeding modality. Study quality was assessed using a modified Newcastle–Ottawa Scale (NOS) and GRADE. Results The pooled estimates for 12‐month HIV‐free survival were 89.8% (95% confidence interval, CI: 86.5%, 93.2%) for infants of mothers on ART for 6 months post‐natally (six studies) and 91.4% (95% CI 87.5%, 95.4%) for infants of mothers on lifelong ART (three studies). Eighteen‐month HIV‐free survival estimates were 89.0% (95% CI 83.9%, 94.2%) with 6 months ART (five studies) and 96.1% (95% CI 92.8%, 99.0%) with lifelong ART (three studies). Twenty‐four‐month HIV‐free survival for infants whose mothers were on ART to 6 months post‐natally (two studies) was 89.2% (95% CI 79.9%, 98.5%). Heterogeneity was considerable throughout. In four studies, HIV‐free survival in breastfed infants ranged from 87% (95% CI 78%, 92%) to 96% (95% CI 91%, 98%) and in formula‐fed infants from 67% (95% CI 35.5%, 87.9%) to 97.6% (95% CI 93.0%, 98.2%). Conclusion Our results highlight the importance of breastfeeding for infant survival and of ART in reducing the risk of mother‐to‐child HIV transmission and support the WHO recommendation to initiate ART for life immediately after HIV diagnosis.
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Affiliation(s)
| | - Stephanie Bispo
- Department of Social Statistics and Demography, University of Southampton, Southampton, UK
| | - Nigel Rollins
- Department of Maternal, New-born, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Marie-Louise Newell
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
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No Need for Lopinavir Dose Adjustment during Pregnancy: a Population Pharmacokinetic and Exposure-Response Analysis in Pregnant and Nonpregnant HIV-Infected Subjects. Antimicrob Agents Chemother 2015; 60:400-8. [PMID: 26525798 DOI: 10.1128/aac.01197-15] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/24/2015] [Indexed: 11/20/2022] Open
Abstract
Lopinavir-ritonavir is frequently prescribed to HIV-1-infected women during pregnancy. Decreased lopinavir exposure has been reported during pregnancy, but the clinical significance of this reduction is uncertain. This analysis aimed to evaluate the need for lopinavir dose adjustment during pregnancy. We conducted a population pharmacokinetic analysis of lopinavir and ritonavir concentrations collected from 84 pregnant and 595 nonpregnant treatment-naive and -experienced HIV-1-infected subjects enrolled in six clinical studies. Lopinavir-ritonavir doses in the studies ranged between 400/100 and 600/150 mg twice daily. In addition, linear mixed-effect analysis was used to compare the area under the concentration-time curve from 0 to 12 h (AUC0-12) and concentration prior to dosing (Cpredose) in pregnant women and nonpregnant subjects. The relationship between lopinavir exposure and virologic suppression in pregnant women and nonpregnant subjects was evaluated. Population pharmacokinetic analysis estimated 17% higher lopinavir clearance in pregnant women than in nonpregnant subjects. Lopinavir clearance values postpartum were 26.4% and 37.1% lower than in nonpregnant subjects and pregnant women, respectively. As the tablet formulation was estimated to be 20% more bioavailable than the capsule formulation, no statistically significant differences between lopinavir exposure in pregnant women receiving the tablet formulation and nonpregnant subjects receiving the capsule formulation were identified. In the range of lopinavir AUC0-12 or Cpredose values observed in the third trimester, there was no correlation between lopinavir exposure and viral load or proportion of subjects with virologic suppression. Similar efficacy was observed between pregnant women and nonpregnant subjects receiving lopinavir-ritonavir at 400/100 mg twice daily. The pharmacokinetic and pharmacodynamic results support the use of a lopinavir-ritonavir 400/100-mg twice-daily dose during pregnancy.
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Abstract
PURPOSE OF REVIEW This review provides an update on current developments with prevention, treatment and cure strategies in the field of pediatric HIV. RECENT FINDINGS/SUMMARY There has been tremendous progress in the prevention and treatment of pediatric HIV infection. With new strategies for prevention of mother-to-child transmission, we are growing ever closer towards elimination of pediatric HIV, though challenges with retention of pregnant woman and their HIV-exposed infants remain. Ongoing vigilance regarding the potential hazards of in utero ART exposure to infants continues with no significant alarms yet identified. Though cure has not been achieved, evidence of the impact of early treatment on reducing HIV-1 reservoir size with subsequent prolonged remission has enlivened efforts to rapidly identify and treat HIV-infected newborns. There is an increasing array of treatment options for pediatric patients and reassuring evidence regarding long-term complications of ART. Unfortunately, despite evidence suggesting the benefit of early treatment, timely identification and treatment of children remains a challenge. Better strategies for effective case-finding and engagement in care are urgently needed in addition to an improved understanding of how to retain HIV-positive children and adolescents on treatment. However, further emboldened by recent international commitments and robust global support, the future is hopeful.
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Affiliation(s)
- Maria H Kim
- Baylor College of Medicine, Department of Pediatrics, Section of Retrovirology, Houston, Texas, USA ; Baylor College of Medicine-Abbott Fund Children's Clinical Center of Excellence, Lilongwe, Malawi
| | - Saeed Ahmed
- Baylor College of Medicine, Department of Pediatrics, Section of Retrovirology, Houston, Texas, USA ; Baylor College of Medicine-Abbott Fund Children's Clinical Center of Excellence, Lilongwe, Malawi
| | - Elaine J Abrams
- ICAP-Columbia University, Mailman School of Public Health, New York NY, USA ; College of Physicians & Surgeons, Columbia University, New York, NY, USA
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Koss CA, Natureeba P, Mwesigwa J, Cohan D, Nzarubara B, Bacchetti P, Horng H, Clark TD, Plenty A, Ruel TD, Achan J, Charlebois ED, Kamya MR, Havlir DV, Gandhi M. Hair concentrations of antiretrovirals predict viral suppression in HIV-infected pregnant and breastfeeding Ugandan women. AIDS 2015; 29:825-30. [PMID: 25985404 PMCID: PMC4438773 DOI: 10.1097/qad.0000000000000619] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Hair concentrations are a noninvasive measure of cumulative antiretroviral exposure and the strongest predictor of viral suppression in large cohorts of nonpregnant patients. We examined hair concentrations of antiretrovirals in relation to virologic outcomes in pregnant and breastfeeding women for the first time. DESIGN AND METHODS The Prevention of Malaria and HIV Disease in Tororo trial (NCT00993031) enrolled HIV-infected pregnant Ugandan women at 12-28 weeks gestation who were randomized to lopinavir or efavirenz-based antiretroviral therapy (ART). Small hair samples were collected at 30-34 weeks gestation and 10-25 weeks postpartum. Efavirenz and lopinavir hair concentrations were measured via liquid chromatography/tandem mass spectrometry. Multivariate logistic regression models examined predictors of viral suppression (HIV-1 RNA ≤400 copies/ml) at delivery and 24 weeks postpartum. RESULTS Among 325 women, median CD4 cell count was 366 cells/μl (interquartile range 270-488) at ART initiation. Mean self-reported 3-day adherence was greater than 97% in each arm. Viral suppression was achieved by 98.0% (efavirenz) and 87.4% (lopinavir) at delivery. At 24 weeks postpartum, 92.5% (efavirenz) and 90.6% (lopinavir) achieved viral suppression; 88% of women were breastfeeding. In multivariate models including self-reported adherence and pretreatment HIV-1 RNA, antiretroviral hair concentrations were the strongest predictor of viral suppression at delivery [efavirenz: adjusted odds ratio (aOR) 1.86 per doubling in concentration, 95% confidence interval (CI) 1.14-3.1, P = 0.013; lopinavir: aOR 1.90, 95% CI 1.33-2.7, P = 0.0004] and 24 weeks postpartum (efavirenz: aOR 1.81, 95% CI 1.22-2.7, P = 0.003; lopinavir: aOR 1.53, 95% CI 1.05-2.2, P = 0.026). CONCLUSION Antiretroviral hair concentrations represent an innovative tool that strongly predicts viral suppression among HIV-infected childbearing women during the critical periods of delivery and breastfeeding.
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Affiliation(s)
- Catherine A Koss
- aHIV/AIDS Division, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA bMakerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda cMedical Research Council Unit, The Gambia dDepartment of Obstetrics, Gynecology and Reproductive Sciences eDepartment of Epidemiology and Biostatistics fHair Analysis Laboratory gCenter for AIDS Prevention Studies hDepartment of Pediatrics, University of California, San Francisco, San Francisco, California, USA iDepartment of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Holtz SA, Thetard R, Konopka SN, Albertini J, Amzel A, Fogg KP. A Systematic Review of Interventions to Reduce Maternal Mortality among HIV-Infected Pregnant and Postpartum Women. Int J MCH AIDS 2015; 4:11-24. [PMID: 27622004 PMCID: PMC4948129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND In high-prevalence populations, HIV-related maternal mortality is high with increased mortality found among HIV-infected pregnant and postpartum women compared to their uninfected peers. The scale-up of HIV-related treatment options and broader reach of programming for HIV-infected pregnant and postpartum women is likely to have decreased maternal mortality. This systematic review synthesized evidence on interventions that have directly reduced mortality among this population. METHODS Studies published between January 1, 2003 and November 30, 2014 were searched using PubMed. Of the 1,373 records screened, 19 were included in the analysis. RESULTS Interventions identified through the review include antiretroviral therapy (ART), micronutrients (multivitamins, vitamin A, and selenium), and antibiotics. ART during pregnancy was shown to reduce mortality. Timing of ART initiation, duration of treatment, HIV disease status, and ART discontinuation after pregnancy influence mortality reduction. Incident pregnancy in women already on ART for their health appears not to have adverse consequences for the mother. Multivitamin use was shown to reduce disease progression while other micronutrients and antibiotics had no beneficial effect on maternal mortality. CONCLUSIONS ART was the only intervention identified that decreased death in HIV-infected pregnant and postpartum women. The findings support global trends in encouraging initiation of lifelong ART for all HIV-infected pregnant and breastfeeding women (Option B+), regardless of their CD4+ count, as an important step in ensuring appropriate care and treatment. GLOBAL HEALTH IMPLICATIONS Maternal mortality is a rare event that highlights challenges in measuring the impact of interventions on mortality. Developing effective patient-centered interventions to reduce maternal morbidity and mortality, as well as corresponding evaluation measures of their impact, requires further attention by policy makers, program managers, and researchers.
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Affiliation(s)
- Sara A Holtz
- Health Programs Group, 4301 North Fairfax Drive, Arlington, Virginia 22203, USA
| | - Rudi Thetard
- African Strategies for Health at Management Sciences for Health, 4301 North Fairfax Drive, Arlington, Virginia 22203, USA
| | - Sarah N Konopka
- African Strategies for Health at Management Sciences for Health, 4301 North Fairfax Drive, Arlington, Virginia 22203, USA
| | - Jennifer Albertini
- United States Agency for International Development (USAID)/Bureau for Africa/Office of Sustainable Development, 1201 Pennsylvania Ave NW, Washington, DC 20004 USA
| | - Anouk Amzel
- USAID/Bureau for Global Health (BGH)/Office of HIV/AIDS, 2100 Crystal Drive, Arlington, VA 22202 USA
| | - Karen P Fogg
- USAID/Bureau for Global Health, 2100 Crystal Drive, Arlington, VA 22202 USA
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