1
|
Mehrabi F, Karamouzian M, Farhoudi B, Moradi Falah Langeroodi S, Mehmandoost S, Abbaszadeh S, Motaghi S, Mirzazadeh A, Sadeghirad B, Sharifi H. Comparison of safety and effectiveness of antiretroviral therapy regimens among pregnant women living with HIV at preconception or during pregnancy: a systematic review and network meta-analysis of randomized trials. BMC Infect Dis 2024; 24:417. [PMID: 38641597 PMCID: PMC11031873 DOI: 10.1186/s12879-024-09303-2] [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: 01/02/2024] [Accepted: 04/08/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Mother-to-child transmission is the primary cause of HIV cases among children. Antiretroviral therapy (ART) plays a critical role in preventing mother-to-child transmission and reducing HIV progression, morbidity, and mortality among mothers. However, after more than two decades of ART during pregnancy, the comparative effectiveness and safety of ART medications during pregnancy are unclear, and existing evidence is contradictory. This study aimed to assess the effectiveness and safety of different ART regimens among pregnant women living with HIV at preconception or during pregnancy. METHODS We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science. We included randomized trials that enrolled pregnant women living with HIV and randomized them to receive ART for at least four weeks. Pairs of reviewers independently completed screening for eligible studies, extracted data, and assessed the risk of bias using the Cochrane risk of bias tool. Our outcomes of interest included low birth weight, stillbirth, preterm birth, mother-to-child transmission of HIV, neonatal death, and congenital anomalies. Network meta-analysis was performed using a random-effects frequentist model, and the certainty of evidence was evaluated using the GRADE approach. RESULTS We found 14 eligible randomized trials enrolling 9,561 pregnant women. The median duration of ART uptake ranged from 6.0 to 17.4 weeks. No treatment was statistically better than a placebo in reducing the rate of neonatal mortality, stillbirth, congenital defects, preterm birth, or low birth weight deliveries. Compared to placebo, zidovudine (ZDV)/lamivudine (3TC) and ZDV monotherapy likely reduce mother-to-child transmission (odds ratio (OR): 0.13; 95% CI: 0.05 to 0.31, high-certainty; and OR: 0.50; 95% CI: 0.33 to 0.74, moderate-certainty). Moderate-certainty evidence suggested that ZDV/3TC was associated with decreased odds of stillbirth (OR: 0.47; 95% CI: 0.09 to 2.60). CONCLUSIONS Our analysis provides high- to moderate-certainty evidence that ZDV/3TC and ZDV are more effective in reducing the odds of mother-to-child transmission, with ZDV/3TC also demonstrating decreased odds of stillbirth. Notably, our findings suggest an elevated odds of stillbirth and preterm birth associated with all other ART regimens.
Collapse
Affiliation(s)
- Fatemeh Mehrabi
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Karamouzian
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Behnam Farhoudi
- Social Determinants of Health Research Center, Amir-al-momenin Hospital, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Shahryar Moradi Falah Langeroodi
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
- Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Soheil Mehmandoost
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Samaneh Abbaszadeh
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Shahrzad Motaghi
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Ali Mirzazadeh
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA.
| |
Collapse
|
2
|
Atowoju I, Dawer P, Asrani M, Panjiyar B. Impact of maternal HIV infection on perinatal outcomes: A systematic review. Int J Gynaecol Obstet 2024. [PMID: 38573155 DOI: 10.1002/ijgo.15528] [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: 11/08/2023] [Revised: 02/28/2024] [Accepted: 03/24/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Maternal HIV infection remains a significant global health concern with potential repercussions on perinatal outcomes. Emphasis on early intervention to improve peri- and postnatal outcomes in infected mothers and infants is a valid therapeutic concern. OBJECTIVES To comprehensively analyze perinatal outcomes associated with maternal HIV infection and evaluate adverse effects associated with the HIV infection in the existing literature. SEARCH STRATEGY A comprehensive search of PubMed, MEDLINE, and Google Scholar was conducted from 2013 to September 2023, using relevant MeSH terms. SELECTION CRITERIA The included studies encompassed original studies, cross-sectional, prospective, retrospective studies and observational studies focused on perinatal outcomes in the context of maternal HIV infection. DATA COLLECTION AND ANALYSIS The selected studies underwent rigorous data collection and comprehensive quality checks and adhered to the PRISMA guidelines. MAIN RESULTS Nine eligible studies from Brazil, China, India, Malawi, Nigeria, Tanzania, the USA, and Canada were included. These studies have consistently demonstrated that maternal HIV infection is associated with adverse perinatal outcomes. The analysis revealed a higher risk of preterm birth (OR 1.57, 95% CI: 1.39-1.78), low birth weight (OR 1.33, 95% CI: 1.18-1.49), and small for gestational age (OR 1.38, 95% CI: 1.24-1.53) among infants born to mothers living with HIV. Notably, the impact of antiretroviral treatment (ART) on these outcomes varied, but maternal HIV infection remained a significant risk factor regardless of income level and geographic region. CONCLUSION Maternal HIV infection is consistently associated with adverse perinatal outcomes, emphasizing the need for targeted interventions and improved prenatal care in pregnant women with HIV infection.
Collapse
Affiliation(s)
- Inioluwa Atowoju
- Department of Obstetrics and Gynecology, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Prachi Dawer
- University College of Medical Sciences, New Delhi, India
| | - Manisha Asrani
- Department of Obstetrics and Gynecology, Pramukh Swami Medical College, Karamsad, Anand, Gujarat, India
| | - Binay Panjiyar
- PGME GCSRT Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Ajibola G, Mdluli C, Bennett K, Sakoi M, Batlang O, Makhema J, Lockman S, Shapiro R, Myer L, Powis K. No increased in utero and peripartum HIV acquisition risk in HIV-exposed preterm infants. South Afr J HIV Med 2023; 24:1509. [PMID: 37928500 PMCID: PMC10623649 DOI: 10.4102/sajhivmed.v24i1.1509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/13/2023] [Indexed: 11/07/2023] Open
Abstract
Background Limited data exist on the differential risk of HIV acquisition between infants born preterm versus those born at term to women living with HIV (WLHIV). With a reported increase in preterm delivery among pregnant WLHIV, understanding the risk of vertical transmission of HIV in preterm infants can inform strategies to optimise the timing of diagnostic testing, antiretroviral prophylaxis, and infant feeding. Objectives To describe the prevalence and timing of HIV acquisition, in utero versus perinatal, among infants with perinatal HIV exposure born prior to 37 weeks completed gestation age compared to those born at term in the Botswana-based Mpepu study and explore predictors of infant HIV acquisition. Method Using data extracted from the Mpepu study, we describe the prevalence, timing and risk factors for HIV acquisition in infants born preterm versus those born at term. Fisher exact testing was used to test for differences in prevalence and timing of HIV and a multivariable logistic regression model was used to assess risk factors for infant HIV acquisition. Results 2866 infants born to WLHIV were included in this secondary analysis. 532 (19%) were born preterm. There was no observed difference in the prevalence of HIV acquisition among infants born preterm versus at term overall (0.8% vs 0.6%, P = 0.54), at birth (0.2% vs 0.3%, P = 1.00) or between 14 and 34 days post-delivery (0.6% vs 0.3%, P = 0.41). The absence of maternal antiretroviral use during pregnancy significantly predicted infant HIV acquisition, with the risk of HIV acquisition reduced by 96% among infants whose mothers were taking antiretroviral treatment (ART) during pregnancy (adjusted odds ratio: 0.003, confidence interval: 0.01-0.02, P < 0.001). Conclusion There was no observed increase of in utero and peripartum HIV acquisition among infants born preterm following foetal exposure to HIV compared to those born at term.
Collapse
Affiliation(s)
| | | | - Kara Bennett
- Bennett Statistical Consulting Inc, New York, United States of America
| | - Maureen Sakoi
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
| | - Oganne Batlang
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
| | - Joseph Makhema
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
| | - Shahin Lockman
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
- Department of Infectious Diseases, Brigham and Womens Hospital, Boston, United States of America
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Roger Shapiro
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Landon Myer
- Department of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kathleen Powis
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, United States of America
- Department of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, United States of America
| |
Collapse
|
4
|
Kourtis AP, Zhu W, Lampe MA, Huang YLA, Hoover KW. Dolutegravir and pregnancy outcomes including neural tube defects in the USA during 2008-20: a national cohort study. Lancet HIV 2023; 10:e588-e596. [PMID: 37506721 PMCID: PMC10614030 DOI: 10.1016/s2352-3018(23)00108-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND A study from Botswana identified an increased risk of neural tube defects (NTDs) in infants of mothers with HIV who were treated with dolutegravir around the time of conception. We aimed to examine associations of dolutegravir use with NTDs and pregnancy loss using large health-care claims databases from the USA, a country with folic acid fortification of food. METHODS In this cohort study, we analysed health-care claims data, recorded in the Merative MarketScan commercial database (MarketScan data) and Centers for Medicare & Medicaid Services Medicaid database (Medicaid data) from Jan 1, 2008, to Dec 31, 2020. We identified pregnancies with enrolment during their entire duration among women aged 15-49 years and we estimated time of conception. For each pregnancy, we determined HIV status and periconceptional exposure to dolutegravir or other antiretroviral agents. We estimated and compared the incidence rate of NTDs, stillbirths, and pregnancy loss (ie, spontaneous or induced abortions) by type of periconceptional antiretroviral exposure. We calculated adjusted risk ratios of the adverse outcomes using Poisson models adjusting for demographic and clinical factors. FINDINGS Of 4 489 315 pregnancies in MarketScan data and 14 405 861 pregnancies in Medicaid data that had full enrolment, we identified 69 pregnancies in MarketScan data and 993 pregnancies in Medicaid data that were associated with HIV and periconceptional dolutegravir exposure. For women without HIV, the NTD rate was 4·1 per 10 000 live births (95% CI 3·9-4·3) in MarketScan and 5·7 per 10 000 live births (5·6-5·8) in Medicaid. No NTD cases were found among those with dolutegravir or non- dolutegravir antiretroviral drug exposure in the MarketScan data; only one NTD case was identified among women with dolutegravir, and three among women with non-dolutegravir antiretroviral exposure in Medicaid. After adjusting for covariates, there were no significant differences in risk ratios of NTD between groups with periconceptional dolutegravir or non-dolutegravir antiretroviral exposure and the group without HIV. However, compared with women without HIV, the risk of pregnancy loss was higher among women exposed to antiretroviral therapy: for dolutegravir exposure the adjusted risk ratio was 1·73 (95% CI 1·20-2·49) in MarketScan data and 1·41 (1·30-1·54) in Medicaid data; for non-dolutegravir antiretroviral exposure the adjusted risk ratio was 1·23 (1·10-1·37) in MarketScan data and 1·11 (1·07-1·15) in Medicaid data. INTERPRETATION We studied the largest US cohort of women with periconceptional or early-pregnancy dolutegravir exposure. Our results do not show an increased risk of NTDs in exposed infants in the USA. Administrative databases can be used, with rigorous methodology, to study correlates of rare outcomes, such as NTDs, and to monitor for adverse pregnancy outcomes in women who receive antiretrovirals. FUNDING US Centers for Disease Control and Prevention.
Collapse
Affiliation(s)
- Athena P Kourtis
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Weiming Zhu
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Margaret A Lampe
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ya-Lin A Huang
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Karen W Hoover
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| |
Collapse
|
5
|
Rebnord T, Mmbaga BT, Sandøy IF, Lie RT, Mchome B, Mahande MJ, Daltveit AK. Time trends in perinatal outcomes among HIV-positive pregnant women in Northern Tanzania: A registry-based study. PLoS One 2023; 18:e0289740. [PMID: 37561712 PMCID: PMC10414606 DOI: 10.1371/journal.pone.0289740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 07/25/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION Maternal HIV infection is associated with increased risk of having a preterm delivery, low birth weight baby, small for gestational age baby and stillbirth. Maternal use of combination antiretroviral treatment is also associated with preterm delivery and low birth weight, although the effects vary by the type of drugs and timing of initiation. OBJECTIVE To examine time trends in adverse perinatal outcomes among HIV-positive compared with HIV-negative women. DESIGN Registry-based cohort study. SETTING Northern Tanzania, 2000-2018. STUDY SAMPLE Mother-baby pairs of singleton deliveries (n = 41 156). METHODS Perinatal outcomes of HIV-positive women were compared with HIV-negative women during time periods representing shifts in prevention of mother-to-child transmission guidelines. Monotherapy was used as first-line therapy before 2007 while combination antiretroviral treatment was routinely used from 2007. Log binomial and quantile regression were used to analyze the data. MAIN OUTCOME MEASURES Preterm delivery, low birth weight, perinatal death, stillbirth, low Apgar score, transfer to neonatal care unit and small for gestational age. RESULTS Overall, maternal HIV infection was associated with a higher risk of low birth weight and small for gestational age. Moreover, this pattern became more pronounced over time for low birth weight, the last time period being an exception. For other outcomes we found none or only a small overall association with maternal HIV infection, although a trend towards higher risk over time in HIV-positive compared with HIV-negative women was observed for preterm delivery and perinatal death. Quantile regression showed an increase in birth weight in babies born to HIV-negative women over time and a corresponding decline in birth weight in babies born to HIV-positive women. CONCLUSION Unfavourable trends in some of the selected perinatal outcomes were seen for HIV-positive compared with HIV-negative women. Potential side-effects of combination antiretroviral treatment in pregnancy should be further explored.
Collapse
Affiliation(s)
- Tormod Rebnord
- Department of Global Public Health and Primary Care (IGS), Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Blandina Theophil Mmbaga
- Department of Paediatrics and Child Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Ingvild Fossgard Sandøy
- Department of Global Public Health and Primary Care (IGS), Faculty of Medicine, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health (CISMAC) and Centre for International Health, University of Bergen, Bergen, Norway
| | - Rolv Terje Lie
- Department of Global Public Health and Primary Care (IGS), Faculty of Medicine, University of Bergen, Bergen, Norway
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Bariki Mchome
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Gynecology and Obstetrics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Michael Johnson Mahande
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Anne Kjersti Daltveit
- Department of Global Public Health and Primary Care (IGS), Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway
| |
Collapse
|
6
|
Sprong KE, Wright CA, Mabenge M, Govender S. Placental histopathology, maternal characteristics and neonatal outcome in cases of preterm birth in a high-risk population in South Africa. S Afr Med J 2023. [DOI: 10.7196/samj.2023.v113i4.16772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Background. Preterm birth remains a global health concern and is one of the most common pregnancy complications associated with perinatal morbidity and mortality.Objective. To investigate placental pathology and its associations with obstetric, maternal and neonatal outcomes in the Eastern Cape region of South Africa (SA) in order to help understand its associations with preterm birth in that region.
Methods. In this prospective study, placentas were collected consecutively from patients attending a public tertiary referral hospital in SA, delivering preterm (n=100; 28 - 34 weeks gestational age) and term (n=20; >36 weeks gestational age). Placentas were submitted for histopathology, and comparisons with maternal characteristics and neonatal outcomes in preterm birth were undertaken.Results. Histological analysis revealed pathology in all preterm placentas (100%), with maternal vascular malperfusion (47%) and abruptio placentae (41%) most commonly identified. Acute chorioamnionitis (21%) was associated with term births (p=0.002). Maternal characteristics and neonatal outcomes significantly associated with preterm birth included pre-eclampsia (p=0.006), neonatal respiratory distress syndrome (p=0.004) and neonatal jaundice (p=0.003). Intrauterine demise (p=0.004) and alcohol abuse (p≤0.005) were significantly associated with term delivery. The number of mothers delivering preterm who were HIV-positive was high (41%).
Conclusion. The pathology identified in all preterm placentas supports the need to update institutional policies for submission of placentas from all preterm births for histopathology, particularly in countries with a high burden of preterm birth.
Collapse
|
7
|
Fonzo M, Zuanna TD, Amoruso I, Resti C, Tsegaye A, Azzimonti G, Sgorbissa B, Centomo M, Ferretti S, Manenti F, Putoto G, Baldovin T, Bertoncello C. The HIV paradox: Perinatal mortality is lower in HIV-positive mothers-A field case-control study in Ethiopia. Int J Gynaecol Obstet 2023. [PMID: 36815783 DOI: 10.1002/ijgo.14738] [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: 11/03/2022] [Revised: 02/02/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE Sub-Saharan African countries have the highest perinatal mortality rates. Although HIV is a risk factor for perinatal death, antioretroviral therapy (ART) programs have been associated with better outcomes. We aimed to investigate how maternal HIV affects perinatal mortality. METHODS The authors performed a nested case-control study at Saint Luke Hospital, Wolisso, Ethiopia. Data on sociodemographic characteristics, current maternal conditions, obstetric history, and antenatal care (ANC) services utilization were collected. The association between perinatal mortality and HIV was assessed with logistic regression adjusting for potential confounders. RESULTS A total of 3525 birthing women were enrolled, including 1175 cases and 2350 controls. Perinatal mortality was lower among HIV-positive women (18.3% vs. 33.6%, P = 0.007). Crude analysis showed a protective effect of HIV (odds ratio, 0.442 [95% confidence interval, 0.241-0.810]), which remained after adjustment (adjusted odds ratio, 0.483 [95% confidence interval, 0.246-0.947]). Among HIV-negative women, access to ANC for women from rural areas was almost half (18.8% vs. 36.2%; P < 0.001), whereas in HIV-positive women, no differences were noted (P = 0.795). CONCLUSION Among HIV-positive mothers, perinatal mortality was halved and differences in access to ANC services by area were eliminated. These data highlight the benefits of integrating ANC and HIV services in promoting access to the health care system, reducing inequalities and improving neonatal mortality.
Collapse
Affiliation(s)
- M Fonzo
- Hygiene and Public Health Unit, DCTVSP, University of Padova, Padova, Italy
| | - T D Zuanna
- Hygiene and Public Health Unit, DCTVSP, University of Padova, Padova, Italy
| | - I Amoruso
- Hygiene and Public Health Unit, DCTVSP, University of Padova, Padova, Italy
| | - C Resti
- Doctors with Africa CUAMM, Addis Ababa, Ethiopia
| | - A Tsegaye
- Doctors with Africa CUAMM, Addis Ababa, Ethiopia
| | | | - B Sgorbissa
- Hygiene and Public Health Unit, DCTVSP, University of Padova, Padova, Italy
| | - M Centomo
- Hygiene and Public Health Unit, DCTVSP, University of Padova, Padova, Italy
| | - S Ferretti
- Hygiene and Public Health Unit, DCTVSP, University of Padova, Padova, Italy
| | - F Manenti
- Doctors with Africa CUAMM, Padova, Italy
| | - G Putoto
- Doctors with Africa CUAMM, Padova, Italy
| | - T Baldovin
- Hygiene and Public Health Unit, DCTVSP, University of Padova, Padova, Italy
| | - C Bertoncello
- Hygiene and Public Health Unit, DCTVSP, University of Padova, Padova, Italy
| |
Collapse
|
8
|
Portwood C, Sexton H, Kumarendran M, Brandon Z, Kirtley S, Hemelaar J. Adverse perinatal outcomes associated with antiretroviral therapy in women living with HIV: A systematic review and meta-analysis. Front Med (Lausanne) 2023; 9:924593. [PMID: 36816720 PMCID: PMC9935588 DOI: 10.3389/fmed.2022.924593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 12/20/2022] [Indexed: 02/05/2023] Open
Abstract
Background Maternal HIV infection is associated with an increased risk of adverse perinatal outcomes. The World Health Organization (WHO) recommends immediate initiation of lifelong antiretroviral therapy (ART) for all people living with HIV, including pregnant women living with HIV (WLHIV). We aimed to assess the risk of adverse perinatal outcomes in WLHIV receiving ART compared to ART-naïve WLHIV and HIV-negative women. Materials and methods We conducted a systematic literature review by searching PubMed, CINAHL, Global Health, and EMBASE for studies published between Jan 1, 1980, and April 20, 2020. Two investigators independently selected relevant studies and extracted data from studies reporting on the association of pregnant WLHIV receiving ART with adverse perinatal outcomes. Perinatal outcomes examined were preterm birth (PTB), very PTB, spontaneous PTB (sPTB), low birth weight (LBW), very LBW (VLBW), term LBW, preterm LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Random-effects meta-analyses examined the risk of adverse perinatal outcomes in WLHIV receiving ART compared to ART-naïve WLHIV and HIV-negative women. Subgroup and sensitivity analyses were performed based on country income status and study quality, and adjustment for confounding factors assessed. Results Of 94,594 studies identified, 73 cohort studies, including 424,277 pregnant women, met the inclusion criteria. We found that WLHIV receiving ART are associated with a significantly decreased risk of PTB (relative risk 0.79, 95% CI 0.67-0.93), sPTB (0.46, 0.32-0.66), LBW (0.86, 0.79-0.93), and VLBW (0.62, 0.39-0.97) compared to ART-naïve WLHIV. However, WLHIV receiving ART are associated with a significantly increased risk of PTB (1.42, 1.28-1.57), sPTB (2.20, 1.32-3.67), LBW (1.58, 1.36-1.84), term LBW (1.88, 1.23-2.85), SGA (1.69, 1.32-2.17), and VSGA (1.22, 1.10-1.34) compared to HIV-negative women. Conclusion ART reduces the risk of adverse perinatal outcomes in pregnant WLHIV, but the risk remains higher than in HIV-negative women. Our findings support the WHO recommendation of immediate initiation of lifelong ART for all people living with HIV, including pregnant WLHIV. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42021248987.
Collapse
Affiliation(s)
- Clara Portwood
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Harriet Sexton
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom,*Correspondence: Joris Hemelaar,
| |
Collapse
|
9
|
Sexton H, Kumarendran M, Brandon Z, Shi C, Kirtley S, Hemelaar J. Adverse perinatal outcomes associated with timing of initiation of antiretroviral therapy: Systematic review and meta-analysis. HIV Med 2023; 24:111-129. [PMID: 35665582 DOI: 10.1111/hiv.13326] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 05/05/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The World Health Organization (WHO) recommends immediate initiation of lifelong antiretroviral therapy (ART) for all people living with HIV, including pregnant women. As a result, an increasing number of women living with HIV conceive while taking ART, the vast majority of whom reside in low- and middle-income countries (LMICs). We aimed to assess the association between timing of ART initiation and perinatal outcomes. METHODS We conducted a systematic literature review by searching PubMed, CINAHL (EBSCOhost), Global Health (Ovid), EMBASE (Ovid), and the Cochrane Central Register of Controlled Trials and four clinical trial databases (WHO International Clinical Trials Registry Platform, the Pan African Clinical Trials Registry, the ClinicalTrials.gov database, and the ISRCTN Registry) from 1 January 1980 to 28 April 2018. We identified studies reporting specific perinatal outcomes among pregnant women living with HIV according to timing of ART initiation and extracted data. Perinatal outcomes assessed were preterm birth (<37 weeks), very preterm birth (<32 weeks), low birthweight (<2500 g), very low birthweight (<1500 g), small for gestational age (<10th centile), very small for gestational age (<3rd centile) and neonatal death (<29 days). Random-effects meta-analyses examined perinatal outcomes associated with preconception and antenatal ART initiation as well as according to trimesters of antenatal initiation. We performed quality assessments and subgroup and sensitivity analyses, and assessed the effect of adjustment for confounders. This systematic review and meta-analyses is registered with PROSPERO, number CRD42021248987. RESULTS Of 51 874 unique citations, 25 studies (eight prospective and 17 retrospective cohort studies) were eligible for analysis, including 40 920 women living with HIV. Preconception ART initiation was associated with a significantly increased risk of preterm birth (relative risk 1.16; 95% confidence interval [CI] 1.03-1.31) compared with antenatal ART initiation. Preconception ART initiation was not significantly associated with very preterm birth, low birthweight, very low birthweight, small for gestational age, very small for gestational age, or neonatal death. First trimester exposure (i.e. preconception or first trimester initiation) was not significantly associated with any increased risk of adverse perinatal outcomes. No significant association between timing of ART initiation and adverse perinatal outcomes was found in the studies of higher quality and those conducted in LMICs. CONCLUSION Preconception ART initiation is associated with preterm birth but no other adverse perinatal outcomes. In LMICs, where most pregnant women living with HIV reside, the timing of ART initiation was not associated with any adverse perinatal outcomes.
Collapse
Affiliation(s)
- Harriet Sexton
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christine Shi
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| |
Collapse
|
10
|
Shallie PD, Naicker T, Nayak NR. Stress-Sensitive Regulators of Fetal Neurodevelopment in HIV and Preeclampsia: An Immunocytochemical Appraisal of Placental OGT and T4 Levels. Arch Immunol Ther Exp (Warsz) 2023; 71:3. [PMID: 36681768 DOI: 10.1007/s00005-023-00668-x] [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: 06/06/2022] [Accepted: 10/03/2022] [Indexed: 01/23/2023]
Abstract
Preeclampsia and HIV are a significant burden to maternal health globally, especially in low-middle income countries such as South Africa. In the KwaZulu-Natal province, SA antenatal HIV prevalence is 41.1%, while PE is 12%. PE and HIV infections are maternal stress and inflammation that impact placental function and fetal development. Therefore, this study investigated the impact of the comorbidity of PE and HIV on placental stress and neurodevelopment. Placentae were obtained from four cohorts of pregnant women: normotensive HIV negative, normotensive HIV positive, preeclamptic HIV negative, and preeclamptic HIV positive. The placental tissue sections were immunostained for OGT and T4. Our findings showed that the maternal weight, diastolic, and systolic blood pressures (BP) were higher in PE vs. the normotensive groups, irrespective of HIV status. In addition, significant changes were noticed in the placental weight, fetoplacental ratio, and placental efficiency coefficient. Our findings showed that the maternal weight, diastolic, and systolic blood pressures (BP) were statistically higher in the PE compared to the normotensive. No significant differences were observed between HIV positive and HIV negative groups. In addition, significant changes were noticed in the placental weight, fetoplacental ratio, and placental coefficient. Furthermore, considerable upregulation in the placental expression of OGT in both the conducting and exchange villi of PE and concomitant downregulation in HIV-positive patients compared with Normotensive and HIV-negative individuals, respectively. Our results provide inferential evidence on the dysregulation of OGT in the comorbidity of PE and HIV. This may mediate a compromised programmed outcome of an adverse maternal environment during pregnancy and consequently affect fetal development.
Collapse
Affiliation(s)
- Philemon D Shallie
- Department of Obstetrics and Gynecology, UMKC School of Medicine, Kansas City, MO, 64108, USA.
| | - Thajasvarie Naicker
- Optics and Imaging Centre, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
| | - Nihar R Nayak
- Department of Obstetrics and Gynecology, UMKC School of Medicine, Kansas City, MO, 64108, USA
| |
Collapse
|
11
|
Brandon O, Chakravarti S, Hemelaar J. Trends in management and outcomes of pregnant women living with HIV between 2008–2013 and 2014–2019: A retrospective cohort study. Front Med (Lausanne) 2022; 9:970175. [DOI: 10.3389/fmed.2022.970175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDespite major advances in the care of pregnant women living with HIV (WLHIV), they remain at increased risk of adverse pregnancy outcomes. This study assesses recent developments in management and outcomes of pregnant WLHIV at a tertiary obstetric unit in the United Kingdom.MethodsWe conducted a retrospective cohort study of WLHIV delivering at the John Radcliffe Hospital, Oxford, during 2008–2019. Detailed data was collected for maternal, virological, obstetric, and perinatal characteristics. To determine changes over time, data from the periods 2008–13 and 2014–19 were compared.ResultsWe identified 116 pregnancies in 94 WLHIV. Between 2008–2013 and 2014–2019, the rate of preconception HIV diagnosis increased from 73 to 90% (p = 0.021) and the proportion of WLHIV on combination ART (cART) at conception increased from 54 to 84% (p = 0.001). The median gestation at which cART was initiated antenatally decreased from 22+1 to 17+1 weeks (p = 0.003). In 2014-2019, 41% of WLHIV received non-nucleoside reverse transcriptase inhibitor-based cART, 37% protease inhibitor-based cART, and 22% of cART regimens contained an integrase inhibitor. The proportion of WLHIV with a viral load <50 copies/mL at delivery rose from 87 to 94% (p = 0.235). Sixty-six percent of WLHIV delivered by Cesarean section, with a significant decrease over time in the rate of both planned (62–39%, p = 0.016) and actual (49–31%, p = 0.044) elective Cesarean. Perinatal outcomes included one case of perinatal HIV transmission (0.86%), 11% preterm birth, 15% small-for-gestational-age, and 2% stillbirth. There was an association between a viral load >50 copies/mL at delivery and preterm delivery (p = 0.0004).ConclusionVirological, obstetric, and perinatal outcomes of WLHIV improved during the study period. Implementation of national guidance has led to an increase in preconception diagnosis and treatment, earlier initiation of antenatal treatment, a reduction in the number of women with a detectable viral load at delivery, and an increase in vaginal deliveries.
Collapse
|
12
|
Worku WZ, Azale T, Ayele TA, Mekonnen DK. Effects of HIV Infection on Pregnancy Outcomes Among Women Attending Antenatal Care in Referral Hospitals of the Amhara Regional State, Ethiopia: A Prospective Cohort Study. Int J Womens Health 2022; 14:1405-1423. [PMID: 36176965 PMCID: PMC9514786 DOI: 10.2147/ijwh.s382685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) has remained to be a significant public health problem worldwide mainly affecting women. Despite a 2 to 3 times higher risk of adverse pregnancy outcomes, around 2 million HIV positive women give birth each year globally. However, there is a dearth of evidences in Ethiopia about the effect of maternal HIV infection on pregnancy outcomes where adverse birth outcomes are still a significant health problem. This study is, therefore, aimed to examine the effect of HIV on the risk of adverse pregnancy outcomes in Amhara Regional State, Ethiopia. Methods A prospective cohort study was conducted among 704 pregnant women (352 women with HIV and 352 women without HIV infection). Systematic random sampling technique was employed to select the study participants. Data on socio-demographic, obstetric, clinical, as well as behavioral and psychosocial characteristics were collected using a validated tool. Data on the outcome variables were also collected following delivery. Modified Poisson regression was employed to estimate the relative risk (RR) of HIV on low birth weight (LBW), preterm birth, and still birth at 95% confidence level. Attributable fraction (AF) was used to report the impact of HIV infection on pregnancy outcomes. Results Of the total 704 pregnant women enrolled for the study, 96.3% (678) completed the study. The mean age of the study participants was 30.8 (SD ± 5.4) for HIV positive and 27 (SD ± 5.4) for HIV negative women. The cumulative incidence of low birth weight, preterm birth, and stillbirth were 21.4%, 9.4%, and 4.1%, respectively. The incidence of LBW was 24.7% among HIV positive and 17.8% among HIV negative women. The incidence of preterm birth was 10.7% among HIV positive and 7.9% among HIV negative women. And the incidence of stillbirth was 3.7% and 4.6% among HIV positive and those HIV negative women. New-borns from women with HIV infection had a higher risk of low birth weight and preterm birth than those HIV negative women (Adjusted Relative Risk (ARR) = 1.47; 95% CI: 1.06–2.03) and (ARR = 1.74; 95% CI: 1.08–2.79), respectively. The attributable risk of HIV on low birth weight was 32% (Attributable Fraction (AF) = 32%, 95% CI: 23–46%), and 43% (AF = 43%, 95% CI: 23–46%) for preterm birth. Conclusion Maternal HIV infection increased the risk of low birth weight and preterm birth. This implies due attention is required while providing maternal health services primarily antenatal care and delivery services. These services should be aimed at reducing adverse pregnancy outcomes with more attention given to women with HIV infection. Moreover, reinforcement of HIV prevention intervention strategies should be considered at all levels.
Collapse
Affiliation(s)
- Workie Zemene Worku
- Department of Community Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Telake Azale
- Department of Health Education and Behavioural Sciences, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tadesse Awoke Ayele
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Dawit Kassahun Mekonnen
- Department of Gynaecology and Obstetrics, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| |
Collapse
|
13
|
Quinn MK, Williams PL, Muhihi A, Duggan CP, Ulenga N, Alwy Al-Beity FM, Perumal N, Aboud S, Fawzi WW, Manji KP, Sudfeld CR. Timing of Antiretroviral Therapy: Initiation and Birth Outcomes Among Pregnant Women With Human Immunodeficiency Virus in Tanzania. J Infect Dis 2022; 226:687-695. [PMID: 35678698 PMCID: PMC9890905 DOI: 10.1093/infdis/jiac224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/06/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Combination antiretroviral therapy (cART) initiation during pregnancy reduces the risk of perinatal human immunodeficiency virus (HIV) transmission; however, studies have suggested that there may be unintended adverse consequences on birth outcomes for selected cART regimens. METHODS We analyzed adverse birth outcomes among a prospective cohort of 1307 pregnant women with HIV in Dar es Salaam who initiated cART during the first or second trimester of a singleton pregnancy. Our primary analysis compared birth outcomes by gestational age at cART initiation among these women initiating cART in pregnancy. RESULTS Among women who initiated cART in pregnancy, there was no relationship of gestational age at cART initiation with the risk of fetal death or stillbirth. However, women who initiated cART before 20 weeks of gestation compared with after 20 weeks had increased risk of preterm birth (risk ratio [RR], 1.30; 95% confidence interval [CI], 1.03-1.67) but decreased risk of small-for-gestational age birth (RR, 0.71; 95% CI, .55-.93). CONCLUSIONS With increasing use of cART preconception and early in pregnancy, clinicians should be aware of the benefits and potential risks of cART regimens to optimize birth outcomes.
Collapse
Affiliation(s)
- M K Quinn
- Correspondence: M. K. Quinn, PhD, Department of Pediatrics, Stanford University School of Medicine, Center for Academic Medicine, Neonatology - MC 5660, 453 Quarry Road, Palo Alto, CA, USA ()
| | - Paige L Williams
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Alfa Muhihi
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Christopher P Duggan
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Fadhlun M Alwy Al-Beity
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nandita Perumal
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wafaie W Fawzi
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher R Sudfeld
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
14
|
Adverse perinatal outcomes associated with HAART and monotherapy: systematic review and meta-analysis. AIDS 2022; 36:1409-1427. [PMID: 35608111 DOI: 10.1097/qad.0000000000003248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Assess adverse perinatal outcomes in women living with HIV (WLHIV) receiving HAART or zidovudine (ZDV) monotherapy, compared with antiretroviral therapy (ART)-naive WLHIV and HIV-negative women. DESIGN Systematic review and meta-analysis. METHODS We conducted a systematic literature review by searching PubMed, CINAHL, Global Health, and EMBASE for studies published during 1 January 1980 to 20 April 2020. We included studies reporting on the association of pregnant WLHIV receiving HAART or ZDV monotherapy with 11 perinatal outcomes: preterm birth (PTB), very PTB, spontaneous PTB (sPTB), low birth weight (LBW), very LBW, term LBW, preterm LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Random-effects meta-analyses were conducted. RESULTS Sixty-one cohort studies assessing 409 781 women were included. WLHIV receiving ZDV monotherapy were associated with a decreased risk of PTB [relative risk 0.70, 95% confidence interval (CI) 0.62-0.79] and LBW (0.77, 0.67-0.88), and comparable risk of SGA, compared with ART-naive WLHIV. WLHIV receiving ZDV monotherapy had a comparable risk of PTB and LBW, and an increased risk of SGA (1.16, 1.04-1.30) compared with HIV-negative women. In contrast, WLHIV receiving HAART were associated with a comparable risk of PTB and LBW, and increased risk of SGA (1.38, 1.09-1.75), compared with ART-naive WLHIV. WLHIV receiving HAART were associated with an increased risk of PTB (1.55, 1.38-1.74), sPTB (2.09, 1.48-2.96), LBW (1.79, 1.51-2.13), term LBW (1.88, 1.23-2.85), SGA (1.80,1.34-2.40), and VSGA (1.22, 1.10-1.34) compared with HIV-negative women. CONCLUSION Pregnant WLHIV receiving HAART have an increased risk of a wide range of perinatal outcomes compared with HIV-negative women.
Collapse
|
15
|
Cowdell I, Beck K, Portwood C, Sexton H, Kumarendran M, Brandon Z, Kirtley S, Hemelaar J. Adverse perinatal outcomes associated with protease inhibitor-based antiretroviral therapy in pregnant women living with HIV: A systematic review and meta-analysis. EClinicalMedicine 2022; 46:101368. [PMID: 35521067 PMCID: PMC9061981 DOI: 10.1016/j.eclinm.2022.101368] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The World Health Organization recommends protease inhibitor (PI)-based antiretroviral therapy (ART) as second-line and third-line regimens in pregnant women living with HIV (WLHIV). US, European, and UK guidelines include PI-based ART as first-line regimens, but advise against the use of lopinavir/ritonavir (LPV/r)-based ART, citing an increased risk of preterm birth (PTB). We aimed to assess the risk of adverse perinatal outcomes in WLHIV receiving PI-ART and the comparative risks associated with different PI-ART regimens. METHODS We conducted a systematic literature review by searching PubMed, CINAHL, Global Health, and EMBASE for studies published between Jan 1, 1980, and April 20, 2020. Two investigators independently selected studies and extracted data from studies reporting on the association of pregnant WLHIV receiving PI-ART with 11 perinatal outcomes: PTB, very PTB (VPTB), spontaneous PTB (sPTB), low birth weight (LBW), very LBW (VLBW), term LBW, preterm LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Pairwise random-effects meta-analyses examined the risk of each adverse perinatal outcome in WLHIV receiving PI-ART compared to non-PI-based ART (non-PI-ART), and comparisons of different PI-ART regimens. Quality assessments of studies were performed, subgroup and sensitivity analyses were conducted based on country income status and study quality, heterogeneity assessed, and the effect of adjustment for confounding factors assessed. The protocol is registered with PROSPERO, CRD42021248987. FINDINGS Of 94,594 studies identified, 34 cohort studies including 57,546 women met the inclusion criteria. Random-effects meta-analyses showed that PI-ART was associated with a significantly increased risk of SGA (Relative Risk [RR] 1.24, 95% CI 1.08-1.43; I2 =66.7%) and VSGA (RR 1.40, 1.09-1.81; I2 =0.0%), but not PTB (RR 1.09, 0.95-1.24; I2 =68.3%), VPTB (RR 1.30, 0.78-2.18; I2 =43.0%), sPTB (RR 1.91, 0.61-5.99; I2 =95.7%), LBW (RR 1.04, 0.85-1.27; I2 =63.9%), VLBW (RR 0.72, 0.37-1.43; I2 =37.9%), term LBW (RR 0.94, 0.30-3.02; I2 =0.0%), stillbirth (RR 1.04, 0.60-1.79; I2 =0.0%), and neonatal death (RR 1.82, 0.97-3.40; I2 =0.0%), compared to non-PI-ART. We found no significant differences in perinatal outcomes between ART regimens containing LPV/r, atazanavir/ritonavir (ATV/r), and darunavir/ritonavir (DRV/r), which are the most commonly used PIs. INTERPRETATION PI-ART is associated with an increased risk of SGA and VSGA, but not PTB or other perinatal outcomes. No significant differences in perinatal outcomes were found between LPV/r, ATV/r, and DRV/r. These findings should inform clinical guidelines, and further efforts should be made to improve perinatal outcomes among pregnant WLHIV. FUNDING None.
Collapse
Affiliation(s)
- Imogen Cowdell
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Katharina Beck
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Clara Portwood
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Harriet Sexton
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
- Corresponding author at: National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| |
Collapse
|
16
|
Nyemba DC, Peters RPH, Medina-Marino A, Klausner JD, Ngwepe P, Myer L, Johnson LF, Joseph Davey DL. Impact of aetiological screening of sexually transmitted infections during pregnancy on pregnancy outcomes in South Africa. BMC Pregnancy Childbirth 2022; 22:194. [PMID: 35264142 PMCID: PMC8908701 DOI: 10.1186/s12884-022-04520-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sexually transmitted infections (STIs) during pregnancy may increase the risk of adverse pregnancy outcomes. STI syndromic management is standard of care in South Africa but has its limitations. We evaluated the impact of diagnosing and treating curable STIs during pregnancy on adverse pregnancy and birth outcomes. METHODS We combined data from two prospective studies of pregnant women attending public sector antenatal care (ANC) clinics in Tshwane District and Cape Town, South Africa. Pregnant women were enrolled, tested and treated for STIs. We evaluated the association between any STI at the first ANC visit and a composite adverse pregnancy outcome (miscarriage, stillbirth, preterm birth, early neonatal death, or low birthweight) using modified Poisson regression models, stratifying by HIV infection and adjusting for maternal characteristics. RESULTS Among 619 women, 61% (n = 380) were from Tshwane District and 39% (n = 239) from Cape Town; 79% (n = 486) were women living with HIV. The prevalence of any STI was 37% (n = 228); C. trachomatis, 26% (n = 158), T. vaginalis, 18% (n = 120) and N. gonorrhoeae, 6% (n = 40). There were 93% (n = 574) singleton live births, 5% (n = 29) miscarriages and 2% (n = 16) stillbirths. Among the live births, there were 1% (n = 3) neonatal deaths, 7% (n = 35) low birthweight in full-term babies and 10% (n = 62) preterm delivery. There were 24% (n = 146) for the composite adverse pregnancy outcome. Overall, any STI diagnosis and treatment at first ANC visit was not associated with adverse outcomes in women living with HIV (adjusted relative risk (aRR); 1.43, 95% CI: 0.95-2.16) or women without HIV (aRR; 2.11, 95% CI: 0.89-5.01). However, C. trachomatis (aRR; 1.57, 95% CI: 1.04-2.39) and N. gonorrhoeae (aRR; 1.69, 95% CI: 1.09-3.08), were each independently associated with the composite adverse outcome in women living with HIV. CONCLUSION Treated STIs at the first ANC visit were not associated with adverse pregnancy outcome overall. In women living with HIV, C. trachomatis or N. gonorrhoeae at first ANC were each independently associated with adverse pregnancy outcome. Our results highlights complex interactions between the timing of STI detection and treatment, HIV infection and pregnancy outcomes, which warrants further investigation.
Collapse
Affiliation(s)
- Dorothy C Nyemba
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. .,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Remco P H Peters
- Research Unit, Foundation for Professional Development, East London, South Africa.,Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa.,Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Andrew Medina-Marino
- Research Unit, Foundation for Professional Development, East London, South Africa.,Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Jeffrey D Klausner
- Department of Population and Public Health Sciences, University of Southern California, Keck School of Medicine, Los Angeles, USA
| | - Phuti Ngwepe
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Dvora L Joseph Davey
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Department of Preventive Medicine, Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, USA
| |
Collapse
|
17
|
Schapkaitz E, Libhaber E, Jacobson BF, Gerber A, Rhemtula H, Büller HR. Profile of antiphospholipid antibodies in HIV-infected and HIV-uninfected women with a history of thrombosis. Int J Lab Hematol 2022; 44:635-642. [PMID: 35132770 DOI: 10.1111/ijlh.13805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/14/2022] [Accepted: 01/22/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Increased antiphospholipid antibodies (aPL) have been described in human immunodeficiency virus (HIV) infection. However, the association between aPL and the increased risk of thrombosis in HIV requires further clarification. METHODS We reviewed the medical records of 215 consecutive women with a history of thrombosis and/or obstetric complications (158 HIV-uninfected and 57 HIV-infected) between July 2017 and March 2021. Participants (n = 215) without clinical criteria manifestations for antiphospholipid syndrome were included as matched controls. Testing for lupus anticoagulant (LAC), anticardiolipin (aCL) and anti-beta2-glycoprotein1 (aβ2GP1) IgM and IgG was performed. RESULTS Thirty-two (10.1%) HIV-uninfected and 15 (13.2%) HIV-infected participants were positive at baseline for one of the five criteria aPL, with no statistically significant difference. The profile of the HIV-infected participants with thrombosis (n = 11) included LAC in 15.8%, aCL IgG in 3.5% and aβ2GP1 IgG in 1.8%. In contrast, the HIV-infected controls (n = 4), included aCL IgM in 1.8% and aβ2GP1 IgM in 5.3%. Only LAC was significantly associated with thrombosis (p < 0.003). On repeat testing, in a HIV-infected sub-population, 2/7 with thrombosis were positive, while 3/3 controls tested negative. CONCLUSION In contrast to earlier reports, the prevalence and expression of aPL in HIV-infected women with a history of thrombosis in the present study, in the era of antiretroviral therapy, were similar to HIV-uninfected women. Baseline LAC positivity was associated with a significantly increased risk for thrombosis in HIV. Future studies are recommended to explore additional coagulation abnormalities in HIV.
Collapse
Affiliation(s)
- Elise Schapkaitz
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Elena Libhaber
- HS Research Office and School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Barry F Jacobson
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Annika Gerber
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Haroun Rhemtula
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
18
|
Nyemba DC, Kalk E, Vinikoor MJ, Madlala HP, Mubiana-Mbewe M, Mzumara M, Moore CB, Slogrove AL, Boulle A, Davies MA, Myer L, Powis K. Growth patterns of infants with in- utero HIV and ARV exposure in Cape Town, South Africa and Lusaka, Zambia. BMC Public Health 2022; 22:55. [PMID: 35000577 PMCID: PMC8744341 DOI: 10.1186/s12889-021-12476-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Infants born HIV-exposed yet remain uninfected (HEU) are at increased risk of poorer growth and health compared to infants born HIV-unexposed (HU). Whether maternal antiretroviral treatment (ART) in pregnancy ameliorates this risk of poorer growth is not well understood. Furthermore, whether risks are similar across high burden HIV settings has not been extensively explored. Methods We harmonized data from two prospective observational studies conducted in Cape Town, South Africa, and Lusaka, Zambia, to compare weight-for-age (WAZ), length-for-age (LAZ) and weight-for-length (WLZ) Z-scores between infants who were HEU and HU, converting infant anthropometric measures using World Health Organisation Growth Standards adjusted for age and sex. Linear mixed effects models were fit to identify risk factors for differences in anthropometrics at 6–10 weeks and 6 months by infant HIV exposures status and by timing of exposure to maternal ART, either from conception or later in gestation. Results Overall 773 mother-infant pairs were included across two countries: women living with HIV (WLHIV), 51% (n = 395) with 65% on ART at conception and 35% initiating treatment in pregnancy. In linear mixed effects models, WAZ and WLZ at 6–10 weeks were lower among infants who were HEU vs HU [β = − 0.29 (95% CI: − 0.46, − 0.12) and [β = − 0.42 (95% CI: − 0.68, − 0.16)] respectively after adjusting for maternal characteristics and infant feeding with a random intercept for country. At 6 months, LAZ was lower [β = − 0.28 CI: − 0.50, − 0.06)] among infants who were HEU, adjusting for the same variables, with no differences in WAZ and WLZ. Within cohort evaluations identified different results with higher LAZ among infants who were HEU from Zambia at 6–10 weeks, [β = + 0.34 CI: + 0.01, + 0.68)] and lower LAZ among infants who were HEU from South Africa [β = − 0.30 CI: − 0.59, − 0.01)] at 6 months, without other anthropometric differences at either site. Conclusion Infant growth trajectories differed by country, highlighting the importance of studying contextual influences on outcomes of infants who were HEU. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-12476-z.
Collapse
Affiliation(s)
- Dorothy C Nyemba
- Division of Epidemiology & Biostatistics, Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa. .,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael J Vinikoor
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hlengiwe P Madlala
- Division of Epidemiology & Biostatistics, Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Maureen Mzumara
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amy L Slogrove
- Department of Paediatrics & Child Health, Faculty of Medicine & Health Sciences, Stellenbosch University, Worcester, South Africa.,Ukwanda Centre for Rural Health, Faculty of Medicine & Health Sciences, Stellenbosch University, Worcester, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Western Cape Government: Health, Cape Town, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Western Cape Government: Health, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kathleen Powis
- Department of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA.,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
19
|
Thompson KD, Meyers DJ, Lee Y, Cu-Uvin S, Wilson IB. HIV-Positive and HIV-Negative Women with Medicaid Have Similar Rates of Stillbirth and Preterm Birth. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2022; 3:1-9. [PMID: 35136871 PMCID: PMC8812497 DOI: 10.1089/whr.2021.0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 04/12/2023]
Abstract
Introduction: Women living with human immunodeficiency virus (WLHIV) may face additional challenges and differential birth outcomes when compared with women without human immunodeficiency virus (HIV). There is limited research to date studying birth outcomes among a nationally representative sample of WLHIV. This study compares stillbirth and prematurity rates between HIV-positive (HIV+) and HIV-negative (HIV-) mothers in the Medicaid program. Methods: We used 12 years (2001-2012) of Medicaid Analytic eXtract data. We included Medicaid claims from the 14 states with the highest prevalence of HIV: California, Florida, Georgia, Illinois, Louisiana, Massachusetts, Maryland, North Carolina, New Jersey, New York, Ohio, Pennsylvania, Texas, and Virginia. Primary outcomes were stillbirth and preterm birth. We used logistic regression models adjusting for age, race, Medicaid coverage, eligibility, substance use, rurality, comorbidities, and state fixed effects to compare differences in rates for women with and without HIV. Results: Our study included a total of 33,078 HIV+ and 7,663,758 HIV- pregnancies from Medicaid enrollees between 2001 and 2012. The proportions of stillbirths and preterm births were higher for HIV+ when compared with HIV- mothers (0.9% vs. 0.7% and 8.0% vs. 6.6%, p < 0.0001). After adjusting for covariates, being HIV+ was not significantly associated with both stillbirth (odds ratio [OR]: 1.05) or prematurity (OR: 1.01). Black race was a strong independent predictor of both stillbirth and prematurity (OR: 1.99 and 1.51, p < 0.01). Rurality and substance abuse were not associated with either outcome. Conclusions: After adjustment for relevant covariates, maternal HIV infection was not associated with increased rates of stillbirth or preterm birth in the Medicaid program in the United States. It is imperative that we understand and eliminate the clinical, social, and contextual factors that are responsible for the strong association between black race and poor perinatal outcomes that we observe.
Collapse
Affiliation(s)
- Kathryn D. Thompson
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- *Address correspondence to: Kathryn D. Thompson, Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA,
| | - David J. Meyers
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Susan Cu-Uvin
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
- Providence/Boston Center for AIDS Research (CFAR), Providence, Rhode Island, USA
| | - Ira B. Wilson
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| |
Collapse
|
20
|
Anderson K, Kalk E, Madlala HP, Nyemba DC, Kassanjee R, Jacob N, Slogrove A, Smith M, Eley BS, Cotton MF, Muloiwa R, Spittal G, Kroon M, Boulle A, Myer L, Davies MA. Increased infectious-cause hospitalization among infants who are HIV-exposed uninfected compared with HIV-unexposed. AIDS 2021; 35:2327-2339. [PMID: 34324450 PMCID: PMC8563388 DOI: 10.1097/qad.0000000000003039] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Increased risk of morbidity and hospitalization has been observed in children who are HIV-exposed uninfected (HEU) compared with HIV-unexposed uninfected (HUU). Studies in the era of universal maternal antiretroviral treatment (ART) are limited. DESIGN Prospective cohort. METHODS We investigated hospitalization between 29 days and 12 months of life in a South African cohort of infants born between February 2017 and January 2019 (HEU = 455; HUU = 458). All mothers known with HIV during pregnancy received ART. We reviewed hospital records and classified and graded infectious diagnoses using a standardized tool. We examined factors associated with infectious-cause hospitalization using mixed-effects Poisson regression. RESULTS Infants HEU vs. HUU had higher all-cause and infectious-cause hospitalization (13 vs. 7%, P = 0.004 and 10 vs. 6%, P = 0.014, respectively). Infectious causes accounted for most hospitalizations (77%). More infants HEU were hospitalized with severe or very severe infections than those HUU (9 vs. 6%; P = 0.031). Mortality (<1%) did not differ between groups. HIV exposure was a significant risk factor for infectious-cause hospitalization [adjusted incidence rate ratios (aIRRs) = 2.8; 95% confidence interval (CI) 1.5-5.4]. Although increased incidence of preterm birth (14 vs. 10%; P < 0.05) and shorter duration of breastfeeding (44 vs. 68% breastfed for ≥3 months, P < 0.001) among infants HEU vs. HUU contributed to increased hospitalization, they did not account for all the increased risk. CONCLUSION Infectious-cause hospitalization incidence was higher among infants HEU vs. HUU, likely partly because of higher incidence of preterm birth and lower breastfeeding rates among infants HEU. The increased infectious disease burden in HEU infants has important implications for health services in sub-Saharan Africa.
Collapse
Affiliation(s)
- Kim Anderson
- Center for Infectious Disease Epidemiology and Research
| | - Emma Kalk
- Center for Infectious Disease Epidemiology and Research
| | | | - Dorothy C Nyemba
- Center for Infectious Disease Epidemiology and Research
- Division of Epidemiology and Biostatistics
| | | | - Nisha Jacob
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town
| | - Amy Slogrove
- Department of Paediatrics and Child Health, Stellenbosch University
| | - Mariette Smith
- Center for Infectious Disease Epidemiology and Research
- Directorate of Health Impact Assessment, Western Cape Provincial Department of Health
| | - Brian S Eley
- Paediatric Infectious Diseases Unit, Department of Paediatrics and Child Health, University of Cape Town
| | - Mark F Cotton
- Paediatric Infectious Diseases Unit, Department of Paediatrics and Child Health, Stellenbosch University
| | - Rudzani Muloiwa
- Department of Paediatrics and Child Health, University of Cape Town
| | | | - Max Kroon
- Division of Neonatal Medicine, Department of Pediatrics and Child Health, University of Cape Town, South Africa
| | - Andrew Boulle
- Center for Infectious Disease Epidemiology and Research
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town
- Directorate of Health Impact Assessment, Western Cape Provincial Department of Health
| | | | - Mary-Ann Davies
- Center for Infectious Disease Epidemiology and Research
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town
- Directorate of Health Impact Assessment, Western Cape Provincial Department of Health
| |
Collapse
|
21
|
Shinar S, Agrawal S, Ryu M, Walmsley S, Serghides L, Yudin MH, Murphy KE. Perinatal outcomes in women living with HIV-1 and receiving antiretroviral therapy-a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2021; 101:168-182. [PMID: 34704251 DOI: 10.1111/aogs.14282] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 08/24/2021] [Accepted: 10/04/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Antiretroviral therapy-naïve pregnant women living with HIV are at an increased risk for adverse pregnancy outcomes. It remains controversial whether this risk persists with antiretroviral therapy. We conducted a systematic review and meta-analysis to evaluate whether pregnant women living with HIV and receiving antiretroviral therapy antenatally, are at an increased risk of adverse outcomes compared with HIV-negative controls. MATERIAL AND METHODS We searched MEDLINE, Embase, International Pharmaceutical Abstracts, EBM Reviews, PubMed (non-MEDLINE records), EBSCO CINAHL Complete, Clarivate Web of Science, African Index Medicus, LILACS and Google Scholar for all observational studies comparing pregnant women living with HIV on antiretroviral therapy with HIV-negative controls from 1 January 1994 to 10 August 2021 with no language or geographic restrictions. Perinatal outcomes included preterm birth (PTB), low birthweight, small-for-gestational age and preeclampsia. Using a random-effects model we pooled raw data to generate odds ratio (OR) with 95% confidence intervals (CI) for each outcome. Sub-analyses for high and low resource countries and time of antiretroviral therapy initiation were performed. This systematic review and meta-analysis is registered with PROSPERO, number CRD42020182722. RESULTS Of the 7900 citations identified, 27 were eligible for analysis (12 636 pregnant women living with HIV on antiretroviral therapy and 7 812 115 HIV-negative controls). ORs (95% CI) of PTB (1.88 [1.63-2.17]), small-for-gestational age (1.60 [1.18-2.17]) and low birthweight (2.15 [1.58-2.92]) were significantly higher in pregnant women living with HIV than in HIV-negative women, while the risk of preeclampsia (0.86 [0.57-1.30]) was comparable. The risk of PTB and low birthweight was higher in both high resource and low resource countries, while the risk of small-for-gestational age was higher only in the former. Preconceptional antiretroviral therapy was associated with a higher risk of PTB compared with antenatal initiation. CONCLUSIONS Pregnant women living with HIV on antiretroviral therapy have an increased risk of PTB, low birthweight and small-for-gestational age in high resource countries, as well as PTB and low birthweight in low income countries compared with HIV-negative controls.
Collapse
Affiliation(s)
- Shiri Shinar
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Swati Agrawal
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Ryu
- Sidney Liswood Health Sciences Library, Sinai Health System, Toronto, Ontario, Canada.,MacDonald/Brayley Health Sciences Library, Trillium Health Partners, Toronto, Ontario, Canada
| | - Sharon Walmsley
- Immunodeficiency Clinic, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, University Health Network, Ontario, Canada
| | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network, Ontario, Canada.,Department of Immunology and Institute of Medical Sciences, University of Toronto, Ontario, Canada
| | - Mark H Yudin
- Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kellie E Murphy
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
22
|
Tukei VJ, Hoffman HJ, Greenberg L, Thabelo R, Nchephe M, Mots’oane T, Masitha M, Chabela M, Mokone M, Mofenson L, Guay L, Tiam A. Adverse Pregnancy Outcomes Among HIV-positive Women in the Era of Universal Antiretroviral Therapy Remain Elevated Compared With HIV-negative Women. Pediatr Infect Dis J 2021; 40:821-826. [PMID: 33990522 PMCID: PMC8357042 DOI: 10.1097/inf.0000000000003174] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Without treatment, HIV infection in pregnant women is associated with adverse pregnancy outcomes. We compared adverse pregnancy outcomes among HIV-positive women on antiretroviral therapy (ART) and HIV-negative women who enrolled for antenatal care in selected health facilities in Maseru district, Lesotho. METHODS We enrolled a cohort of HIV-positive and HIV-negative women at their first antenatal visit and followed them through delivery. Study data on miscarriage, stillbirth, preterm birth, low birth weight and birth defects were collected through participant interviews and medical record abstraction. We used the Rao-Scott χ2 test and the t test to assess differences in characteristics and outcomes between HIV-positive and HIV-negative women and generalized estimating equations for multivariable analysis. RESULTS A total of 614 HIV-positive and 390 HIV-negative pregnant women were enrolled in the study with delivery information on 571 (93.1%) and 352 (90.3%) respectively. In the delivery cohort, the median age at enrolment was 28 years for HIV-positive women and 23 years for HIV-negative women with median gestational ages of 20 and 21 weeks, respectively. A total of 149 singleton pregnancies had documented adverse pregnancy outcomes; 33 (9.6%) HIV-negative pregnancies and 116 (20.6%) HIV-positive pregnancies. Compared with their HIV-negative counterparts, HIV-positive women were more likely to experience an adverse pregnancy outcome, adjusted odds ratio (AOR) 2.6 [95% confidence interval (CI): 1.71-3.97]; an intrauterine death (miscarriage or stillbirth), AOR 2.64 [95% CI: 1.25-5.49]; or a low birth weight delivery, AOR 1.89 [95% CI: 1.16-3.09]. CONCLUSION Adverse pregnancy outcomes remained 2-3 times higher among HIV-positive women compared with HIV-negative women despite universal ART.
Collapse
Affiliation(s)
- Vincent J. Tukei
- From the Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Heather J. Hoffman
- Department of Biostatistics and Bioinformatics, George Washington University Milken Institute School of Public Health, Washington, District of Columbia
| | - Lauren Greenberg
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
| | | | | | | | - Matseliso Masitha
- From the Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Mammatli Chabela
- From the Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Majoalane Mokone
- From the Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
| | - Laura Guay
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
- Department of Epidemiology, George Washington University Milken Institute School of Public Health, Washington, District of Columbia
| | - Appolinaire Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
- Department of global public health and primary care, Center for International Health, University of Bergen, Bergen, Norway
| |
Collapse
|
23
|
Maternal HIV infection is associated with distinct systemic cytokine profiles throughout pregnancy in South African women. Sci Rep 2021; 11:10079. [PMID: 33980919 PMCID: PMC8115111 DOI: 10.1038/s41598-021-89551-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 04/27/2021] [Indexed: 01/02/2023] Open
Abstract
Maternal HIV infection is associated with adverse pregnancy outcomes, but the mechanisms remain unknown. The course of pregnancy is regulated by immunological processes and HIV infection and antiretroviral therapy (ART) impact key immune mechanisms, which may disrupt the immune programme of pregnancy. We evaluated a broad range of systemic cytokines at each trimester of pregnancy in 56 women living with HIV (WLHIV) and 68 HIV-negative women, who were enrolled in a prospective pregnancy cohort study in Soweto, South Africa. The pro-inflammatory cytokine IP-10 was detected in each trimester in all WLHIV, which was significantly more than in HIV-negative women. The anti-viral cytokine IFNλ1 was detected more frequently in WLHIV, whereas IFNβ and IFNλ2/3 were detected more frequently in HIV-negative women. Th1 cytokines IL-12 and IL-12p70, Th2 cytokine IL-5, and Th17 cytokine IL-17A were detected more frequently in WLHIV throughout pregnancy. Il-6, IL-9, and IL-10 were more commonly detected in WLHIV in the first trimester. Trends of increased detection of Th1 (IL-2, IL-12p70), Th2 (IL-4, Il-5, Il-13) and Th17 (IL-17A, Il-17F, IL-21, IL-22) cytokines were associated with small-for-gestational-age babies. Our findings indicate that maternal HIV/ART is associated with distinct systemic cytokine profiles throughout pregnancy.
Collapse
|
24
|
Nyemba DC, Kalk E, Madlala HP, Malaba TR, Slogrove AL, Davies MA, Boulle A, Myer L, Powis KM. Lower birth weight-for-age and length-for-age z-scores in infants with in-utero HIV and ART exposure: a prospective study in Cape Town, South Africa. BMC Pregnancy Childbirth 2021; 21:354. [PMID: 33947351 PMCID: PMC8097797 DOI: 10.1186/s12884-021-03836-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 04/27/2021] [Indexed: 12/03/2022] Open
Abstract
Background Successful scale-up of antiretroviral therapy (ART) during pregnancy has minimized infant HIV acquisition, and over 1 million infants are born HIV-exposed but uninfected (HEU), with an increasing proportion also exposed in utero to maternal ART. While benefits of ART in pregnancy outweigh risks, some studies have reported associations between in utero ART exposure and impaired fetal growth, highlighting the need to identify the safest ART regimens for use in pregnancy. Methods We compared birth anthropometrics of infants who were HEU with those HIV-unexposed (HU) in Cape Town, South Africa. Pregnant women had gestational age assessed by ultrasound at enrolment. Women living with HIV were on ART (predominately tenofovir-emtricitabine-efavirenz) either prior to conception or initiated during pregnancy. Birth weights and lengths were converted to weight-for-age (WAZ) and length-for-age (LAZ) z-scores using Intergrowth-21st software. Linear regression was used to compare mean z-scores adjusting for maternal and pregnancy characteristics. Results Among 888 infants, 49% (n = 431) were HEU and 51% (n = 457) HU. Of 431 HEU infants, 62% (n = 268) were exposed to HIV and antiretrovirals (ARVs) from conception and 38% (n = 163) were exposed to ARVs during gestation but after conception (median fetal ARV exposure of 21 weeks [IQR; 17–26]). In univariable analysis, infants who were HEU had lower mean WAZ compared with HU [β = − 0.15 (95% Confidence Interval (CI): − 0.28, − 0.020)]. After adjustment for maternal age, gravidity, alcohol use, marital and employment status the effect remained [adjusted β − 0.14 (95%CI: − 0.28, − 0.01]. Similar differences were noted for mean LAZ in univariable [β − 0.20 (95%CI: − 0.42, − 0.01] but not multivariable analyses [adjusted β − 0.18 (95%CI: − 0.41, + 0.04] after adjusting for the same variables. Mean WAZ and LAZ did not vary by in utero ARV exposure duration among infants who were HEU. Conclusion In a cohort with high prevalence of ART exposure in pregnancy, infants who were HEU had lower birth WAZ compared with those HU. Studies designed to identify the mechanisms and clinical significance of these disparities, and to establish the safest ART for use in pregnancy are urgently needed. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03836-z.
Collapse
Affiliation(s)
- Dorothy C Nyemba
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa. .,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Hlengiwe P Madlala
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Thokozile R Malaba
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Amy L Slogrove
- Department of Paediatrics & Child Health, Faculty of Medicine & Health Sciences, Stellenbosch University, Worcester, South Africa.,Ukwanda Centre for Rural Health, Faculty of Medicine & Health Sciences, Stellenbosch University, Worcester, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Western Cape Government: Health, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Western Cape Government: Health, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kathleen M Powis
- Department of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA.,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| |
Collapse
|
25
|
Preterm birth and severe morbidity in hospitalized neonates who are HIV exposed and uninfected compared with HIV unexposed. AIDS 2021; 35:921-931. [PMID: 33821822 PMCID: PMC8076534 DOI: 10.1097/qad.0000000000002856] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Infants who are HIV exposed but uninfected (HEU) compared with HIV unexposed uninfected (HUU) have an increased risk of adverse birth outcomes, morbidity and hospitalization. In the era of universal maternal antiretroviral treatment, there are few insights into patterns of neonatal morbidity specifically. DESIGN A prospective cohort study. METHODS We compared neonatal hospitalizations among infants who were HEU (n = 463) vs. HUU (n = 466) born between 2017 and 2019 to a cohort of pregnant women from a large antenatal clinic in South Africa. We examined maternal and infant factors associated with hospitalization using logistic regression. RESULTS Hospitalization rates were similar between neonates who were HEU and HUU (13 vs. 16%; P = 0.25). Overall, most hospitalizations occurred directly after birth (87%); infection-related causes were identified in 34%. The most common reason for hospitalization unrelated to infection was respiratory distress (25%). Very preterm birth (<32 weeks) (29 vs. 11%; P = 0.01) as well as very low birthweight (<1500 g) (34 vs. 16%; P = 0.02) occurred more frequently among hospitalized neonates who were HEU. Of those hospitalized, risk of intensive care unit (ICU) admission was higher in neonates who were HEU (53%) than HUU (27%) [risk ratio = 2.1; 95% confidence interval (95% CI) 1.3-3.3]. Adjusted for very preterm birth, the risk of ICU admission remained higher among neonates who were HEU (aRR = 1.8; 95% CI 1.1-2.9). CONCLUSION Neonates who were HEU (vs. HUU) did not have increased all-cause or infection-related hospitalization. However, very preterm birth, very low birthweight and ICU admission were more likely in hospitalized neonates who were HEU, indicating increased severity of neonatal morbidity.
Collapse
|
26
|
Adolescent, Pregnant, and HIV-Infected: Risk of Adverse Pregnancy and Perinatal Outcomes in Young Women from Southern Mozambique. J Clin Med 2021; 10:jcm10081564. [PMID: 33917713 PMCID: PMC8068130 DOI: 10.3390/jcm10081564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/19/2021] [Accepted: 04/06/2021] [Indexed: 01/06/2023] Open
Abstract
Sub-Saharan Africa concentrates the burden of HIV and the highest adolescent fertility rates. However, there is limited information about the impact of the interaction between adolescence and HIV infection on maternal health in the region. Data collected prospectively from three clinical trials conducted between 2003 and 2014 were analysed to evaluate the association between age, HIV infection, and their interaction, with the risk of maternal morbidity and adverse pregnancy and perinatal outcomes in women from southern Mozambique. Logistic regression and negative binomial models were used. A total of 2352 women were included in the analyses; 31% were adolescents (≤19 years) and 29% HIV-infected women. The effect of age on maternal morbidity and pregnancy and perinatal adverse outcomes was not modified by HIV status. Adolescence was associated with an increased incidence of hospital admissions (IRR 0.55, 95%CI 0.37–0.80 for women 20–24 years; IRR 0.60, 95%CI 0.42–0.85 for women >25 years compared to adolescents; p-value < 0.01) and outpatient visits (IRR 0.86, 95%CI 0.71–1.04; IRR 0.76, 95%CI 0.63–0.92; p-value = 0.02), and an increased likelihood of having a small-for-gestational age newborn (OR 0.50, 95%CI 0.38–0.65; OR 0.43, 95%CI 0.34–0.56; p-value < 0.001), a low birthweight (OR 0.40, 95%CI 0.27–0.59; OR 0.37, 95%CI 0.26–0.53; p-value <0.001) and a premature birth (OR 0.42, 95%CI 0.24–0.72; OR 0.51, 95%CI 0.32–0.82; p-value < 0.01). Adolescence was associated with an increased risk of poor morbidity, pregnancy and perinatal outcomes, irrespective of HIV infection. In addition to provision of a specific maternity care package for this vulnerable group interventions are imperative to prevent adolescent pregnancy.
Collapse
|
27
|
IKUMI NM, MALABA TR, PILLAY K, COHEN MC, MADLALA HP, MATJILA M, ANUMBA D, MYER L, NEWELL ML, GRAY CM. Differential impact of antiretroviral therapy initiated before or during pregnancy on placenta pathology in HIV-positive women. AIDS 2021; 35:717-726. [PMID: 33724257 PMCID: PMC8630811 DOI: 10.1097/qad.0000000000002824] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the association between timing of antiretroviral treatment (ART) initiation in HIV-infected women and placental histopathology. DESIGN A nested substudy in a larger cohort of HIV-infected women which examined the association between ART status and birth outcomes. METHODS Placentas (n = 130) were examined for histopathology from two ART groups: stable (n = 53), who initiated ART before conception and initiating (n = 77), who started ART during pregnancy [median (interquartile range) 15 weeks gestation (11-18)]. Using binomial regression we quantified associations between ART initiation timing with placental histopathology and pregnancy outcomes. RESULTS One-third of all placentas were less than 10th percentile weight-for-gestation and there was no significant difference between ART groups. Placental diameter, thickness, cord insertion position and foetal-placental weight ratio were also similar by group. However, placentas from the stable group showed increased maternal vascular malperfusion (MVM) (39.6 vs. 19.4%), and decreased weight (392 vs. 422 g, P = 0.09). MVM risk was twice as high [risk ratios 2.03 (95% confidence interval: 1.16-3.57); P = 0.01] in the stable group; the increased risk remaining significant when adjusting for maternal age [risk ratios 2.04 (95% confidence interval: 1.12-3.72); P = 0.02]. Furthermore, MVM was significantly associated with preterm delivery and low birth weight (P = 0.002 and <0.0001, respectively). CONCLUSION Preconception initiation of ART was associated with an increased MVM risk, and may contribute to placental dysfunction. The association between MVM with preterm delivery and low birth weight suggests that a placenta-mediated mechanism likely links the putative association between long-term use of ART and adverse birth outcomes.
Collapse
Affiliation(s)
- Nadia M IKUMI
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Thokozile R MALABA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Komala PILLAY
- Division of Anatomical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
| | - Marta C COHEN
- Department of Histopathology, Sheffield Children’s NHS Foundation Trust , Sheffield, UK
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK, Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town South Africa
| | - Hlengiwe P MADLALA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Mushi MATJILA
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town South Africa
| | - Dilly ANUMBA
- Academic Unit of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Landon MYER
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Marie-Louise NEWELL
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Clive M GRAY
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
| | | |
Collapse
|
28
|
Piske M, Qiu AQ, Maan EJ, Sauvé LJ, Forbes JC, Alimenti A, Janssen PA, Money DM, Côté HCF. Preterm Birth and Antiretroviral Exposure in Infants HIV-exposed Uninfected. Pediatr Infect Dis J 2021; 40:245-250. [PMID: 33480662 DOI: 10.1097/inf.0000000000002984] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Infants HIV-exposed and uninfected (IHEU) who are born to women living with HIV are at an increased risk of preterm birth (PTB). Antenatal exposure to certain maternal antiretroviral therapy (ART) regimens has been associated with PTB, although existing studies in this domain are limited and report discordant findings. We determined odds of PTB among IHEU by antenatal ART regimens and timing of exposure, adjusting for maternal risk factors. METHODS We retrospectively studied IHEU born in British Columbia (BC), Canada between 1990 and 2012 utilizing provincial health administrative databases. We included data from a control group of infants HIV-unexposed and uninfected (IHUU) matched ~3:1 for each IHEU on age, sex and geocode. RESULTS A total of 411 IHEU and 1224 IHUU were included in univariable analysis. PTB was more frequent among IHEU (20%) compared with IHUU (7%). IHEU were more often antenatally exposed to alcohol, tobacco, as well as prescription, nonprescription, and illicit drugs (IHEU: 36%, 8% and 35%; vs. IHUU: 3%, 1% and 9%, respectively). After adjusting for maternal substance use and smoking exposure, IHEU remained at increased odds of PTB [adjusted odds ratio (aOR) (95% CI): 2.66; (1.73, 4.08)] compared with matched IHUU controls. ART-exposed IHEU (excluding those with NRTIs only ART) had lower adjusted odds of PTB compared with IHEU with no maternal ART exposure, regardless of regimen [aOR range: 0.16-0.29 (0.02-0.95)]. Odds of PTB between IHEU exposed to ART from conception compared with IHEU exposed to ART postconception did not differ [aOR: 0.91 (0.47, 1.76)]; however, both groups experienced lower odds of PTB compared with IHEU with no maternal ART [preconception: aOR: 0.28 (0.08, 0.89); postconception: aOR 0.30 (0.11, 0.83)]. CONCLUSIONS BC IHEU were over twice as likely to be born preterm compared with demographically matched controls. Maternal substance use in pregnancy modulated this risk; however, we found no adverse associations of PTB with exposure to antenatal ART.
Collapse
Affiliation(s)
- Micah Piske
- From the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Annie Q Qiu
- BC Women's Hospital, Vancouver, British Columbia
| | - Evelyn J Maan
- BC Women's Hospital, Vancouver, British Columbia
- Women's Health Research Institute, Vancouver, British Columbia
| | - Laura J Sauvé
- BC Women's Hospital, Vancouver, British Columbia
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - John C Forbes
- BC Women's Hospital, Vancouver, British Columbia
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Ariane Alimenti
- BC Women's Hospital, Vancouver, British Columbia
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Patricia A Janssen
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia
- Women's Health Research Institute, Vancouver, British Columbia
| | - Deborah M Money
- BC Women's Hospital, Vancouver, British Columbia
- Women's Health Research Institute, Vancouver, British Columbia
- Department of Obstetrics, University of British Columbia, Vancouver, British Columbia
| | - Hélène C F Côté
- From the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Women's Health Research Institute, Vancouver, British Columbia
| |
Collapse
|
29
|
Amenyogbe N, Dimitriu P, Cho P, Ruck C, Fortuno ES, Cai B, Alimenti A, Côté HCF, Maan EJ, Slogrove AL, Esser M, Marchant A, Goetghebuer T, Shannon CP, Tebbutt SJ, Kollmann TR, Mohn WW, Smolen KK. Innate Immune Responses and Gut Microbiomes Distinguish HIV-Exposed from HIV-Unexposed Children in a Population-Specific Manner. THE JOURNAL OF IMMUNOLOGY 2020; 205:2618-2628. [PMID: 33067377 DOI: 10.4049/jimmunol.2000040] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 09/15/2020] [Indexed: 12/21/2022]
Abstract
In both high- and low-income countries, HIV-negative children born to HIV-positive mothers (HIV exposed, uninfected [HEU]) are more susceptible to severe infection than HIV-unexposed, uninfected (HUU) children, with altered innate immunity hypothesized to be a cause. Both the gut microbiome and systemic innate immunity differ across biogeographically distinct settings, and the two are known to influence each other. And although the gut microbiome is influenced by HIV infection and may contribute to altered immunity, the biogeography of immune-microbiome correlations among HEU children have not been investigated. To address this, we compared the innate response and the stool microbiome of 2-y-old HEU and HUU children from Belgium, Canada, and South Africa to test the hypothesis that region-specific immune alterations directly correlate to differences in their stool microbiomes. We did not detect a universal immune or microbiome signature underlying differences between HEU versus HUU that was applicable to all children. But as hypothesized, population-specific differences in stool microbiomes were readily detected and included reduced abundances of short-chain fatty acid-producing bacteria in Canadian HEU children. Furthermore, we did not identify innate immune-microbiome associations that distinguished HEU from HUU children in any population. These findings suggest that maternal HIV infection is independently associated with differences in both innate immunity and the stool microbiome in a biogeographical population-specific way.
Collapse
Affiliation(s)
- Nelly Amenyogbe
- Department of Experimental Medicine, The University of British Columbia, Vancouver, British Columbia V5Z 1M9, Canada; .,Telethon Kids Institute, Perth, Western Australia 6009, Australia
| | - Pedro Dimitriu
- Department of Microbiology and Immunology, Life Sciences Institute, The University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada
| | - Patricia Cho
- Department of Experimental Medicine, The University of British Columbia, Vancouver, British Columbia V5Z 1M9, Canada
| | - Candice Ruck
- Department of Experimental Medicine, The University of British Columbia, Vancouver, British Columbia V5Z 1M9, Canada
| | - Edgardo S Fortuno
- Division of Infectious Diseases, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia V6H 3V4, Canada.,Division of Palliative, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Bing Cai
- Division of Infectious Diseases, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia V6H 3V4, Canada
| | - Ariane Alimenti
- Department of Pediatrics, BC Women's Hospital and Health Centre, The University of British Columbia, Vancouver, British Columbia V6H 3V4, Canada
| | - Hélène C F Côté
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia V6T 1Z7, Canada
| | - Evelyn J Maan
- Oak Tree Clinic, BC Women's Hospital, Vancouver, British Columbia V5Z 0A7, Canada
| | - Amy L Slogrove
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Worcester 6849, South Africa
| | - Monika Esser
- The Immunology Unit, Division of Medical Microbiology, Department of Pathology, National Health Laboratory Service, Stellenbosch University, Cape Town 7505, South Africa
| | - Arnaud Marchant
- Institut d'Immunologie Médicale, Université Libre de Bruxelles, Charleroi B-6041, Belgium
| | - Tessa Goetghebuer
- Département de Pédiatrie, Centre Hospitalier Universitaire St Pierre, Université Libre de Bruxelles, B-1000, Belgium
| | - Casey P Shannon
- Prevention of Organ Failure Centre of Excellence, Centre for Heart Lung Innovation, St. Paul's Hospital, The University of British Columbia, Vancouver, British Columbia V6Z 2K5, Canada.,Centre for Heart Lung Innovation, St. Paul's Hospital, The University of British Columbia, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Scott J Tebbutt
- Prevention of Organ Failure Centre of Excellence, Centre for Heart Lung Innovation, St. Paul's Hospital, The University of British Columbia, Vancouver, British Columbia V6Z 2K5, Canada.,Department of Medicine, Division of Respiratory Medicine, The University of British Columbia, Vancouver, British Columbia V5Z 1M9, Canada
| | - Tobias R Kollmann
- Telethon Kids Institute, Perth, Western Australia 6009, Australia.,Division of Infectious Diseases, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia V6H 3V4, Canada
| | - William W Mohn
- Department of Microbiology and Immunology, Life Sciences Institute, The University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada;
| | - Kinga K Smolen
- Department of Experimental Medicine, The University of British Columbia, Vancouver, British Columbia V5Z 1M9, Canada.,Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA 02115; and.,Harvard Medical School, Boston, MA 02115
| |
Collapse
|
30
|
Akoto C, Chan CYS, Tshivuila-Matala COO, Ravi K, Zhang W, Vatish M, Norris SA, Hemelaar J. Innate lymphoid cells are reduced in pregnant HIV positive women and are associated with preterm birth. Sci Rep 2020; 10:13265. [PMID: 32764636 PMCID: PMC7413261 DOI: 10.1038/s41598-020-69966-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 07/21/2020] [Indexed: 01/13/2023] Open
Abstract
Preterm birth is the leading cause of neonatal and child mortality worldwide. Globally, 1.4 million pregnant women are estimated to be living with HIV/AIDS, the majority of whom live in sub-Saharan Africa. Maternal HIV infection and antiretroviral treatment (ART) have been associated with increased rates of preterm birth, but the underlying mechanisms remain unknown. Acute HIV infection is associated with a rapid depletion of all three subsets of innate lymphoid cells (ILCs), ILC1s, ILC2s and ILC3s, which is not reversed by ART. ILCs have been found at the maternal-fetal interface and we therefore investigated the potential association between maternal HIV infection, peripheral ILC frequencies and preterm birth. In our study of pregnant South African women with accurately dated pregnancies, we show that maternal HIV infection is associated with reduced levels of all three ILC subsets. Preterm birth was also associated with lower levels of all three ILC subsets in early pregnancy. ILC frequencies were lowest in HIV positive women who experienced preterm birth. Moreover, ILC levels were reduced in pregnancies resulting in spontaneous onset of preterm labour and in extreme preterm birth (< 28 weeks gestation). Our findings suggest that reduced ILC frequencies may be a link between maternal HIV infection and preterm birth. In addition, ILC frequencies in early pregnancy may serve as predictive biomarkers for women who are at risk of delivering preterm.
Collapse
Affiliation(s)
- Charlene Akoto
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Christina Y S Chan
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Chrystelle O O Tshivuila-Matala
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK.,South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Krithi Ravi
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Wei Zhang
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Manu Vatish
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Shane A Norris
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK.,South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Joris Hemelaar
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK. .,South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.
| |
Collapse
|
31
|
Akoto C, Chan CYS, Ravi K, Zhang W, Vatish M, Norris SA, Hemelaar J. γδ T cell frequencies are altered in HIV positive pregnant South African women and are associated with preterm birth. PLoS One 2020; 15:e0235162. [PMID: 32584913 PMCID: PMC7316337 DOI: 10.1371/journal.pone.0235162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 06/10/2020] [Indexed: 12/24/2022] Open
Abstract
Background Preterm birth is the leading cause of neonatal and child mortality worldwide. Maternal HIV infection and antiretroviral treatment (ART) increase the rate of preterm birth, but the underlying mechanisms remain unknown, limiting progress in prediction, prevention and treatment. While overall γδ T cell levels remain constant, acute HIV infection is associated with a depletion of the Vδ2 subset and an increase in the Vδ1 subset, which do not return to baseline with ART. γδ T cells have also been implicated in adverse pregnancy outcomes and we therefore investigated the potential association between maternal HIV infection, peripheral γδ T cell frequencies and preterm birth. Methods Study participants were HIV positive (n = 47) and HIV negative (n = 45) women enrolled in a prospective pregnancy cohort study at Chris Hani Baragwanath Academic Hospital in Soweto, South Africa. Women were enrolled in early pregnancy and gestational age was accurately determined by first trimester ultrasound scan. Peripheral blood samples were collected in each trimester and peripheral blood mononuclear cells isolated. Frequencies of γδ T cells, Vδ1+ and Vδ2+ γδ T cell subsets, and CCR6 chemokine receptor expression were determined by flow cytometry. Results Total γδ T cell levels were similar between HIV positive and HIV negative women throughout pregnancy. However, in each trimester maternal HIV infection was associated with reduced levels of the Vδ2+ subset and increased levels of the Vδ1+ subset, leading to a reversal of the Vδ1/Vδ2 ratio. Timing of ART initiation among HIV positive women did not affect levels of γδ T cells, the Vδ1+ and Vδ2+ subsets, or the Vδ1/Vδ2 ratio. Importantly, preterm birth was associated with lower total γδ T cell levels in early pregnancy and γδ T cell frequencies were lowest in HIV positive women who delivered preterm. Moreover, in the first trimester the proportion of Vδ1+ T cells that were CCR6+ was significantly reduced in HIV+ women and women who delivered preterm, resulting in the lowest proportion of CCR6+ Vδ1 T cells in HIV positive women who delivered preterm. Conclusions Our findings suggest that altered γδ T cell frequencies may link maternal HIV infection and preterm birth. γδ T cell frequencies in early pregnancy may serve as predictive biomarkers to identify women at risk of delivering preterm.
Collapse
Affiliation(s)
- Charlene Akoto
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Christina Y. S. Chan
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Krithi Ravi
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Wei Zhang
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Manu Vatish
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Shane A. Norris
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
- Department of Paediatrics, South African Medical Research Council Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Joris Hemelaar
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
- Department of Paediatrics, South African Medical Research Council Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| |
Collapse
|
32
|
Abstract
Purpose of Review The population of HIV-exposed uninfected (HEU) children is expanding rapidly, and over one million HEU infants are born each year globally. Several recent studies have reported that HEU children, particularly in low- and middle-income countries, are at risk of poor outcomes, including impaired growth and neurodevelopment. However, the reasons for poor clinical outcomes amongst HEU children remain unclear. Recent Findings We summarise the findings from recent large studies that have characterised growth and neurodevelopment in HEU children, identified risk factors and explored underlying mechanistic pathways. We propose a conceptual framework to explain how exposure to HIV and antiretroviral therapy (ART) may lead to adverse growth and neurodevelopment in uninfected children, and review the available evidence and research gaps. Summary We propose that HEU children are affected both indirectly, through the augmentation of universal risk factors underlying poor growth and neurodevelopment, and directly through HIV/ART-specific pathways, which ultimately may converge through a series of common pathogenic mechanisms. In the era of universal ART, a better understanding of these pathways is crucial to inform future prevention and intervention strategies.
Collapse
|
33
|
Ravi K, Chan CYS, Akoto C, Zhang W, Vatish M, Norris SA, Klenerman P, Hemelaar J. Changes in the Vα7.2+ CD161++ MAIT cell compartment in early pregnancy are associated with preterm birth in HIV-positive women. Am J Reprod Immunol 2020; 83:e13240. [PMID: 32255246 DOI: 10.1111/aji.13240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/06/2020] [Accepted: 03/06/2020] [Indexed: 12/15/2022] Open
Abstract
PROBLEM Human immunodeficiency virus (HIV) infection is associated with an increased risk of adverse pregnancy outcomes, including preterm birth (PTB), despite viral suppression with antiretroviral therapy. Mucosal-associated invariant T (MAIT) cells are an immune cell subset involved in antimicrobial immunity at mucosal surfaces. MAIT cells have been found at the maternal-foetal interface, and MAIT cells are typically depleted early in HIV infection. We aimed to investigate changes in MAIT cells in relation to maternal HIV/ART status and PTB. METHOD OF STUDY We conducted flow cytometric analysis of peripheral blood samples from 47 HIV-positive (HIV+) and 45 HIV-negative (HIV-) pregnant women enrolled in a prospective pregnancy cohort study in Soweto, South Africa. Frequencies of Vα7.2+ CD161++ MAIT cells and proportions of CD4+ , CD8+ and double-negative MAIT cells were compared between women with and without HIV infection, and between women with and without PTB or spontaneous preterm labour (Sp-PTL). RESULTS Although overall MAIT cell frequencies were the same between HIV+ and HIV- patients, HIV+ patients had a higher proportion of CD8+ MAIT cells in the first two trimesters. Women with PTB and Sp-PTL also had a higher proportion of CD8+ MAIT cells in the first trimester compared to women without these outcomes. The association between changes in MAIT cell subsets and PTB/Sp-PTL was present in both HIV+ and HIV- women, and an additive effect on MAIT cell subsets was seen in women with both HIV infection and PTB. CONCLUSIONS Interactions between HIV-related and pregnancy-related changes in MAIT cell subsets and distribution may lead to imbalances in peripheral MAIT cell subsets in early pregnancy. This may contribute to the increased risk of PTB in HIV+ patients by altering the overall functionality of the peripheral MAIT cell compartment.
Collapse
Affiliation(s)
- Krithi Ravi
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, UK
| | - Christina Y S Chan
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, UK
| | - Charlene Akoto
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, UK
| | - Wei Zhang
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, UK
| | - Manu Vatish
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, UK
| | - Shane A Norris
- South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Paul Klenerman
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK.,NIHR Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Joris Hemelaar
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, UK.,South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
34
|
Li H, Liu J, Tan D, Huang G, Zheng J, Xiao J, Wang H, Huang Q, Feng N, Zhang G. Maternal HIV infection and risk of adverse pregnancy outcomes in Hunan province, China: A prospective cohort study. Medicine (Baltimore) 2020; 99:e19213. [PMID: 32080112 PMCID: PMC7034691 DOI: 10.1097/md.0000000000019213] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study described the prevalence of adverse pregnancy outcomes (APOs) in Chinese HIV-infected pregnant women, and examined the relationship between maternal HIV infection /HIV-related factors and APOs.This prospective cohort study was carried out among 483 HIV-infected pregnant women and 966 HIV-uninfected pregnant women. The HIV-infected and HIV-uninfected women were enrolled from midwifery hospitals in Hunan province between October 2014 and September 2017. All data were extracted in a standard structured form, including maternal characteristics, HIV infection status, HIV-related factors and their pregnancy outcomes. APOs were assessed by maternal HIV infection status and HIV-related factors using logistic regression analysis.The incidences of stillbirth (3.9% vs 1.1%), preterm birth (PTB) (8.9% vs 3.7%), low birth weight (LBW) (12.2% vs 3.1%) and small for gestational age (SGA) (21.3% vs 7.0%) were higher in HIV-infected women than HIV-uninfected women, with adjusted ORs of 2.77 (95%CI: 1.24-6.17), 2.37 (95%CI: 1.44-3.89), 4.20 (95%CI: 2.59-6.82) and 3.26 (95%CI: 3.26-4.64), respectively. No differences were found in neonatal asphyxia or birth defects between HIV-infected and HIV-uninfected groups, with adjusted ORs of 1.12 (95%CI: 0.37-3.43) and 1.10 (95%CI: 0.51-2.39), respectively. Among HIV-infected pregnant women, different antiretroviral (ARV) regimens were significantly associated with stillbirths, but not PTB, LBW or SGA. Compared with untreated HIV infection (10.1%), both mono/dual therapy and HAART were associated with a reduced risk of stillbirths (2.0% and 3.2%, respectively), with an AOR of 0.19 (95%CI: 0.04-0.92) and 0.31 (95%CI: 0.11-0.85), respectively. Initial time of ARV drugs use and HIV infection status of the sexual partner were not associated with maternal APOs.The findings of this study indicated that maternal HIV infection was associated with significantly increased risks of stillbirth, PTB, LBW and SGA, but not neonatal asphyxia or birth defects. On the condition that most HIV-infected pregnant women started ARV therapy in or after the second trimester, both mono/dual therapy and HAART had a protective effect on stillbirth compared with untreated HIV infection. As some important confounders were not effectively controlled and the specific regimens of HAART were not analyzed, the above findings may have certain bias.
Collapse
Affiliation(s)
- Huixia Li
- Department of Child Health Care
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital
| | | | | | | | - Jianfei Zheng
- Department of Emergency Medicine, Second Xiangya Hospital, Central South University
| | | | - Hua Wang
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital
- Department of Maternal Health Care, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan Province
| | | | - Na Feng
- Department of Health Care, Shenzhen Nanshan Maternal and Child Health Care Hospital, Shenzhen, Guangdong Province
| | - Guoqiang Zhang
- Department of AIDS Prevention and Control, Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan Province, China
| |
Collapse
|
35
|
Association between HIV antiretroviral therapy and preterm birth based on antenatal ultrasound gestational age determination: a comparative analysis. AIDS 2019; 33:2403-2413. [PMID: 31764105 DOI: 10.1097/qad.0000000000002367] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the association between HIV antiretroviral therapy (ART) and preterm birth (PTB), when defined by gold standard antenatal ultrasound versus newborn exam. DESIGN A secondary analysis of the PROMISE 1077BF/1077FF randomized controlled trial, which compared antiretroviral strategies to reduce perinatal HIV transmission and improve maternal health. The trial used newborn exam (i.e. New Ballard Score, NBS) to assess gestational age. This analysis included liveborn singleton pregnancies with both newborn exam and ultrasound data. The primary exposure was the trial's antiretroviral strategies: zidovudine with intrapartum nevirapine ('ZDV alone'); zidovudine/lamivudine/lopinavir-ritonavir ('ZDV-based ART'); or tenofovir/emtricitabine/lopinavir-ritonavir ('TDF-based ART'). The primary outcome was PTB less than 37 and less than 34 weeks based on the gold standard of ultrasound dating. We evaluated the association between antiretroviral strategy and PTB. We fit multivariable logistic regression models, adjusting for maternal characteristics, obstetric history, and HIV disease severity. RESULTS Among 720 assessed pregnant women, PTB less than 37 weeks was 15.4% by NBS and 18.3% by ultrasound. The NBS was specific but not sensitive for PTB less than 37 weeks (92.0% and 48.5%). Women receiving ZDV-based and TDF-based ART had significantly higher odds of PTB less than 37 by ultrasound compared with ZDV alone (adjusted odds ratios: 1.68; 95% confidence interval 1.10-2.57, and 2.71; 95% confidence interval 1.39-5.29), as well as for PTB less than 34 weeks. These results held for ultrasounds performed less than 24 weeks, and were generally consistent with prior analyses from the PROMISE trial using the NBS. CONCLUSION Women starting HIV ART in pregnancy remained at higher risk of PTB when determined by ultrasound, consistent with prior data using newborn exam. However, newborn exam misclassified cases of PTB compared with gold standard ultrasound.
Collapse
|
36
|
Weckman AM, Ngai M, Wright J, McDonald CR, Kain KC. The Impact of Infection in Pregnancy on Placental Vascular Development and Adverse Birth Outcomes. Front Microbiol 2019; 10:1924. [PMID: 31507551 PMCID: PMC6713994 DOI: 10.3389/fmicb.2019.01924] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/05/2019] [Indexed: 12/16/2022] Open
Abstract
Healthy fetal development is dependent on nutrient and oxygen transfer via the placenta. Optimal growth and function of placental vasculature is therefore essential to support in utero development. Vasculogenesis, the de novo formation of blood vessels, and angiogenesis, the branching and remodeling of existing vasculature, mediate the development and maturation of placental villi, which form the materno-fetal interface. Several lines of evidence indicate that systemic maternal infection and consequent inflammation can disrupt placental vasculogenesis and angiogenesis. The resulting alterations in placental hemodynamics impact fetal growth and contribute to poor birth outcomes including preterm delivery, small-for-gestational age (SGA), stillbirth, and low birth weight (LBW). Furthermore, pathways involved in maternal immune activation and placental vascularization parallel those involved in normal fetal development, notably neurovascular development. Therefore, immune-mediated disruption of angiogenic pathways at the materno-fetal interface may also have long-term neurological consequences for offspring. Here, we review current literature evaluating the influence of maternal infection and immune activation at the materno-fetal interface and the subsequent impact on placental vascular function and birth outcome. Immunomodulatory pathways, including chemokines and cytokines released in response to maternal infection, interact closely with the principal pathways regulating placental vascular development, including the angiopoietin-Tie-2, vascular endothelial growth factor (VEGF), and placental growth factor (PlGF) pathways. A detailed mechanistic understanding of how maternal infections impact placental and fetal development is critical to the design of effective interventions to promote placental growth and function and thereby reduce adverse birth outcomes.
Collapse
Affiliation(s)
- Andrea M Weckman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Michelle Ngai
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Julie Wright
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Chloe R McDonald
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Kevin C Kain
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|