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Mandelbrot L, Tubiana R, Frange P, Peytavin G, Le Chenadec J, Canestri A, Morlat P, Brunet-Cartier C, Sibiude J, Peretti D, Chambrin V, Chabrol A, Bui E, Simon-Toulza C, Marchand L, Paul C, Delmas S, Avettand-Fenoel V, Warszawski J. Maintenance darunavir/ritonavir monotherapy to prevent perinatal HIV transmission, ANRS-MIE 168 MONOGEST study. J Antimicrob Chemother 2023:7185847. [PMID: 37248782 DOI: 10.1093/jac/dkad161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVES Because NRTIs can have fetal toxicities, we evaluated a perinatal NRTI-sparing strategy to prevent perinatal HIV transmission. Our primary objective was to determine the proportion maintaining a viral load (VL) of <50 copies/mL up to delivery on darunavir/ritonavir monotherapy, without requiring treatment intensification. METHODS In a one-arm, multicentre Phase 2 clinical trial, eligible patients in the first trimester of pregnancy on ART with plasma VL < 50 copies/mL received maintenance monotherapy with darunavir/ritonavir, 600/100 mg twice daily. VL was monitored monthly. ART was intensified in the case of VL > 50 copies/mL. Neonates received nevirapine prophylaxis for 14 days. RESULTS Of 89 patients switching to darunavir/ritonavir monotherapy, 4 miscarried before 22 weeks' gestation, 2 changed treatment for elevated liver enzymes without virological failure, and 83 were evaluable for the main outcome. Six had virological failure confirmed on a repeat sample (median VL = 193 copies/mL; range 78-644), including two before switching to monotherapy. In these six cases, ART was intensified with tenofovir disoproxil fumarate/emtricitabine. The success rate was 75/83, 90.4% (95% CI, 81.9%-95.7%) considering two patients with VL missing at delivery as failures, and 77/83, 92.8% (95% CI, 84.9%-97.3%) when considering them as successes since both had undetectable VL on darunavir/ritonavir throughout pregnancy. In ITT, the last available VL before delivery was <50 copies/mL in all of the patients. There was no case of perinatal HIV transmission. CONCLUSIONS Darunavir/ritonavir maintenance monotherapy required intensification in nearly 10% of cases. This limits its widespread use, thus other regimens should be evaluated in order to limit exposure to antiretrovirals, particularly NRTIs, during pregnancy.
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Affiliation(s)
- Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris Hôpital Louis Mourier Service de Gynécologie-Obstétrique, F-92700 Colombes, France
- Université Paris Cité, F-75006 Paris, France
- INSERM, IAME, F-75018 Paris, France
| | - Roland Tubiana
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Service Maladies infectieuses, F-75013 Paris, France
- INSERM, Sorbonne Université, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Pierre Frange
- Université Paris Cité, F-75006 Paris, France
- Laboratoire de microbiologie clinique, Groupe hospitalier Assistance Publique-Hôpitaux de Paris (APHP) Centre-Université Paris Cité, Hôpital Necker-Enfants Malades, F-75015 Paris, France
| | - Gilles Peytavin
- INSERM, IAME, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Laboratoire de Pharmaco-toxicologie, Hôpital Bichat, F-75018 Paris, France
| | | | - Ana Canestri
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service de Maladies Infectieuses, F-75020 Paris, France
| | - Philippe Morlat
- Service de Médecine interne et Maladies infectieuses, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Université de Bordeaux, Bordeaux, France
| | - Cécile Brunet-Cartier
- Service de Maladies infectieuses, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Jeanne Sibiude
- Assistance Publique-Hôpitaux de Paris Hôpital Louis Mourier Service de Gynécologie-Obstétrique, F-92700 Colombes, France
- Université Paris Cité, F-75006 Paris, France
- INSERM, IAME, F-75018 Paris, France
| | - Delphine Peretti
- Assistance Publique-Hôpitaux de Paris, Hôpital Kremlin-Bicêtre, Service de Maladies Infectieuses, Le Kremlin-Bicêtre, France
| | - Véronique Chambrin
- Assistance Publique-Hôpitaux de Paris, Hôpital Antoine Béclère, Service de Maladies Infectieuses, Clamart, France
| | - Amélie Chabrol
- Centre Hospitalier du Sud Francilien, Service de Maladies Infectieuses, Evry, France
| | - Eida Bui
- Assistance Publique-Hôpitaux de Paris, Hôpital Trousseau, Service de Maladies Infectieuses, F-75012 Paris, France
| | - Caroline Simon-Toulza
- Service de Médecine interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Lucie Marchand
- Agence Nationale de Recherches sur le sida et les hépatites virales ANRS|Maladies infectieuses émergentes, Paris, France
| | - Christelle Paul
- Agence Nationale de Recherches sur le sida et les hépatites virales ANRS|Maladies infectieuses émergentes, Paris, France
| | - Sandrine Delmas
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale, SC10-US19, Villejuif, France
| | - Véronique Avettand-Fenoel
- Université Paris Cité, F-75006 Paris, France
- Laboratoire de microbiologie clinique, Groupe hospitalier Assistance Publique-Hôpitaux de Paris (APHP) Centre-Université Paris Cité, Hôpital Necker-Enfants Malades, F-75015 Paris, France
- INSERM U1016, CNRS, UMR8104, Institut Cochin, Paris, France
| | - Josiane Warszawski
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris, Epidemiology and Public Health Service, Service, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
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Waters MD, Warren S, Hughes C, Lewis P, Zhang F. Human genetic risk of treatment with antiviral nucleoside analog drugs that induce lethal mutagenesis: The special case of molnupiravir. ENVIRONMENTAL AND MOLECULAR MUTAGENESIS 2022; 63:37-63. [PMID: 35023215 DOI: 10.1002/em.22471] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/28/2021] [Accepted: 01/08/2022] [Indexed: 06/14/2023]
Abstract
This review considers antiviral nucleoside analog drugs, including ribavirin, favipiravir, and molnupiravir, which induce genome error catastrophe in SARS-CoV or SARS-CoV-2 via lethal mutagenesis as a mode of action. In vitro data indicate that molnupiravir may be 100 times more potent as an antiviral agent than ribavirin or favipiravir. Molnupiravir has recently demonstrated efficacy in a phase 3 clinical trial. Because of its anticipated global use, its relative potency, and the reported in vitro "host" cell mutagenicity of its active principle, β-d-N4-hydroxycytidine, we have reviewed the development of molnupiravir and its genotoxicity safety evaluation, as well as the genotoxicity profiles of three congeners, that is, ribavirin, favipiravir, and 5-(2-chloroethyl)-2'-deoxyuridine. We consider the potential genetic risks of molnupiravir on the basis of all available information and focus on the need for additional human genotoxicity data and follow-up in patients treated with molnupiravir and similar drugs. Such human data are especially relevant for antiviral NAs that have the potential of permanently modifying the genomes of treated patients and/or causing human teratogenicity or embryotoxicity. We conclude that the results of preclinical genotoxicity studies and phase 1 human clinical safety, tolerability, and pharmacokinetics are critical components of drug safety assessments and sentinels of unanticipated adverse health effects. We provide our rationale for performing more thorough genotoxicity testing prior to and within phase 1 clinical trials, including human PIG-A and error corrected next generation sequencing (duplex sequencing) studies in DNA and mitochondrial DNA of patients treated with antiviral NAs that induce genome error catastrophe via lethal mutagenesis.
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Affiliation(s)
- Michael D Waters
- Michael Waters Consulting USA, Hillsborough, North Carolina, USA
| | | | - Claude Hughes
- Duke University Medical Center, Durham, North Carolina, USA
| | | | - Fengyu Zhang
- Global Clinical and Translational Research Institute, Bethesda, Maryland, USA
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3
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Lin SH, Wang Y, Hartley SW, Karyadi DM, Lee OW, Zhu B, Zhou W, Brown DW, Beilstein-Wedel E, Hazra R, Kacanek D, Chadwick EG, Marsit CJ, Poirier MC, Brummel SS, Chanock SJ, Engels EA, Machiela MJ. In-utero exposure to zidovudine-containing antiretroviral therapy and clonal hematopoiesis in HIV-exposed uninfected newborns. AIDS 2021; 35:1525-1535. [PMID: 33756513 PMCID: PMC8286286 DOI: 10.1097/qad.0000000000002894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Zidovudine (ZDV) has been extensively used in pregnant women to prevent vertical transmission of HIV but few studies have evaluated potential mutagenic effects of ZDV during fetal development. DESIGN Our study investigated clonal hematopoiesis in HIV-exposed uninfected (HEU) newborns, 94 of whom were ZDV-exposed and 91 antiretroviral therapy (ART)-unexposed and matched for potential confounding factors. METHODS Utilizing high depth sequencing and genotyping arrays, we comprehensively examined blood samples collected during the first week after birth for potential clonal hematopoiesis associated with fetal ZDV exposure, including clonal single nucleotide variants (SNVs), small insertions and deletions (indels), and large structural copy number or copy neutral alterations. RESULTS We observed no statistically significant difference in the number of SNVs and indels per person in ZDV-exposed children (adjusted ratio [95% confidence interval, CI] for expected number of mutations = 0.79 [0.50--1.22], P = 0.3), and no difference in the number of large structural alterations. Mutations in common clonal hematopoiesis driver genes were not found in the study population. Mutational signature analyses on SNVs detected no novel signatures unique to the ZDV-exposed children and the mutational profiles were similar between the two groups. CONCLUSION Our results suggest that clonal hematopoiesis at levels detectable in our study is not strongly influenced by in-utero ZDV exposure; however, additional follow-up studies are needed to further evaluate the safety and potential long-term impacts of in-utero ZDV exposure in HEU children as well as better investigate genomic aberrations occurring late in pregnancy.
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Affiliation(s)
- Shu-Hong Lin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville
| | - Youjin Wang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville
| | - Stephen W Hartley
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville
| | - Danielle M Karyadi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville
| | - Olivia W Lee
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville
| | - Bin Zhu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville
| | - Weiyin Zhou
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville
- Cancer Genomics Research Laboratory, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Derek W Brown
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville
| | - Erin Beilstein-Wedel
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rohan Hazra
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Deborah Kacanek
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ellen G Chadwick
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Carmen J Marsit
- Departments of Environmental Health and Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Miriam C Poirier
- Carcinogen-DNA Interactions Section, Laboratory of Cancer Biology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Sean S Brummel
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Stephen J Chanock
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville
| | - Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville
| | - Mitchell J Machiela
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville
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Hleyhel M, Goujon S, Sibiude J, Tubiana R, Dollfus C, Faye A, Mandelbrot L, Clavel J, Warszawski J, Blanche S. Risk of cancer in children exposed to antiretroviral nucleoside analogues in utero: The french experience. ENVIRONMENTAL AND MOLECULAR MUTAGENESIS 2019; 60:404-409. [PMID: 29206312 DOI: 10.1002/em.22162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/03/2017] [Accepted: 11/15/2017] [Indexed: 05/23/2023]
Abstract
All nucleoside analogues for treating HIV infection, due to their capacity to integrate into and alter human DNA, are experimentally genotoxic to some extent. The long-term oncogenic risk after in utero exposure remains to be determined. Cancer incidence in uninfected children exposed to nucleos(t)ide reverse transcriptase inhibitors (NRTIs) was evaluated, by cross-checking against the National Cancer Registry, in the French perinatal study of children born to HIV+ mothers. Twenty-one cancers were identified in 15,163 children (median age: 9.9 years [interquartile range (IQR): 5.8-14.2]) exposed to at least one NRTI in utero between 1990 and 2014. Five of these children were exposed to zidovudine monotherapy, and 15 to various combinations, seven of which included didanosine. Overall, the total number of cases was not significantly different from that expected for the general population (SIR = 0.8[0.47-1.24]), but the number of cases after didanosine exposure was twice that expected (SIR = 2.5 [1.01-5.19]). Didanosine accounted for only 10% of prescriptions but was associated with one-third of cancers. In multivariate analysis, didanosine exposure was significantly associated with higher risk (HR = 3.0 [0.9-9.8]). This risk was specifically linked to first-trimester exposure (HR = 5.5 [2.1-14.4]). Three cases of pineoblastoma, a very rare cancer, were observed, whereas 0.03 were expected. Two were associated with didanosine exposure. Despite reassuring data overall, there is strong evidence to suggest that didanosine displays transplacental oncogenicity. These findings cannot be extrapolated to other NRTIs, but they highlight the need for comprehensive evaluations of the transplacental genotoxicity of this antiretroviral class. Environ. Mol. Mutagen., 60:404-409, 2019. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Mira Hleyhel
- Epidemiology and Population Health Center, Institut National de la Santé et de la Recherche Médicale (INSERM), Le Kremlin-Bicêtre, U1018, France
| | - Stéphanie Goujon
- Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Université Paris Descartes, Epidemiology and Biostatistics, INSERM UMR1153, Sorbonne Paris Cité Research Center, Villejuif, France
- French National Registry of Childhood Cancers, Villejuif, France
| | - Jeanne Sibiude
- Gynecology and Obstetrics Department, Hôpital Louis Mourier, Hôpitaux Universitaires Paris Nord Val de Seine, AP-HP, Colombes, France
| | - Roland Tubiana
- Infectious Diseases Department, Hôpital Pitié Salpétrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | | | - Albert Faye
- Pediatric Department, Hôpital Robert Debré, AP-HP, Université Paris Diderot, Sorbonne Paris-Cité, Paris, France
| | - Laurent Mandelbrot
- Gynecology and Obstetrics Department, Hôpital Louis Mourier, Hôpitaux Universitaires Paris Nord Val de Seine, AP-HP, Colombes, France
| | - Jacqueline Clavel
- Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Université Paris Descartes, Epidemiology and Biostatistics, INSERM UMR1153, Sorbonne Paris Cité Research Center, Villejuif, France
- French National Registry of Childhood Cancers, Villejuif, France
| | - Josiane Warszawski
- Epidemiology and Population Health Center, Institut National de la Santé et de la Recherche Médicale (INSERM), Le Kremlin-Bicêtre, U1018, France
- Hôpital Bicêtre, AP-HP, Université Paris Sud, Le Kremlin-Bicêtre, France
| | - Stéphane Blanche
- Immunology Hematology Rheumatology Unit, Pediatric Department, Hôpital Necker-Enfants Malades AP-HP, Université Paris Descartes, Paris, France
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Gantner P, Sylla B, Morand-Joubert L, Frange P, Lacombe K, Khuong MA, Duvivier C, Launay O, Karmochkine M, Arvieux C, Ménard A, Piroth L, Canestri A, Trias D, Peytavin G, Landman R, Ghosn J. "Real life" use of raltegravir during pregnancy in France: The Coferal-IMEA048 cohort study. PLoS One 2019; 14:e0216010. [PMID: 31017957 PMCID: PMC6481866 DOI: 10.1371/journal.pone.0216010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/11/2019] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Limited "real life" data on raltegravir (RAL) use during pregnancy are available. Thus, we aimed at describing effectiveness and safety of RAL-based combined antiretroviral therapy (cART) in this setting. METHODS HIV-1-infected women receiving RAL during pregnancy between 2008 and 2014 in ten French centers were retrospectively analysed for: (1) proportion of women receiving RAL anytime during pregnancy who achieved a plasma HIV-RNA (pVL) < 50 copies/mL at delivery, and (2) description of demographics, immuno-virological parameters and safety in women and new-borns. RESULTS We included 94 women (median age, 33 years) of which 85% originated from Sub-Saharan Africa and 16% did not have regular health insurance coverage. Sixteen women were cART-naïve (median HIV diagnosis at 30 weeks of gestation), whereas 78 were already on cART before pregnancy (40% with pVL < 50 copies/mL). RAL was initiated before pregnancy (n = 33), during the second trimester (n = 11) and the third trimester of pregnancy (n = 50). No RAL discontinuations due to adverse events were observed. Overall, at the time of delivery, pVL was < 50 copies/mL in 70% and < 400 copies/mL in 84% of women. Specifically, pVL at delivery was < 50 copies/mL in 82%, 55% and 56% of cases when RAL was started before pregnancy, during the second or third trimester of pregnancy, respectively. Median term was 38 weeks of gestation, no defect was reported and all new-borns were HIV non-infected at Month 6. CONCLUSIONS RAL appears safe and effective in this "real-life" study. No defect and no HIV transmission was reported in new-borns.
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Affiliation(s)
- Pierre Gantner
- Hôpitaux Universitaires de Strasbourg, Laboratoire de Virologie, Strasbourg, France
| | - Babacar Sylla
- IMEA, CHU Bichat Claude Bernard, Paris, France Paris, France
| | - Laurence Morand-Joubert
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), AP-HP, Laboratoire de Virologie, Hôpital Saint-Antoine, Paris, France
| | - Pierre Frange
- APHP, Hopital Necker Enfants malades, Laboratoire de Microbiologie clinique, Paris, France
- EHU 7328, Institut Imagine, Université Paris Descartes, Paris, France
| | - Karine Lacombe
- Inserm UMR-S1136, IPLESP, AP-HP, Hôpital Saint Antoine, Department of Infectious Diseases, Paris, France
| | - Marie-Aude Khuong
- Hôpital Delafontaine, Department of Infectious Diseases, Saint Denis, France
| | - Claudine Duvivier
- APHP, Hopital Necker Enfants Malades, Department of Infectious Diseases, Centre d’Infectiologie Necker – Pasteur, IHU Imagine, Paris, France
| | - Odile Launay
- Université Paris Descartes, APHP, CIC Cochin Pasteur, Paris, France
| | - Marina Karmochkine
- APHP, Hopital Européen Georges Pompidou, Department of Clinical Immunology, Paris, France
| | | | - Amélie Ménard
- Institut hospitalo-universitaire (IHU) Méditerranée infection, Marseille, France
| | - Lionel Piroth
- Département d’Infectiologie, CHU Dijon, Dijon, France
| | - Ana Canestri
- APHP, Hôpital Tenon, Maladies Infectieuses, Paris, France
| | | | - Gilles Peytavin
- APHP, Hopital Bichat Claude Bernard, Department of Pharmacology-Toxicology, Paris, France
- INSERM IAME UMR-S 1137, Université Paris Diderot, Paris, France
| | - Roland Landman
- IMEA, CHU Bichat Claude Bernard, Paris, France Paris, France
- INSERM IAME UMR-S 1137, Université Paris Diderot, Paris, France
- APHP, Hopital Bichat Claude Bernard, Department of Infectious Diseases, Paris, France
| | - Jade Ghosn
- INSERM IAME UMR-S 1137, Université Paris Diderot, Paris, France
- APHP, Hopital Bichat Claude Bernard, Department of Infectious Diseases, Paris, France
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T-Cell Receptor Excision Circles in HIV-Exposed, Uninfected Newborns Measured During a National Newborn Screening Program for Severe Combined Immunodeficiency. J Pediatr 2018; 202:311-314.e2. [PMID: 29980289 DOI: 10.1016/j.jpeds.2018.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/18/2018] [Accepted: 06/01/2018] [Indexed: 12/28/2022]
Abstract
Severe combined immunodeficiency screening by measuring T-receptor excision circles at birth allows evaluation of the impact of various maternal conditions on newborn immunity. The slight decrease observed in a French cohort of newborns to HIV-infected mothers can be explained by the confounding factors of prematurity and African descent.
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7
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Rough K, Seage GR, Williams PL, Hernandez-Diaz S, Huo Y, Chadwick EG, Currier JS, Hoffman RM, Barr E, Shapiro DE, Patel K. Birth Outcomes for Pregnant Women with HIV Using Tenofovir-Emtricitabine. N Engl J Med 2018; 378:1593-1603. [PMID: 29694825 PMCID: PMC5984044 DOI: 10.1056/nejmoa1701666] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND In a previous trial of antiretroviral therapy (ART) involving pregnant women with human immunodeficiency virus (HIV) infection, those randomly assigned to receive tenofovir, emtricitabine, and ritonavir-boosted lopinavir (TDF-FTC-LPV/r) had infants at greater risk for very premature birth and death within 14 days after delivery than those assigned to receive zidovudine, lamivudine, and ritonavir-boosted lopinavir (ZDV-3TC-LPV/r). METHODS Using data from two U.S.-based cohort studies, we compared the risk of adverse birth outcomes among infants with in utero exposure to ZDV-3TC-LPV/r, TDF-FTC-LPV/r, or TDF-FTC with ritonavir-boosted atazanavir (ATV/r). We evaluated the risk of preterm birth (<37 completed weeks of gestation), very preterm birth (<34 completed weeks), low birth weight (<2500 g), and very low birth weight (<1500 g). Risk ratios with 95% confidence intervals were estimated with the use of modified Poisson models to adjust for confounding. RESULTS There were 4646 birth outcomes. Few infants or fetuses were exposed to TDF-FTC-LPV/r (128 [2.8%]) as the initial ART regimen during gestation, in contrast with TDF-FTC-ATV/r (539 [11.6%]) and ZDV-3TC-LPV/r (954 [20.5%]). As compared with women receiving ZDV-3TC-LPV/r, women receiving TDF-FTC-LPV/r had a similar risk of preterm birth (risk ratio, 0.90; 95% confidence interval [CI], 0.60 to 1.33) and low birth weight (risk ratio, 1.13; 95% CI, 0.78 to 1.64). As compared to women receiving TDF-FTC-ATV/r, women receiving TDF-FTC-LPV/r had a similar or slightly higher risk of preterm birth (risk ratio, 1.14; 95% CI, 0.75 to 1.72) and low birth weight (risk ratio, 1.45; 95% CI, 0.96 to 2.17). There were no significant differences between regimens in the risk of very preterm birth or very low birth weight. CONCLUSIONS The risk of adverse birth outcomes was not higher with TDF-FTC-LPV/r than with ZDV-3TC-LPV/r or TDF-FTC-ATV/r among HIV-infected women and their infants in the United States, although power was limited for some comparisons. (Funded by the National Institutes of Health and others.).
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Affiliation(s)
- Kathryn Rough
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - George R Seage
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Paige L Williams
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Sonia Hernandez-Diaz
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Yanling Huo
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Ellen G Chadwick
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Judith S Currier
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Risa M Hoffman
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Emily Barr
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - David E Shapiro
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Kunjal Patel
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
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Toward a universal antiretroviral regimen: special considerations of pregnancy and breast feeding. Curr Opin HIV AIDS 2018; 12:359-368. [PMID: 28426519 DOI: 10.1097/coh.0000000000000386] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW As optimized antiretroviral therapy (ART) regimens are prepared for introduction in low-income and middle-income countries (LMIC), we consider the current evidence related to dosing, efficacy and safety during pregnancy and breastfeeding of next-generation first-line and second-line ART regimens proposed for imminent introduction in the global marketplace. RECENT FINDINGS Pregnancy pharmacokinetic considerations include potentially insufficient efavirenz exposure if dosed at 400 mg/day, the need for twice daily darunavir dosing and the paucity of data related to tenofovir alafenamide and dolutegravir dosing, safety and efficacy. Increasingly evidence suggests an association with adverse birth outcomes, particularly in women conceiving on ART, and with varying risk by drug and drug combination. Clinical trials and studies are in progress or planned that aim to determine dosing, safety and efficacy of several new antiretrovirals (ARVs). SUMMARY Having a universal, highly potent and safe ART regimen for all individuals living with HIV in LMIC including pregnant women is clearly the most beneficial strategy to keep mothers alive and healthy and to prevent transmission of HIV to their children. It will have to be determined whether the use of this next generation of optimized ARVs will also optimize health outcomes of pregnant women and their children.
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Health and survival of HIV perinatally exposed but uninfected children born to HIV-infected mothers. Curr Opin HIV AIDS 2017; 11:465-476. [PMID: 27716731 DOI: 10.1097/coh.0000000000000300] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The number of HIV-exposed but uninfected (HEU) infants exposed to both HIV and multiple antiretroviral drugs in utero and during prolonged breastfeeding is increasing in low-income countries where HIV prevalence is the highest. We review recent evidence on the effects of perinatal/postnatal exposure to maternal HIV and combined antiretroviral therapy (cART) on health outcomes of HEU children (mitochondrial and metabolic toxicity, adverse pregnancy outcomes, neurodevelopment, growth, infectious morbidity, and mortality). RECENT FINDINGS Several studies have reported ART-associated mitochondrial toxicity and metabolic disorders with conflicting results on adverse pregnancy outcomes, underscoring the need to conduct further investigations on these questions. Studies about congenital abnormalities report no significant differences between HEU exposed to ART and HIV-unexposed (HUU) children. Updated French data showed no significant difference in cancer incidence between HEU cART-exposed children and the general paediatric population. Furthermore, HEU children exposed to maternal cART have modest but significant impairment of development and a higher risk of growth impairment. Finally, HEU have higher risks of infections (mainly low respiratory tract infections and diarrhoea) and malaria than HUU children, particularly in children not breastfed or after early weaning. Higher mortality risk from infectious disease is reported in HEU compared to HUU children. SUMMARY As we move toward the elimination of mother-to-child transmission of HIV, HEU children are an emerging population whose health outcomes remain to be fully described. Future large cohorts of HEU children using careful comparison groups of HUU in the post-ART era are needed to better understand their long-term health outcomes.
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10
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Abstract
BACKGROUND Evaluation of long-term tolerance to antiretroviral exposure during pregnancy is required. An increased risk of cancer has been suggested in children exposed in utero to didanosine. METHODS Updated evaluation of cancer incidence in uninfected children exposed to nucleos(t)ide reverse transcriptase inhibitors (NRTIs) in the French perinatal study of children born to HIV+ mothers, by cross-checking with the National Cancer Registry. Associations between cancer risk and exposure to NRTIs were evaluated by univariate survival analysis and Cox proportional hazard models. Standardized incidence ratios (SIR) were used for comparison with the general population. RESULTS A total of 21 cancers were identified in 15 163 children (median age: 9.9 years [interquartile range (IQR): 5.8-14.2]) exposed to at least one NRTI in utero, between 1990 and 2014. Five children were exposed to zidovudine monotherapy, and 16 to various combinations, seven including didanosine. Didanosine accounted for only 10% of prescriptions but was associated with one-third of cancers. In a multivariate analysis, didanosine exposure was significantly associated with higher risk [hazard ratio = 3.0 (0.9-9.8)]. The risk was specifically linked with first-trimester exposure [hazard ratio = 5.5 (2.1-14.4)]. Overall, the total number of cases was not significantly different from that expected for the general population [SIR = 0.8 (0.47-1.24)], but was twice that expected after didanosine exposure [SIR = 2.5 (1.01-5.19)]. CONCLUSION There are strong arguments to suggest that didanosine displays transplacental oncogenicity. Although not extrapolable to other NRTIs, they stress the need for comprehensive evaluation of the transplacental genotoxicity of this antiretroviral class.
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Smith C, Weinberg A, Forster JE, Levin MJ, Davies J, Pappas J, Kinzie K, Barr E, Paul S, McFarland EJ. Maternal Lopinavir/Ritonavir Is Associated with Fewer Adverse Events in Infants than Nelfinavir or Atazanavir. Infect Dis Obstet Gynecol 2016; 2016:9848041. [PMID: 27127401 PMCID: PMC4834394 DOI: 10.1155/2016/9848041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/09/2016] [Indexed: 01/31/2023] Open
Abstract
Combination antiretroviral therapy (cART) is successfully used for prevention of perinatal HIV transmission. To investigate safety, we compared adverse events (AE) among infants exposed to different maternal cART regimens. We reviewed 158 HIV-uninfected infants born between 1997 and 2009, using logistic regression to model grade ≥1 AE and grade ≥3 AE as a function of maternal cART and confounding variables (preterm, C-section, illicit drug use, race, ethnicity, infant antiretrovirals, and maternal viremia). Frequently used cART regimens included zidovudine (63%), lamivudine (80%), ritonavir-boosted lopinavir (37%), nelfinavir (26%), and atazanavir (10%). At birth, anemia occurred in 13/140 infants (9%), neutropenia in 27/107 (25%), thrombocytopenia in 5/133 (4%), and liver enzyme elevation in 21/130 (16%). Corresponding rates of AE at 4 weeks were 59/141 (42%), 54/130 (42%), 3/137 (2%), and 3/104 (3%), respectively. Serious AE (grade ≥ 3) exceeded 2% only for neutropenia (13% at birth; 9% at 4 weeks). Compared with infants exposed to maternal lopinavir/ritonavir, infants exposed to nelfinavir and atazanavir had a 5-fold and 4-fold higher incidence of AE at birth, respectively. In conclusion, hematologic and hepatic AE were frequent, but rarely serious. In this predominantly protease inhibitor-treated population, lopinavir/ritonavir was associated with the lowest rate of infant AE.
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Affiliation(s)
- Christiana Smith
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Adriana Weinberg
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Jeri E. Forster
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO 80045, USA
| | - Myron J. Levin
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Jill Davies
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Denver Health Medical Center, Denver, CO 80204, USA
| | | | - Kay Kinzie
- Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Emily Barr
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Suzanne Paul
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Elizabeth J. McFarland
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA
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12
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Abstract
Pulmonary malignancies are a major source of morbidity and mortality in HIV-infected persons. Non-AIDS-defining lung cancers (mostly non-small cell lung cancers) are now a leading cause of cancer death among HIV-infected persons. HIV-associated factors appear to affect the risk of lung cancer and may adversely impact cancer treatment and outcomes. HIV infection also may modify the potential harms and benefits of lung cancer screening with computed tomography. AIDS-defining lung malignancies include pulmonary Kaposi sarcoma and pulmonary lymphoma, both of which are less prevalent with widespread adoption of antiretroviral therapy.
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Affiliation(s)
- Keith Sigel
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert Pitts
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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