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Purswani MU, Jacobson DL, DiMeglio LA, Yao TJ, Kopp JB, Van Dyke RB, Yu W, Siberry GK. Phosphaturia in HIV-Exposed Uninfected Neonates Associated with Maternal Use of Tenofovir Disoproxil Fumarate in Late Pregnancy. J Pediatric Infect Dis Soc 2024; 13:396-405. [PMID: 38820092 DOI: 10.1093/jpids/piae054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 05/29/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF) is often used in treating pregnant women living with HIV. Third-trimester TDF exposure is associated with a 12% reduction in bone mineral content in HIV-exposed uninfected (HEU) neonates. The potential mechanisms underlying this observation are unknown. METHODS The TDF study enrolled newborns of gestational age ≥36 weeks from the Surveillance Monitoring for Antiretroviral Therapy and Toxicities study based on in utero TDF exposure (TDF use ≥8 weeks in the third trimester vs none). Blood and urine samples were collected cross-sectionally within 30 days of birth to assess renal function (serum creatinine, serum phosphate, eGFR, percent tubular reabsorption of phosphate [PTRP]), and bone turnover (serum parathyroid hormone, 25-OH vitamin D [25(OH)D], and urinary cross-linked N-telopeptide of type 1 collagen). For each biomarker, a LOESS plot was fit using values at age at specimen collection; regression lines over age were fit among samples collected from 4 to 30 days, to compare slopes by TDF exposure. RESULTS Among 141 neonates, 77 were TDF-exposed and 64 TDF-unexposed. Between age 4 and 30 days, PTRP decreased more rapidly in the TDF-exposed compared to the unexposed group with slopes of -0.58 vs -0.08/day (difference -0.50/day [95% CI -0.88, -0.11]). Slopes for 25(OH)D were similar in both groups, but serum levels were lower in TDF-exposed neonates (median [IQR]: 22 [19, 29] vs 26 [22, 37] ng/mL). No differences were observed for other biomarkers. CONCLUSIONS Third-trimester in utero exposure to TDF is associated with increased urinary loss of phosphate and lower serum concentrations of 25(OH)D in HEU neonates.
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Affiliation(s)
- Murli U Purswani
- Division of Pediatric Infectious Disease, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, New York, USA
| | - Denise L Jacobson
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Linda A DiMeglio
- Division of Pediatric Endocrinology and Diabetology, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tzy-Jyun Yao
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Jeffrey B Kopp
- Kidney Disease Section, NIDDK, NIH, Bethesda, Maryland, USA
| | - Russell B Van Dyke
- Section of Pediatric Infectious Diseases, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Wendy Yu
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - George K Siberry
- Prevention Care and Treatment Division, Office of HIV/AIDS, United States Agency for International Development, Washington, District of Columbia, USA
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Williams PL, Karalius B, Patel K, Aschengrau A, Chakhtoura N, Enriquez N, Moye J, Garvie PA, Monte D, Seage GR, Zorrilla C, Mussi-Pinhata MM. Fetal growth assessed via ultrasound in relation to maternal HIV infection status and antiretroviral regimens. AIDS 2024; 38:567-577. [PMID: 37991521 PMCID: PMC10922527 DOI: 10.1097/qad.0000000000003796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To evaluate effects of maternal HIV and antiretroviral treatment (ART) on intrauterine fetal growth. DESIGN Prospective cohort studies of HIV and ZIKA infection among women living with HIV (WLHIV) and women not living with HIV (WNLHIV) conducted in Brazil and the US from 2016 to 2020. METHODS We evaluated fetal growth via repeated ultrasounds and calculated z scores for fetal growth measures using Intergrowth-21st standards among women with singleton pregnancies. Adjusted linear mixed models were fit for each fetal growth z score by HIV status. Among WLHIV, we compared fetal growth z scores by the most common maternal ART regimens, stratified by timing of ART initiation. RESULTS We included 166 WLHIV and 705 WNLHIV; none had Zika infection. The z scores were similar for WLHIV and WNLHIV for femur length (latest third trimester median = 1.08) and estimated fetal weight (median ≈0.60); adjusted mean differences in fetal weight z scores by HIV status were less than 0.1 throughout gestation. Other fetal growth measurements were lower for WLHIV than WNLHIV early in gestation but increased more rapidly over gestation. Among WLHIV not on ART at conception, adjusted mean z scores were generally similar across regimens initiated during pregnancy but somewhat lower for atazanavir-based regimens for biparietal diameter compared with efavirenz-based or raltegravir-based regimens. Among WLHIV on ART at conception, mean z scores were similar across ART regimens. CONCLUSION Within our cohorts, fetal growth was lower in WLHIV than WNLHIV early in gestation but similar by the end of gestation, which is reassuring. Among WLHIV, fetal growth measures were generally similar across ART regimens evaluated.
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Affiliation(s)
- Paige L Williams
- Center for Biostatistics in AIDS Research
- Department of Biostatistics
- Department of Epidemiology, Harvard T. H. Chan School of Public Health
| | - Brad Karalius
- Department of Epidemiology, Harvard T. H. Chan School of Public Health
| | - Kunjal Patel
- Center for Biostatistics in AIDS Research
- Department of Epidemiology, Harvard T. H. Chan School of Public Health
| | - Ann Aschengrau
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Nahida Chakhtoura
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | | | - Jack Moye
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Patricia A Garvie
- Research Department, Children's Diagnostic & Treatment Center, Fort Lauderdale, FL
| | | | - George R Seage
- Department of Epidemiology, Harvard T. H. Chan School of Public Health
| | | | - Marisa M Mussi-Pinhata
- Research Department, Children's Diagnostic & Treatment Center, Fort Lauderdale, FL
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
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3
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Joseph Davey DL, Nyemba DC, Mvududu R, Mashele N, Johnson L, Bekker LG, Dean SS, Bheemraj K, Coates TJ, Myer L. Pregnancy outcomes following self-reported and objective-measured exposure to oral preexposure prophylaxis in South Africa. AIDS 2024; 38:75-83. [PMID: 37720980 PMCID: PMC10715696 DOI: 10.1097/qad.0000000000003729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVE To compare pregnancy outcomes using self-reported and objective levels of intracellular tenofovir diphosphate (TFV-DP) in pregnant women using preexposure prophylaxis (PrEP). DESIGN We enrolled pregnant women >15 years without HIV at first antenatal care visit in an observational cohort study to compare pregnancy outcomes by PrEP use. METHODS Exposure defined as: any PrEP use [tenofovir disoproxil and emtricitabine (TDF/FTC]) prescription + reported taking PrEP], or objectively-measured TFV-DP in dried blood spots in PrEP-using pregnant women. The primary outcome was a composite of pregnancy loss, preterm birth (<37weeks), low birthweight (<2500 g), small for gestational age ([SGA] ≤ tenth percentile), or neonatal death. Multivariable logistic regression models evaluated individual and composite adverse outcomes by self-reported or objectively measured PrEP use adjusting for age, gestational age, gravidity and socio-economic status. RESULTS Between August 19 and February 23, we followed 1195 pregnant women and ascertained 1145 pregnancy outcomes (96%); 72% ( n = 826) reported taking PrEP while pregnant, 16% did not take PrEP ( n = 178), 12% were unconfirmed ( n = 141). Overall, 94.5% ( n = 1082) had singleton live births with a median birthweight of 3.2 kg [interquartile range (IQR) = 2.9-3.5], with no difference in pregnancy loss between self-reported PrEP exposed vs. unexposed [4.0 vs. 5.6%; adjusted odds ratio (aOR) = 0.65, 95% confidence interval (CI) = 0.32-1.47]. Composite adverse outcomes did not differ by reported PrEP use (20% for both groups; aOR = 1.07, 95% CI = 0.71-1.63). Comparing objective PrEP use (any TFV-DP vs. no TFV-DP or not on PrEP), adverse outcomes did not differ (aOR = 0.64, 95% CI = 0.39-1.04), nor did other outcomes including preterm birth nor SGA. CONCLUSIONS Pregnancy outcomes did not differ by PrEP exposure (self-reported or objective), suggesting real-world efficacy that TDF/FTC as PrEP is safe in pregnancy.
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Affiliation(s)
- Dvora Leah Joseph Davey
- Department of Epidemiology, Fielding School of Public Health
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Dorothy C. Nyemba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
- Wits RHI, University of the Witwatersrand, Johannesburg
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | | | - Sarah Schoetz Dean
- Department of Epidemiology, Fielding School of Public Health
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Kalisha Bheemraj
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Thomas J. Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
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Mandelbrot L, Tubiana R, Frange P, Peytavin G, Le Chenadec J, Canestri A, Morlat P, Brunet-Cartier C, Sibiude J, Peretti D, Chambrin V, Chabrol A, Bui E, Simon-Toulza C, Marchand L, Paul C, Delmas S, Avettand-Fenoel V, Warszawski J. Maintenance darunavir/ritonavir monotherapy to prevent perinatal HIV transmission, ANRS-MIE 168 MONOGEST study. J Antimicrob Chemother 2023:7185847. [PMID: 37248782 DOI: 10.1093/jac/dkad161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVES Because NRTIs can have fetal toxicities, we evaluated a perinatal NRTI-sparing strategy to prevent perinatal HIV transmission. Our primary objective was to determine the proportion maintaining a viral load (VL) of <50 copies/mL up to delivery on darunavir/ritonavir monotherapy, without requiring treatment intensification. METHODS In a one-arm, multicentre Phase 2 clinical trial, eligible patients in the first trimester of pregnancy on ART with plasma VL < 50 copies/mL received maintenance monotherapy with darunavir/ritonavir, 600/100 mg twice daily. VL was monitored monthly. ART was intensified in the case of VL > 50 copies/mL. Neonates received nevirapine prophylaxis for 14 days. RESULTS Of 89 patients switching to darunavir/ritonavir monotherapy, 4 miscarried before 22 weeks' gestation, 2 changed treatment for elevated liver enzymes without virological failure, and 83 were evaluable for the main outcome. Six had virological failure confirmed on a repeat sample (median VL = 193 copies/mL; range 78-644), including two before switching to monotherapy. In these six cases, ART was intensified with tenofovir disoproxil fumarate/emtricitabine. The success rate was 75/83, 90.4% (95% CI, 81.9%-95.7%) considering two patients with VL missing at delivery as failures, and 77/83, 92.8% (95% CI, 84.9%-97.3%) when considering them as successes since both had undetectable VL on darunavir/ritonavir throughout pregnancy. In ITT, the last available VL before delivery was <50 copies/mL in all of the patients. There was no case of perinatal HIV transmission. CONCLUSIONS Darunavir/ritonavir maintenance monotherapy required intensification in nearly 10% of cases. This limits its widespread use, thus other regimens should be evaluated in order to limit exposure to antiretrovirals, particularly NRTIs, during pregnancy.
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Affiliation(s)
- Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris Hôpital Louis Mourier Service de Gynécologie-Obstétrique, F-92700 Colombes, France
- Université Paris Cité, F-75006 Paris, France
- INSERM, IAME, F-75018 Paris, France
| | - Roland Tubiana
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Service Maladies infectieuses, F-75013 Paris, France
- INSERM, Sorbonne Université, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Pierre Frange
- Université Paris Cité, F-75006 Paris, France
- Laboratoire de microbiologie clinique, Groupe hospitalier Assistance Publique-Hôpitaux de Paris (APHP) Centre-Université Paris Cité, Hôpital Necker-Enfants Malades, F-75015 Paris, France
| | - Gilles Peytavin
- INSERM, IAME, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Laboratoire de Pharmaco-toxicologie, Hôpital Bichat, F-75018 Paris, France
| | | | - Ana Canestri
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service de Maladies Infectieuses, F-75020 Paris, France
| | - Philippe Morlat
- Service de Médecine interne et Maladies infectieuses, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Université de Bordeaux, Bordeaux, France
| | - Cécile Brunet-Cartier
- Service de Maladies infectieuses, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Jeanne Sibiude
- Assistance Publique-Hôpitaux de Paris Hôpital Louis Mourier Service de Gynécologie-Obstétrique, F-92700 Colombes, France
- Université Paris Cité, F-75006 Paris, France
- INSERM, IAME, F-75018 Paris, France
| | - Delphine Peretti
- Assistance Publique-Hôpitaux de Paris, Hôpital Kremlin-Bicêtre, Service de Maladies Infectieuses, Le Kremlin-Bicêtre, France
| | - Véronique Chambrin
- Assistance Publique-Hôpitaux de Paris, Hôpital Antoine Béclère, Service de Maladies Infectieuses, Clamart, France
| | - Amélie Chabrol
- Centre Hospitalier du Sud Francilien, Service de Maladies Infectieuses, Evry, France
| | - Eida Bui
- Assistance Publique-Hôpitaux de Paris, Hôpital Trousseau, Service de Maladies Infectieuses, F-75012 Paris, France
| | - Caroline Simon-Toulza
- Service de Médecine interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Lucie Marchand
- Agence Nationale de Recherches sur le sida et les hépatites virales ANRS|Maladies infectieuses émergentes, Paris, France
| | - Christelle Paul
- Agence Nationale de Recherches sur le sida et les hépatites virales ANRS|Maladies infectieuses émergentes, Paris, France
| | - Sandrine Delmas
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale, SC10-US19, Villejuif, France
| | - Véronique Avettand-Fenoel
- Université Paris Cité, F-75006 Paris, France
- Laboratoire de microbiologie clinique, Groupe hospitalier Assistance Publique-Hôpitaux de Paris (APHP) Centre-Université Paris Cité, Hôpital Necker-Enfants Malades, F-75015 Paris, France
- INSERM U1016, CNRS, UMR8104, Institut Cochin, Paris, France
| | - Josiane Warszawski
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris, Epidemiology and Public Health Service, Service, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
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Moodley D, Lombard C, Govender V, Naidoo M, Desmond AC, Naidoo K, Mhlongo O, Sebitloane M, Newell ML, Clark R, Rooney JF, Gray G, Lombard C, Govender V, Naidoo M, Desmond AC, Naidoo KL, Mhlongo O, Sebitloane M, Newell ML, Clark R, Rooney JF, Gray GE, Ngaleka L, Pillay N, Booi S, Samsunder N, Pillay L, Gray R, Gazu R, Nkosi T. Pregnancy and neonatal safety outcomes of timing of initiation of daily oral tenofovir disoproxil fumarate and emtricitabine pre-exposure prophylaxis for HIV prevention (CAP016): an open-label, randomised, non-inferiority trial. Lancet HIV 2023; 10:e154-e163. [PMID: 36746169 DOI: 10.1016/s2352-3018(22)00369-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 11/26/2022] [Accepted: 11/29/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The safety of tenofovir disoproxil fumarate and emtricitabine as pre-exposure prophylaxis (PrEP) in pregnant women not living with HIV is uncertain. We aimed to compare pregnancy and neonatal outcomes in women exposed and not exposed to PrEP during pregnancy. METHODS In this single-site, open-label, randomised, non-inferiority trial in Durban, South Africa, we evaluated pregnancy and neonatal outcomes in pregnant women aged 18 years or older, not living with HIV, and at 14-28 weeks' gestation at the time of enrolment. Eligible participants were randomly assigned (1:1) using a computer-generated permuted block (block size of ten) randomisation list to immediate initiation or deferred initiation of PrEP until breastfeeding cessation. Participants in the immediate PrEP group received a monthly supply of once daily oral tenofovir disoproxil fumarate 300 mg and emtricitabine 200 mg. Participants in the deferred PrEP group received standard of care for HIV prevention. The primary outcomes were the occurrence of preterm live birth (<37 weeks gestational age) and very preterm birth (<34 weeks gestational age) determined by menstrual dating, low birthweight (<2500 g), very low birthweight (<1500 g), stillbirth (≥20 weeks gestational age), and small for gestational age (birthweight less than the tenth percentile). Post-natal safety outcomes will be reported elsewhere. We used binomial regression models to estimate risk differences and two-sided 90% CIs. Immediate PrEP was non-inferior to deferred PrEP if the upper bound of the 90% CI of the risk difference was less than the upper predefined non-inferiority margin for preterm birth (7·5%), very preterm birth (2·6%), low birthweight (5·5%), very low birthweight (1·2%), stillbirth (1·0%), and small for gestational age (3·7%). All outcomes were analysed in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT3227731. FINDINGS Between Sept 25, 2017, and Dec 6, 2019, we screened 693 women, of whom 540 were randomly assigned to immediate PrEP (n=271) or deferred PrEP (n=269). The median gestational age was 19 weeks (IQR 15-23 for immediate PrEP and 16-23 for deferred PrEP). The risk difference between the immediate PrEP group and the deferred PrEP group for preterm birth was -4·7% (90% CI -10·7 to 1·2; immediate PrEP was non-inferior), for very preterm birth was 0·6% (-3·4 to 4·6; upper limit exceeded the non-inferiority margin), for low birthweight was 2·5% (-1·6 to 6·6; upper limit exceeded the non-inferiority margin), for very low birthweight was 0% (-1·4 to 1·4; upper limit exceeded the non-inferiority margin), for stillbirth was 1·2% (-1·5 to 3·8; upper limit exceeded the non-inferiority margin), and for small for gestational age was 0·9% (-1·2 to 2·9; immediate PrEP was non-inferior). INTERPRETATION In our study, PrEP was not associated with preterm birth or small for gestational age infants. Our data support the use of tenofovir disoproxil fumarate and emtricitabine in pregnancy and our reassuring findings can be used to allay safety concerns among pregnant women. FUNDING South African Medical Research Council and Gilead Sciences.
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Affiliation(s)
- Dhayendre Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa; Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa.
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Tygerberg, South Africa; Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Tygerberg, South Africa
| | - Vani Govender
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Megeshinee Naidoo
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Alicia C Desmond
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Kimesh Naidoo
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Ottacia Mhlongo
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | - Motshedisi Sebitloane
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Marie-Louise Newell
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Human Health and Development, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | | | - Glenda Gray
- South African Medical Research Council, Cape Town, South Africa
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6
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Poliektov NE, Badell ML. Antiretroviral Options and Treatment Decisions During Pregnancy. Paediatr Drugs 2023; 25:267-282. [PMID: 36729360 DOI: 10.1007/s40272-023-00559-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/03/2023]
Abstract
The majority of pediatric human immunodeficiency virus (HIV) infections are the result of vertical transmissions that occur during pregnancy, childbirth, and breastfeeding. The treatment of all pregnant persons living with HIV remains a global health initiative. Early and consistent use of antiretroviral therapy throughout pregnancy and childbirth drastically reduces the risk of perinatal transmission of HIV, resulting in fewer children living with the disease worldwide. Given that the maternal HIV viral load is the strongest predictor of perinatal transmission, suppressive antiretroviral treatment during pregnancy is the principal means to eliminate transmission of HIV from mother to child. With the use of combined antiretroviral therapy, typically with dual-nucleoside reverse transcriptase inhibitors plus an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, HIV-infected mothers can now achieve virologic suppression to undetectable levels and yield a perinatal transmission rate of less than 2%. Important considerations of HIV treatment in pregnancy include the safety and efficacy of antiretroviral drugs, altered pregnancy-related pharmacokinetics, potential for birth defects or adverse neonatal outcomes, and individualized delivery planning based on maternal viral load. This practical review article summarizes the options, considerations, and recommendations for antiretroviral treatment in pregnancy to reduce perinatal HIV transmission and optimize health outcomes for mothers and infants worldwide.
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Affiliation(s)
- Natalie E Poliektov
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Martina L Badell
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA.
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7
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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.
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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
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8
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Wedderburn CJ, Weldon E, Bertran-Cobo C, Rehman AM, Stein DJ, Gibb DM, Yeung S, Prendergast AJ, Donald KA. Early neurodevelopment of HIV-exposed uninfected children in the era of antiretroviral therapy: a systematic review and meta-analysis. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:393-408. [PMID: 35483380 PMCID: PMC9090907 DOI: 10.1016/s2352-4642(22)00071-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are 15·4 million children who are HIV-exposed and uninfected worldwide. Early child development crucially influences later academic and socioeconomic factors. However, the neurodevelopmental outcomes of HIV-exposed uninfected (HEU) children in the era of maternal antiretroviral therapy (ART) remain unclear. We aimed to examine the effects of in-utero exposure to HIV and ART on child neurodevelopment. METHODS For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, Africa-Wide Information, PsycInfo, and Global Health databases from inception to May 27, 2020, for studies from the past two decades reporting neurodevelopment of HEU children aged 0-5 years compared with HIV-unexposed (HU) children (aim 1), and effects of different maternal ART regimens on neurodevelopment of HEU children (aim 2). We did narrative syntheses for both aims, and a random-effects meta-analysis of high-quality studies comparing HEU children and HU children, to obtain weighted pooled estimates of effect sizes. This study was registered with PROSPERO, CRD42018075910. FINDINGS We screened 35 527 records and included 45 articles from 31 studies. Overall, 12 (57%) of 21 studies comparing HEU children and HU children found worse neurodevelopment in HEU children in at least one domain. Study design and methodological quality were variable, with heterogeneity across populations. Meta-analysis included eight high-quality studies comparing 1856 HEU children with 3067 HU children at ages 12-24 months; among HEU children with available data, 1709 (99%) of 1732 were exposed to ART. HEU children had poorer expressive language (effect size -0·17 [95% CI -0·27 to -0·07], p=0·0013) and gross motor function (-0·13 [-0·20 to -0·07], p<0·0001) than HU children, but similar cognitive development (-0·06 [-0·19 to 0·06], p=0·34), receptive language development (-0·10 [-0·23 to 0·03], p=0·14), and fine motor skills (-0·05 [-0·15 to 0·06], p=0·36). Results suggested little or no evidence of an effect of specific maternal ART regimens on neurodevelopment; study heterogeneity prevented meta-analysis. INTERPRETATION HEU children are at risk of subtle impairments in expressive language and gross motor development by age 2 years. We found no consistent effect of maternal ART regimens analysed, although evidence was scarce. We highlight the need for large high-quality longitudinal studies to assess the neurodevelopmental trajectories of HEU children and to investigate underlying mechanisms to inform intervention strategies. FUNDING Wellcome Trust and Medical Research Council.
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Affiliation(s)
- Catherine J Wedderburn
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; The Neuroscience Institute, University of Cape Town, Cape Town, South Africa; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK; MRC Clinical Trials Unit, University College London, London, UK.
| | - Ella Weldon
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Cesc Bertran-Cobo
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Andrea M Rehman
- MRC International Statistics & Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Dan J Stein
- The Neuroscience Institute, University of Cape Town, Cape Town, South Africa; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; MRC Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Diana M Gibb
- MRC Clinical Trials Unit, University College London, London, UK
| | - Shunmay Yeung
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew J Prendergast
- Blizard Institute, Queen Mary University of London, London, UK; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kirsten A Donald
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; The Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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9
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Pan CQ, Dai E, Duan Z, Han G, Zhao W, Wang Y, Zhang H, Zhu B, Jiang H, Zhang S, Zhang X, Zou H, Chen X, Chen Y. Long-term safety of infants from mothers with chronic hepatitis B treated with tenofovir disoproxil in China. Gut 2022; 71:798-806. [PMID: 33789963 DOI: 10.1136/gutjnl-2020-322719] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 03/04/2021] [Accepted: 03/15/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The physical and neuromental development of infants remains uncertain after fetal exposure to tenofovir disoproxil fumarate (TDF) for the prevention of mother-to-child transmission of HBV. We aimed to investigate the safety of TDF therapy during the third trimester of pregnancy. DESIGN Infants from a previous randomised controlled trial were recruited for our long-term follow-up (LTFU) study. Mothers with chronic hepatitis B were randomised to receive TDF therapy or no treatment during the third trimester. Infants' physical growth or malformation, bone mineral density (BMD) and neurodevelopment, as assessed using Bayley-III assessment, were examined at 192 weeks of age. RESULTS Of 180 eligible infants, 176/180 (98%) were enrolled and 145/176 (82%) completed the LTFU (control group: 75; TDF-treated group: 70). In the TDF-treated group, the mean duration of fetal exposure to TDF was 8.57±0.53 weeks. Congenital malformation rates were similar between the two groups at week 192. The mean body weight of boys in the control and TDF-treated groups was significantly higher (19.84±3.46 kg vs. 18.47±2.34 kg; p=0.03) and within the normal range (18.48±2.35 kg vs. 17.80±2.50 kg; p=0.07), respectively, when compared with the national standard. Other prespecified outcomes (head circumference, height, BMD, and cognitive, motor, social-emotional, and adaptive behaviour measurements) were all comparable between the groups. CONCLUSION Infants with fetal exposure to TDF had normal physical growth, BMD and neurodevelopment at week 192. Our findings provide evidence on the long-term safety of infants after fetal exposure to maternal TDF therapy for preventing hepatitis B transmission. TRIAL REGISTRATION NUMBER NCT01488526.
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Affiliation(s)
- Calvin Q Pan
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China .,Division of Gastroenterology and Hepatology, Department of Medicine, NYU Langone Health, NYU Grossman School of Medicine, New York City, New York, USA
| | - Erhei Dai
- Division of Liver Diseases, The Fifth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Zhongping Duan
- Hepatology Center Department 4, Beijing Youan Hospital Capital Medical University, Beijing, China
| | - Guorong Han
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of the Southeast University, Nanjing, China
| | - Wenjing Zhao
- Central Laboratory, Hepatobiliary Disease Hospital of Ji Lin Province, Changchun, Ji Lin, China
| | - Yuming Wang
- Southwest University Public Health Hospital, Institute of Infectious Diseases, Southwest Hospital, Army Medical University, Chongqing, China
| | - Huaihong Zhang
- Department of Infectious Diseases, Nanyang Center Hospital, Nanyang, Henan, China
| | - Baoshen Zhu
- Department of Gynecology and Obstetrics, The Fifth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Hongxiu Jiang
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of the Southeast University, Nanjing, China
| | - Shuqin Zhang
- Department of Artificial Liver, Hepatology Hospital of Jilin Province, Changchun, China
| | - Xiaohu Zhang
- Department of Infectious Diseases, Nanyang Center Hospital, Nanyang, Henan, China
| | - Huaibin Zou
- Hepatology Center Department 4, Beijing Youan Hospital Capital Medical University, Beijing, China
| | - Xiuli Chen
- Division of Liver Diseases, The Fifth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Yu Chen
- Hepatology Center Department 4, Beijing Youan Hospital Capital Medical University, Beijing, China
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10
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Yu W, Jacobson DL, Williams PL, Patel K, Geffner ME, Van Dyke RB, Kacanek D, DiMeglio LA, Jao J. Growth patterns of uninfected children born to women living with perinatally versus nonperinatally acquired HIV. AIDS 2022; 36:593-603. [PMID: 34860195 PMCID: PMC8881380 DOI: 10.1097/qad.0000000000003136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to compare long-term growth between HIV-exposed uninfected children (CHEU) born to women with perinatally acquired HIV (CHEU-PHIV) and CHEU born to women with nonperinatally acquired HIV (CHEU-NPHIV). DESIGN A longitudinal analysis of anthropometric measurements from a U.S.-based multisite prospective cohort study enrolling CHEU and their mothers since April 2007. METHODS CHEU were evaluated for growth annually from birth through age 5 and again at age 7 years. Z-scores were calculated using U.S. growth references for weight (WTZ), height (HTZ), and weight-for-length or BMI-for-age (WLZ/BMIZ). Mid-upper arm circumference (MUACZ) and triceps skinfold thickness (TSFZ) Z-scores were obtained from ages 1 and 2, respectively, through age 7 years. Piecewise mixed-effects models, overall and stratified by race and sex, were fit to assess differential growth patterns across age by maternal PHIV status. RESULTS One thousand four hundred fifty-four singleton infants (286 CHEU-PHIV and 1168 CHEU-NPHIV) were included. CHEU-PHIV had slower growth rates than CHEU-NPHIV for WTZ and WLZ/BMIZ at earlier ages and continued to have lower mean WTZ [-0.27, 95% confidence interval (95% CI): -0.50, -0.04] and WLZ/BMIZ (-0.39, 95% CI: -0.67, -0.11) through age 7. Among non-Black boys, CHEU-PHIV had slightly lower WTZ and WLZ/BMIZ at birth than CHEU-NPHIV and these growth deficits persisted through age 7 years. CONCLUSION Compared with CHEU-NPHIV, CHEU-PHIV had diminished growth in early childhood with differences most pronounced among non-Black male children. Further longitudinal follow-up of CHEU-PHIV into young adulthood is needed to understand whether these early effects of maternal PHIV status on growth persist and have other health consequences.
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Affiliation(s)
- Wendy Yu
- Center for Biostatistics in AIDS Research
| | | | - Paige L Williams
- Center for Biostatistics in AIDS Research, Departments of Biostatistics and Epidemiology
| | - Kunjal Patel
- Center for Biostatistics in AIDS Research, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Mitchell E Geffner
- The Saban Research Institute of Children's Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, California
| | - Russell B Van Dyke
- Tulane University School of Medicine, Department of Pediatrics, New Orleans, Los Angeles
| | | | - Linda A DiMeglio
- Indiana University School of Medicine, Department of Pediatrics, Indianapolis, Indiana
| | - Jennifer Jao
- Northwestern University Feinberg School of Medicine, Department of Pediatrics, Department of Medicine, Chicago, Illinois, USA
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11
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Toledo G, Landes M, van Lettow M, Tippett Barr BA, Bailey H, Thorne C, Crichton S. No Difference in Growth Outcomes up to 24 Months of Age by Duration of Exposure to Maternal Antiretroviral Therapy Among Children Who Are HIV-Exposed and Uninfected in Malawi. Front Pediatr 2022; 10:882468. [PMID: 35795331 PMCID: PMC9251312 DOI: 10.3389/fped.2022.882468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/05/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND With the implementation of lifelong antiretroviral therapy (ART) for HIV treatment and prevention, the proportion of children exposed to ART in utero from conception is increasing. We estimated the effect of timing of ART exposure on growth of children HIV-exposed and uninfected (CHEU) up to Up to 24 months of age in Malawi. METHODS Data were collected from a prospective cohort of infants HIV-exposed aged 1-6 months (enrollment) and their mothers with HIV enrolled in the National Evaluation of Malawi's Prevention of Mother-to-Child Transmission of HIV Programme (2014-2018). Anthropometry was measured at enrollment, visit 1 (approximately 12 months), and visit 2 (approximately 24 months). Weight-for-age (WAZ) and length-for-age (LAZ) were calculated using the WHO Growth Standards. Multivariable mixed-effects models with linear splines for age were used to examine differences in growth by timing of ART exposure (from conception, first/second trimester, or third trimester/postpartum). Models were adjusted for confounders selected a priori guided by a conceptual framework. Hypothesized interactions and potential mediators were explored, and interactions with splines were included in final models if P < 0.1. RESULTS A total of 1,206 singleton CHEU and their mothers were enrolled and 563 completed the follow-up through 24 months of age. Moreover, 48% of CHEU were exposed to ART from conception, 40% from first/second trimester, and 12% from third trimester/postpartum. At enrollment, 12% of infants had low birthweight (LBW), 98% had been breastfed in past 7 days, and 57% were enrolled in an HIV care clinic. CHEU growth trajectories demonstrated cohort-wide growth faltering after the age of 12 months. Of 788 and 780 CHEU contributing to WAZ and LAZ multivariable models, respectively, there was no evidence of differences in mean WAZ or LAZ among those exposed from conception or first/second trimester vs. third trimester/postpartum and no evidence of a difference in WAZ or LAZ rate of change by timing of ART exposure (all interactions P > 1.0). CONCLUSION Reassuringly, ART exposure from conception was not associated with decreased WAZ or LAZ in CHEU Up 24 months of age. Overall growth trajectories suggest CHEU experience growth faltering after 12 months of age and may need support through and beyond the first 2 years of life.
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Affiliation(s)
- Gabriela Toledo
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Megan Landes
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Monique van Lettow
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Heather Bailey
- Institute for Global Health, University College London, London, United Kingdom
| | - Claire Thorne
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Siobhan Crichton
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
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12
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Krečmerová M, Majer P, Rais R, Slusher BS. Phosphonates and Phosphonate Prodrugs in Medicinal Chemistry: Past Successes and Future Prospects. Front Chem 2022; 10:889737. [PMID: 35668826 PMCID: PMC9163707 DOI: 10.3389/fchem.2022.889737] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/26/2022] [Indexed: 12/25/2022] Open
Abstract
Compounds with a phosphonate group, i.e., -P(O)(OH)2 group attached directly to the molecule via a P-C bond serve as suitable non-hydrolyzable phosphate mimics in various biomedical applications. In principle, they often inhibit enzymes utilizing various phosphates as substrates. In this review we focus mainly on biologically active phosphonates that originated from our institute (Institute of Organic Chemistry and Biochemistry in Prague); i.e., acyclic nucleoside phosphonates (ANPs, e.g., adefovir, tenofovir, and cidofovir) and derivatives of non-nucleoside phosphonates such as 2-(phosphonomethyl) pentanedioic acid (2-PMPA). Principal strategies of their syntheses and modifications to prodrugs is reported. Besides clinically used ANP antivirals, a special attention is paid to new biologically active molecules with respect to emerging infections and arising resistance of many pathogens against standard treatments. These new structures include 2,4-diamino-6-[2-(phosphonomethoxy)ethoxy]pyrimidines or so-called "open-ring" derivatives, acyclic nucleoside phosphonates with 5-azacytosine as a base moiety, side-chain fluorinated ANPs, aza/deazapurine ANPs. When transformed into an appropriate prodrug by derivatizing their charged functionalities, all these compounds show promising potential to become drug candidates for the treatment of viral infections. ANP prodrugs with suitable pharmacokinetics include amino acid phosphoramidates, pivaloyloxymethyl (POM) and isopropoxycarbonyloxymethyl (POC) esters, alkyl and alkoxyalkyl esters, salicylic esters, (methyl-2-oxo-1,3-dioxol-4-yl) methyl (ODOL) esters and peptidomimetic prodrugs. We also focus on the story of cytostatics related to 9-[2-(phosphonomethoxy)ethyl]guanine and its prodrugs which eventually led to development of the veterinary drug rabacfosadine. Various new ANP structures are also currently investigated as antiparasitics, especially antimalarial agents e.g., guanine and hypoxanthine derivatives with 2-(phosphonoethoxy)ethyl moiety, their thia-analogues and N-branched derivatives. In addition to ANPs and their analogs, we also describe prodrugs of 2-(phosphonomethyl)pentanedioic acid (2-PMPA), a potent inhibitor of the enzyme glutamate carboxypeptidase II (GCPII), also known as prostate-specific membrane antigen (PSMA). Glutamate carboxypeptidase II inhibitors, including 2-PMPA have been found efficacious in various preclinical models of neurological disorders which are caused by glutamatergic excitotoxicity. Unfortunately its highly polar character and hence low bioavailability severely limits its potential for clinical use. To overcome this problem, various prodrug strategies have been used to mask carboxylates and/or phosphonate functionalities with pivaloyloxymethyl, POC, ODOL and alkyl esters. Chemistry and biological characterization led to identification of prodrugs with 44-80 fold greater oral bioavailability (tetra-ODOL-2-PMPA).
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Affiliation(s)
- Marcela Krečmerová
- Institute of Organic Chemistry and Biochemistry, Academy of Sciences of the Czech Republic (ASCR), Prague, Czechia
- *Correspondence: Marcela Krečmerová,
| | - Pavel Majer
- Institute of Organic Chemistry and Biochemistry, Academy of Sciences of the Czech Republic (ASCR), Prague, Czechia
| | - Rana Rais
- Departments of Neurology, Pharmacology and Molecular Sciences, Johns Hopkins Drug Discovery, Baltimore, MD, United States
| | - Barbara S. Slusher
- Departments of Neurology, Pharmacology and Molecular Sciences, Psychiatry and Behavioral Sciences, Neuroscience, Medicine, Oncology, Johns Hopkins Drug Discovery, Baltimore, MD, United States
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13
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Stalter RM, Pintye J, Mugwanya KK. Safety review of tenofovir disoproxil fumarate/emtricitabine pre-exposure prophylaxis for pregnant women at risk of HIV infection. Expert Opin Drug Saf 2021; 20:1367-1373. [PMID: 33998936 PMCID: PMC9010110 DOI: 10.1080/14740338.2021.1931680] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/14/2021] [Indexed: 02/07/2023]
Abstract
Introduction: Pregnancy is a period of elevated HIV risk in high-burden settings, motivating the need for prevention tools that are both safe for use and effective during pregnancy. Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) is recommended by the World Health Organization, including for pregnant and postpartum women at substantial risk of HIV infection. Although TDF use during pregnancy appears generally safe, data on PrEP use during pregnancy remain limited.Areas covered: We provide an overview of the clinical pharmacology and efficacy of daily TDF-based PrEP and summarize current evidence on the safety of PrEP use by pregnant HIV-uninfected women. We synthesize relevant studies assessing pregnancy outcomes among pregnant women who are living with HIV (WLHIV) and using TDF-based therapy. Finally, we make comparison to the safety profiles of other emerging HIV prevention options.Expert opinion: The current evidence indicates that TDF/FTC PrEP use is not associated with increased risk of adverse pregnancy and early infant growth outcomes. While safety data are generally reassuring, there is need for continued accrual of data on growth and pregnancy outcomes in PrEP research, implementation projects, and controlled pharmacokinetic studies to support current evidence and to understand concentration-efficacy relationship in pregnant women.
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Affiliation(s)
- Randy M. Stalter
- Epidemiology Department, University of Washington, Seattle, WA, USA
| | - Jillian Pintye
- School of Nursing, University of Washington, Seattle, WA, USA
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14
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Kinai E, Nguyen HDT, Do HQ, Matsumoto S, Nagai M, Tanuma J, Nguyen KV, Pham TN, Oka S. Influence of maternal use of tenofovir disoproxil fumarate or zidovudine in Vietnamese pregnant women with HIV on infant growth, renal function, and bone health. PLoS One 2021; 16:e0250828. [PMID: 33914827 PMCID: PMC8084453 DOI: 10.1371/journal.pone.0250828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/14/2021] [Indexed: 11/18/2022] Open
Abstract
Tenofovir disoproxil fumarate (TDF) is still widely prescribed for human immunodeficiency virus (HIV)-infected pregnant women, despite its renal and bone toxicity. Although TDF-exposed infants often show transient growth impairment, it is not clear whether maternal TDF causes infantile rickets via maternal/fetal renal dysfunction in Asian populations. This prospective observational study was conducted in Vietnam and involved pregnant HIV-infected women treated with TDF-based regimen (TDF group) or zidovudine-based regimen (AZT-group). At birth, 3, 12, and 18 months of age, and included body length, weight, head circumference, serum alkaline phosphatase (ALP), creatinine, calcium, phosphorus, urine-β2-microglobulin (U-BMG), percentage of tubular reabsorption of phosphate (%TRP), and radiographic wrist score for rickets. Age-adjusted multivariate linear regression analysis evaluated the association of TDF/AZT use during pregnancy with fetal renal function and bone health. The study included 63 mother-infant pairs (TDF group = 53, AZT group = 10). In the mothers, detectable U-BMG (>252 μg/L) was observed more frequently in the TDF- than AZT group (89 vs 50%, p<0.001), but other renal/bone parameters were similar. In infants, maternal TDF use was not associated with growth impairment, renal dysfunction, or abnormal bone findings, but with a slightly higher ALP levels (p = 0.019). However, shorter length was associated with maternal AZT (p = 0.021), and worse radiographic scores were associated with LPV/r (p = 0.024). In Vietnamese population, TDF usage during pregnancy was not associated with infant transient rickets, growth impairment, or renal dysfunction, despite mild maternal tubular impairment. Maternal AZT and LPV/r influenced infant growth and bone health, though further studies are needed to confirm this finding.
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Affiliation(s)
- Ei Kinai
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
- * E-mail:
| | | | - Ha Quan Do
- National Hospital of Obstetrics and Gynecology, Hanoi, Vietnam
| | - Shoko Matsumoto
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Moeko Nagai
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Junko Tanuma
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | | | | | - Shinichi Oka
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
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15
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Kapito-Tembo AP, Bauleni A, Wesevich A, Ongubo D, Hosseinipour MC, Dube Q, Mwale P, Corbett A, Mwapasa V, Phiri S. Growth and Neurodevelopment Outcomes in HIV-, Tenofovir-, and Efavirenz-Exposed Breastfed Infants in the PMTCT Option B+ Program in Malawi. J Acquir Immune Defic Syndr 2021; 86:81-90. [PMID: 33027153 DOI: 10.1097/qai.0000000000002515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pregnant and breastfeeding women in Option B+ in Malawi received antiretroviral drugs (ARVs) containing efavirenz (EFV) and tenofovir disoproxil fumarate (TDF). However, effects on growth, renal, bone metabolism, and neurodevelopment of long-term exposure to low doses of these drugs through breast milk in HIV-exposed infants are unclear. METHODS Prospective cohorts of TDF-and-EFV-exposed and TDF-and-EFV-unexposed breastfed infants of HIV-infected and HIV-uninfected mothers in Option B+ were recruited in 2:1 ratio, respectively, followed from birth to 18 months. Infants with low birth weight, premature birth, and congenital abnormalities were excluded. Anthropometrics were assessed at birth, 6 weeks, 3, 6, 12, and 18 months. Neurodevelopment assessments used the Bayley Scales of Infant and Toddler Development III from 6 weeks. Creatinine, alkaline phosphatase, and phosphorus were assessed at 3, 6, and 12 months. RESULTS Of 260 HIV-and-ARV-exposed and 125 HIV-and-ARV-unexposed infants enrolled at birth, 87% and 57%, 78% and 59%, 77% and 54%, 73% and 51%, and 65% and 43% completed 6-weeks, 3, 6, 12, and 18 months visits, respectively. There were no significant differences in the mean Z-scores for length-for-age, weight-for-age, weight-for-length, mid-upper arm circumference-for-age, and head circumference-for-age between groups except at 6-weeks for length-for-age. No bone fractures occurred. Neurodevelopment outcomes were similar between groups. Of creatinine, alkaline phosphatase, and serum phosphate measurements, 1.7%, 2.6%, and 3.3% reached any toxicity levels grades 1-4, respectively, with no differences between groups. CONCLUSION Long-term exposure to EFV and TDF through breastfeeding in infants of HIV-infected mothers does not seem to result in significant growth, neurodevelopment, renal, or bone adverse outcomes. Data support safety of breastfeeding through 18 months within the Option B+ program.
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Affiliation(s)
- Atupele P Kapito-Tembo
- MAC Communicable Diseases Action Centre, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Malawi
| | - Andy Bauleni
- MAC Communicable Diseases Action Centre, University of Malawi College of Medicine, Blantyre, Malawi
| | | | | | - Mina C Hosseinipour
- UNC Project-Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Queen Dube
- Ministry of Health Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Patrick Mwale
- MAC Communicable Diseases Action Centre, University of Malawi College of Medicine, Blantyre, Malawi
| | - Amanda Corbett
- UNC Eshleman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Victor Mwapasa
- Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Malawi
| | - Sam Phiri
- Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lighthouse Trust, Kamuzu Central Hospital, Lilongwe, Malawi ; and
- Department of Global Health, University of Washington, Seattle, WA
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16
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Lee YS, Lee HS, Kim JH, Chang SW, Hyun MH, Bak H, Kim S, Lee MJ, Lee CU, Jung YK, Seo YS, Yim HJ, Yeon JE, Um SH, Byun KS. Role of tenofovir disoproxil fumarate in prevention of perinatal transmission of hepatitis B virus from mother to child: a systematic review and meta-analysis. Korean J Intern Med 2021; 36:76-85. [PMID: 31878771 PMCID: PMC7820648 DOI: 10.3904/kjim.2018.465] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/23/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS To prevent the perinatal transmission of hepatitis B virus (HBV) from mother to child, administration of an antiviral agent during pregnancy has been attempted in women who are either hepatitis B e antigen positive or have a high viral load. In this systematic review and meta-analysis with randomized controlled trials, we analyzed the efficacy and safety of tenofovir disoproxil fumarate (TDF) in preventing the perinatal transmission of HBV in pregnant women who have high HBV DNA titers. METHODS Multiple comprehensive databases (PubMed, EMBASE, and Cochrane databases) were searched for studies evaluating the efficacy of TDF for the prevention of perinatal transmission of HBV. RESULTS Two studies (one open label study and one double blind study) were included and analyzed. Intention-to-treat analysis (527 pregnancies) showed that the preventive effect of TDF was not significant (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.13 to 2.17; p = 0.38, I2 = 81%). However, the per-protocol analysis showed that TDF significantly reduced perinatal transmission (OR, 0.10; 95% CI, 0.01 to 0.77; p = 0.03, I2 = 0%). There was no significant difference between the TDF group and the control group with respect to maternal and fetal safety outcomes. CONCLUSION In pregnant women who have high HBV DNA titers, TDF can reduce the perinatal transmission from mother to child without significant adverse events.
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Affiliation(s)
- Young-Sun Lee
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Ha Seok Lee
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Ji Hoon Kim
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
- Correspondence to Ji Hoon Kim, M.D. Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea Tel: +82-2-2626-1038 Fax: +82-2-2626-3011 E-mail:
| | - Sung Won Chang
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Myung Han Hyun
- Divisions of Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Haein Bak
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Sehwa Kim
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Min-jin Lee
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Chan Uk Lee
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Young Kul Jung
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Yeon Seok Seo
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Hyung Joon Yim
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Jong Eun Yeon
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Soon Ho Um
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Kwan Soo Byun
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
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Ndiaye A, Suneson K, Njuguna I, Ambler G, Hanke T, John-Stewart G, Jaoko W, Reilly M. Growth patterns and their contributing factors among HIV-exposed uninfected infants. MATERNAL AND CHILD NUTRITION 2020; 17:e13110. [PMID: 33269548 PMCID: PMC7988866 DOI: 10.1111/mcn.13110] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 06/11/2020] [Accepted: 10/25/2020] [Indexed: 02/06/2023]
Abstract
With expanded HIV treatment and prevention programmes, most infants born to HIV‐positive women are uninfected, but the patterns and determinants of their growth are not well described. This study aimed to assess growth patterns in a cohort of HIV‐exposed uninfected (HEU) infants who participated in an experimental HIV vaccine trial and to test for associations with maternal and infant factors, including in‐utero exposure to antiretroviral therapy (ART), mode of delivery, exclusive breastfeeding, mother's education and receipt of the vaccine. Infants in the trial were seen at regular clinic visits from birth to 48 weeks of age. From the anthropometric measurements at these visits, weight‐for‐age z‐scores (WAZ), weight‐for‐length z‐scores (WLZ) and length‐for‐age z‐scores (LAZ) were computed using World Health Organization (WHO) software and reference tables. Growth patterns were investigated with respect to maternal and infant factors, using linear mixed regression models. From 94 infants included at birth, growth data were available for 75.5% at 48 weeks. The determinants of infant growth in this population are multifactorial: infant LAZ during the first year was significantly lower among infants delivered by caesarean section (p = 0.043); both WAZ and LAZ were depressed among infants with longer exposure to maternal ART (WAZ: p = 0.015; LAZ: p < 0.0001) and among infants of mothers with lower educational level (WAZ: p = 0.038; LAZ: p < 0.0001); the effect of maternal education was modified by breastfeeding practice, with no differences seen in exclusively breastfed infants. These findings inform intervention strategies to preserve growth in this vulnerable infant population.
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Affiliation(s)
- Aminata Ndiaye
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Klara Suneson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden.,Faculty of Medicine, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden
| | - Irene Njuguna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Gwen Ambler
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Tomas Hanke
- Jenner Institute, University of Oxford, Oxford, UK
| | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Departments of Global Health, Pediatrics, and Medicine, University of Washington, Seattle, Washington, USA
| | - Walter Jaoko
- KAVI-Institute of Clinical Research, University of Nairobi, Nairobi, Kenya
| | - Marie Reilly
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
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18
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Schüttfort G, Höfler S, Kann G, Königs C, de Leuw P, Herrmann E, Stephan C, Haberl A. Influence of tenofovir exposure in utero on primary dentition. Eur J Pediatr 2020; 179:1761-1768. [PMID: 32424746 DOI: 10.1007/s00431-020-03660-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/24/2020] [Accepted: 04/22/2020] [Indexed: 12/11/2022]
Abstract
Tenofovir disoxoproxil fumarate (TDF) is recommended for antiretroviral treatment for pregnant women living with HIV. As a comparative method to study bone density, we investigated the influence of in utero tenofovir exposure on the prevalence and distribution of developmental defects of enamel (DDE) in the primary dentition, as the mineralization process in teeth is higher and more complex and thus more vulnerable. HIV-exposed children with in utero exposition to tenofovir were included in this prospective observational single-center study. Dental status and enamel defects were assessed by an experienced dentist following a standardized protocol. Further information was collected using a standardized questionnaire, available in German and English. The prevalence of developmental defects in children with intrauterine tenofovir exposure was compared with literature data from a recent study of 377 healthy children in Germany and literature data from a study of 1221 healthy African children. Thirty-one children (mean age 2.1 ± 0.3 years; 41.9% female) were included. Median tenofovir exposure in utero was 28 weeks (mean ± 10.52 SD). Prevalence of developmental defects in the primary dentition in tenofovir-exposed children was similar compared to data of unexposed children (16.1% vs. 5.3%, p = 0.051 (compared to German cohort); 16.1% vs. 33.3%, p = 0.068 (compared to African cohort)).Conclusion: HIV-uninfected infants with in utero exposure to TDF showed no significant differences in the prevalence of DDE in comparison to cross-sectional data of HIV- and TDF-unexposed children; thus, the in utero exposure to TDF did not negatively influence the prevalence or distribution of DDE. What is Known: • There are no data available on the prevalence of developmental defects of enamel (DDE) in the primary dentition in intrauterine HIV- and tenofovir-exposed children. • Conclusions can be drawn from intrauterine milk tooth development to bone development and mineralization. What is New: • Prevalence of developmental defects in the primary dentition in tenofovir-exposed children was similar compared to data of unexposed children. • Preterm birth and hospitalization did not show a significant association on the prevalence of developmental defects in the primary dentition.
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Affiliation(s)
- Gundolf Schüttfort
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Stephan Höfler
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Gerrit Kann
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Christoph Königs
- Department of Pediatrics and Adolescent Medicine, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Philipp de Leuw
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Eva Herrmann
- Department for Biostatistics and Mathematical Modelling, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Christoph Stephan
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Department for Biostatistics and Mathematical Modelling, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Annette Haberl
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Department for Biostatistics and Mathematical Modelling, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
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19
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Differences in Growth of HIV-exposed Uninfected Infants in Ethiopia According to Timing of In-utero Antiretroviral Therapy Exposure. Pediatr Infect Dis J 2020; 39:730-736. [PMID: 32516280 PMCID: PMC7360102 DOI: 10.1097/inf.0000000000002678] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are concerns about the adverse effect of in-utero exposure to antiretroviral therapy (ART) on the growth of HIV exposed-uninfected (HEU) infants. We compared growth of HEU-infants according to the timing and type of ART exposure. METHODS A retrospective cohort study was conducted by abstracting clinical data from HIV-infected mothers and HEU-infants in Addis Ababa, Ethiopia between February 2013 and October 2016. Mixed-effects linear models were used to compare changes in weight and length and cox proportional hazard models were used to evaluate stunting (length-for-age z score <-2.0) and underweight (weight-for-age z score <-2.0). RESULTS A total of 624 HEU-infants were included in the analyses. Infants exposed to ART from conception had a lower rate of change in length [β = -0.54, 95% confidence interval (CI): -1.00 to -0.08] the first 3 months of life, as compared with infants exposed from late pregnancy. Risk of stunting was 51.9 per 100 person-years and risk of underweight was 26.7 per 100 person-years. Exposure to ART from conception was associated with a higher rate of stunting as compared with exposure from late pregnancy (adjusted hazard ratio = 1.95, 95% CI: 1.27-2.99). Infants born to mothers with advanced disease had a higher incidence of underweight compared with infants born to mothers with early-stage disease adjusted hazard ratio = 1.99, 95% CI: 1.32-3.03). CONCLUSIONS In HEU-infants, exposure to ART from conception was associated with decrease growth during early infancy and higher incidence of stunting compared with treatment exposure later in pregnancy. Close monitoring of HEU-infants' growth and prompt nutritional intervention is essential.
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20
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Seidel V, Weizsäcker K, Henrich W, Rancourt RC, Bührer C, Krüger R, Feiterna-Sperling C. Safety of tenofovir during pregnancy: early growth outcomes and hematologic side effects in HIV-exposed uninfected infants. Eur J Pediatr 2020; 179:99-109. [PMID: 31659467 DOI: 10.1007/s00431-019-03481-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 08/27/2019] [Accepted: 09/23/2019] [Indexed: 11/25/2022]
Abstract
Intrauterine exposure to zidovudine-based combination antiretroviral therapy (cART) can cause severe anemia within the first weeks of life. Tenofovir disoproxil fumarate (TDF)-based regimens may have less hematologic side effects but may affect growth parameters. This study aimed to assess the safety of TDF for prevention of mother-to-child transmission (PMTCT) in HIV-exposed uninfected infants regarding early growth outcomes and hematologic side effects. Our retrospective observational cohort study included children born (n = 232) to HIV-infected mothers (n = 228) on cART. Blood counts were compared at birth, 4-6 weeks, and 3, 12 and 18 months of age. Growth parameters were measured at birth and 12 and 18 months of age. Data were analyzed according to treatment group (TDF and non-TDF cART regimes). The median hemoglobin (Hgb) was significantly lower in the non-TDF-based group at birth (15.4 g/dl vs. 16.9 g/dl; **p = 0.002) and at 4-6 weeks of age (9.9 g/dl vs. 10.4 g/dl; **p = 0.004). The mean corpuscular volume was higher in the non-TDF-based group (109 fl vs. 105 fl; ***p < 0.001) as well at 4-6 weeks (102 fl vs. 95 fl; ***p < 0.001). In the TDF-based group, a higher proportion of neutropenia (grade 2 and higher) compared to the non-TDF-group (21.4% vs. 11%; *p = 0.015) was observed at three months of age. This effect was transient. There was no difference in growth.Conclusions: TDF appears to have no major side effects in our cohort. Transient anemia was observed more commonly with non-TDF regimens. However, our research suggests a potential delayed effect of TDF on neutrophils at 3 months of age.What is Known:• TDF is suspected to affect the growth of HIV-exposed uninfected infants.• Non-TDF-based cART regimes for prevention of mother-to-child transmission of HIV often result in transient anemia in the infant.What is New:• TDF appears to have no major side effects regarding the growth of HIV-exposed uninfected infants.• Our research suggests a potential delayed effect of TDF on neutrophils at 3 months of age in these infants.
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Affiliation(s)
- Vera Seidel
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178, Berlin, Germany.
| | - Katharina Weizsäcker
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Rebecca C Rancourt
- Division of 'Experimental Obstetrics', Clinic of Obstetrics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Renate Krüger
- Department of Pediatric Pneumology, Immunology and Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Cornelia Feiterna-Sperling
- Department of Pediatric Pneumology, Immunology and Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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21
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Williams PL, Yildirim C, Chadwick EG, Van Dyke RB, Smith R, Correia KF, DiPerna A, Seage GR, Hazra R, Crowell CS. Association of maternal antiretroviral use with microcephaly in children who are HIV-exposed but uninfected (SMARTT): a prospective cohort study. Lancet HIV 2019; 7:e49-e58. [PMID: 31740351 DOI: 10.1016/s2352-3018(19)30340-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/08/2019] [Accepted: 08/01/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Perinatal HIV transmission has substantially decreased with combination antiretroviral regimens, but complications in children who are HIV-exposed but uninfected, such as microcephaly, warrant ongoing surveillance. We aimed to evaluate whether individual in utero antiretroviral exposures were associated with increased risk of microcephaly based on long-term follow-up of infants and children who are HIV-exposed but uninfected. METHODS We evaluated children aged younger than 18 years who were HIV-exposed but uninfected with at least one head circumference measurement while enrolled in the Surveillance Monitoring for ART Toxicities (SMARTT) study at 22 clinical sites in the USA, including Puerto Rico. This prospective cohort study was done by the Pediatric HIV/AIDS Cohort Study network. Microcephaly was defined as having a head circumference Z score <-2 according to the 2000 US Centers for Disease Control and Prevention growth charts for children 6-36 months old and according to Nellhaus standards (head circumference <2nd percentile) after 36 months (SMARTT criteria); an alternate definition for microcephaly was based on applying Nellhaus standards across all ages (Nellhaus criteria). Modified Poisson regression models were fit to obtain relative risks (RRs) for associations between in utero antiretroviral exposure and microcephaly status, adjusted for potential confounders. Neurodevelopmental functioning was compared in children who are HIV-exposed but uninfected with or without microcephaly. FINDINGS Between March 21, 2007, and Aug 1, 2017, 3055 participants enrolled in SMARTT had at least one head circumference measurement. The cumulative incidence of microcephaly over a median of 5·1 years of follow-up (IQR 3·0-7·2) was 159 (5·2%, 95% CI 4·4-6·1) by Nellhaus criteria and 70 (2·3%, 1·8-2·9) by SMARTT criteria. In adjusted models, in utero exposure to efavirenz (4·7% exposed) was associated with increased risk of microcephaly by both Nellhaus standards (adjusted RR 2·02, 95% CI 1·16-3·51) and SMARTT criteria (2·56, 1·22-5·37). These associations were more pronounced in children exposed to combination regimens of efavirenz that included zidovudine plus lamivudine than those including tenofovir plus emtricitabine. Protective associations were observed for darunavir exposure (adjusted RR 0·50, 95% CI 0·24-1·00). Children who are HIV-exposed but uninfected with microcephaly had lower mean scores on neurodevelopmental assessments at age 1 and 5 years and a higher prevalence of neurodevelopmental impairment than those without microcephaly. INTERPRETATION These findings support consideration of alternatives to efavirenz as part of first-line antiretroviral therapy for pregnant women. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development.
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Affiliation(s)
- Paige L Williams
- Center for Biostatistics in AIDS Research, Harvard T H Chan School of Public Health, Boston, MA, USA.
| | - Cenk Yildirim
- Center for Biostatistics in AIDS Research, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Ellen G Chadwick
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Renee Smith
- University of Illinois at Chicago, Chicago, IL, USA
| | | | | | - George R Seage
- Center for Biostatistics in AIDS Research, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Rohan Hazra
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Claudia S Crowell
- Seattle Children's Hospital and University of Washington, Seattle, WA, USA
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22
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Mehta UC, van Schalkwyk C, Naidoo P, Ramkissoon A, Mhlongo O, Maharaj NR, Naidoo N, Fieggen K, Urban MF, Krog S, Welte A, Dheda M, Pillay Y, Moran NF. Birth outcomes following antiretroviral exposure during pregnancy: Initial results from a pregnancy exposure registry in South Africa. South Afr J HIV Med 2019; 20:971. [PMID: 31616571 PMCID: PMC6779987 DOI: 10.4102/sajhivmed.v20i1.971] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/04/2019] [Indexed: 11/29/2022] Open
Abstract
Background In 2013, a pregnancy exposure registry and birth defects surveillance (PER/BDS) system was initiated in eThekwini District, KwaZulu-Natal (KZN), to assess the impact of antiretroviral treatment (ART) on birth outcomes. Objectives At the end of the first year, we assessed the risk of major congenital malformations (CM) and other adverse birth outcomes (ABOs) detected at birth, in children born to women exposed to ART during pregnancy. Method Data were collected from women who delivered at Prince Mshiyeni Memorial Hospital, Durban, from 07 October 2013 to 06 October 2014, using medicine exposure histories and birth outcomes from maternal interviews, clinical records and neonatal surface examination. Singleton births exposed to only one ART regimen were included in bivariable analysis for CM risk and multivariate risk analysis for ABO risk. Results Data were collected from 10 417 women with 10 517 birth outcomes (4013 [38.5%] HIV-infected). Congenital malformations rates in births exposed to Efavirenz during the first trimester (T1) (RR 0.87 [95% CI 0.12–6.4; p = 0.895]) were similar to births not exposed to ART during T1. However, T1 exposure to Nevirapine was associated with the increased risk of CM (RR 9.28 [95% CI 2.3–37.9; p = 0.002]) when compared to the same group. Other ABOs were more frequent in the combination of HIV/ART-exposed births compared to HIV-unexposed births (29.9% vs. 26.0%, adjusted RR 1.23 [1.14–1.31; p < 0.001]). Conclusion No association between T1 use of EFV-based ART regimens and CM was observed. Associations between T1 NVP-based ART regimen and CM need further investigation. HIV- and ART-exposed infants had more ABOs compared to HIV-unexposed infants.
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Affiliation(s)
- Ushma C Mehta
- Centre for Infectious Disease Epidemiology and Research (CIDER), School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Cari van Schalkwyk
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch, South Africa
| | - Prineetha Naidoo
- Maternal and Adolescent Child Health Systems (MatCH), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Arthi Ramkissoon
- Maternal and Adolescent Child Health Systems (MatCH), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Otty Mhlongo
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | | | - Niree Naidoo
- Prince Mshiyeni Memorial Hospital, Durban, South Africa
| | - Karen Fieggen
- Division of Human Genetics, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael F Urban
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Shaun Krog
- VP Health Systems, KwaZulu-Natal, Durban, South Africa
| | - Alex Welte
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch, South Africa
| | - Mukesh Dheda
- Programmatic Pharmacovigilance Unit, National Department of Health, Pretoria, South Africa
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | - Neil F Moran
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
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23
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Dettinger JC, Kinuthia J, Pintye J, Abuna F, Begnel E, Mugwanya K, Sila J, Lagat H, Baeten JM, John‐Stewart G. Perinatal outcomes following maternal pre-exposure prophylaxis (PrEP) use during pregnancy: results from a large PrEP implementation program in Kenya. J Int AIDS Soc 2019; 22:e25378. [PMID: 31498563 PMCID: PMC6733245 DOI: 10.1002/jia2.25378] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/31/2019] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION The World Health Organization, while recommending pre-exposure prophylaxis (PrEP) for HIV-negative pregnant and postpartum women in HIV high-burden settings, advocates for continued safety evaluation of PrEP in this population. METHODS The PrEP Implementation in Young Women and Adolescents (PrIYA) program delivered PrEP to pregnant and postpartum women integrated within routine maternal and child health clinics (MCH) at 16 sites in Western Kenya. PrEP exposure and perinatal outcome data were collected among women obtaining postnatal services during programme evaluation. PrEP use was self-reported and confirmed with clinical records. Perinatal outcomes including gestational age at birth, birthweight, congenital malformations and infant growth outcomes were abstracted from clinical records for mother-infant pairs attending the six week visit. Associations between infant outcomes and maternal prenatal PrEP use were assessed using univariate and multivariate logistic and linear regression. RESULTS The PrIYA evaluation identified 1530 postpartum mother-infant pairs with data on prenatal PrEP exposure: 206 with prenatal PrEP use, 1324 without. Median maternal age was 24 years in both groups. PrEP users (any reported PrEP use) were significantly more likely to report HIV risk factors such as: intimate partner violence, sexually transmitted infections and having a partner with positive or unknown HIV status. Most mothers initiated PrEP during the second trimester (n = 116, 57%) and used PrEP for more than one month (n = 110, 58%). The mean birthweight was 3.3 kg and gestational age at birth was 38.5 weeks in both groups. There were no major differences between PrEP exposed and unexposed infants in rates of preterm birth and low birthweight. There were no congenital malformations identified in the PrEP-exposed group and five reported in the PrEP unexposed group. At six weeks postpartum, infants in both groups had similar growth. No differences in infant outcomes were found by duration PrEP exposure, trimester of PrEP initiation, a subset analysis of women 15 to 24 years old or in multivariate analyses. This analysis demonstrates that monitoring of infant outcomes is feasible within large-scale programmatic implementation of PrEP among pregnant and postpartum populations. CONCLUSIONS Pregnancy outcomes and early infant growth did not differ by PrEP exposure.
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Affiliation(s)
| | - John Kinuthia
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of Obstetrics/GynecologyKenyatta National HospitalNairobiKenya
| | - Jillian Pintye
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Felix Abuna
- University of Washington – KenyaNairobiKenya
| | - Emily Begnel
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | | | - Joseph Sila
- University of Washington – KenyaNairobiKenya
| | | | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Grace John‐Stewart
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
- Department of PediatricsUniversity of WashingtonSeattleWAUSA
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Selph SS, Bougatsos C, Dana T, Grusing S, Chou R. Screening for HIV Infection in Pregnant Women: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 321:2349-2360. [PMID: 31184704 DOI: 10.1001/jama.2019.2593] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Prenatal screening for HIV can inform use of interventions to reduce the risk of mother-to-child transmission. The US Preventive Services Task Force (USPSTF) previously found strong evidence that prenatal HIV screening reduced risk of mother-to-child transmission. The previous evidence review was conducted in 2012. OBJECTIVE To update the 2012 review on prenatal HIV screening to inform the USPSTF. DATA SOURCES Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews from 2012 to June 2018, with surveillance through January 2019. STUDY SELECTION Pregnant persons 13 years and older; randomized clinical trials and cohort studies of screening vs no screening; risk of mother-to-child transmission or maternal or infant harms associated with antiretroviral therapy (ART) during pregnancy; screening yield at different intervals or in different risk groups. DATA EXTRACTION AND SYNTHESIS One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. MAIN OUTCOMES AND MEASURES Mother-to-child transmission; harms of screening and treatment; screening yield. RESULTS Sixty-two studies were included in this review, including 29 new studies. There remains no direct evidence on effects of prenatal screening vs no screening on risk of mother-to-child HIV transmission, maternal or infant clinical outcomes, or the yield of repeat or alternative screening strategies. New evidence confirms that combination ART is highly effective at reducing the risk of mother-to-child transmission, with some new cohort studies reporting rates of mother-to-child transmission less than 1% when combination ART was started early in pregnancy (when begun in first trimester, 0%-0.4%; when begun after first trimester, or at any time if timing of ART initiation not reported, 0.4%-2.8%). New evidence on harms of ART was also largely consistent with the previous review. Evidence from primarily observational studies found prenatal combination ART with a boosted protease inhibitor associated with increased risk of preterm delivery (range, 14.4%-26.1%). For other birth outcomes (low birth weight, small for gestational age, stillbirth, birth defects, neonatal death), results were mixed and depended on the specific antiretroviral drug or drug regimen given and timing of prenatal therapy. CONCLUSIONS AND RELEVANCE Combination ART was highly effective at reducing risk of mother-to-child HIV transmission. Use of certain ART regimens during pregnancy was associated with increased risk of harms that may be mitigated by selection of ART regimen. The 2012 review found that avoidance of breastfeeding and cesarean delivery in women with viremia also reduced risk of transmission and that prenatal screening accurately diagnosed HIV infection.
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Affiliation(s)
- Shelley S Selph
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Christina Bougatsos
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Sara Grusing
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
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Pintye J, Baeten JM, Celum C, Mugo N, Ngure K, Were E, Bukusi EA, John-Stewart G, Heffron RA. Maternal Tenofovir Disoproxil Fumarate Use During Pregnancy Is Not Associated With Adverse Perinatal Outcomes Among HIV-infected East African Women: A Prospective Study. J Infect Dis 2019; 216:1561-1568. [PMID: 29040666 DOI: 10.1093/infdis/jix542] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/06/2017] [Indexed: 11/15/2022] Open
Abstract
Background Tenofovir disoproxil fumarate (TDF) is commonly used in antiretroviral treatment (ART) and pre-exposure prophylaxis regimens. We evaluated the relationship between adverse perinatal outcomes and prenatal TDF use. Methods Longitudinal data were analyzed from human immunodeficiency virus (HIV)-infected women who became pregnant during 2 HIV prevention studies conducted among HIV-serodiscordant couples in Kenya and Uganda. Pregnancies included were singleton, not terminated by an induced abortion, and had documented 3-drug ART use. Multivariate generalized estimating equation models were used to determine the association of prenatal TDF and perinatal outcomes. Results The most frequent ART regimens were TDF/3TC/EFV (39%) and AZT/3TC/NVP (34%); 49% of pregnancies had prenatal TDF exposure and 6% used a protease inhibitor. Neonatal death, preterm birth, and pregnancy loss occurred in 2%, 8%, and 12% of pregnancies, respectively. No differences were observed between pregnancies with and without exposure to TDF in the frequency of pregnancy loss (adjusted prevalence rate ratio [aPRR] 1.19, P = .8) or neonatal death (aPRR 0.68, P = .6). Preterm birth occurred less frequently among pregnancies exposed to TDF (aPRR, 0.34, P = .02). Conclusion Maternal TDF use did not adversely affect perinatal outcomes.
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Affiliation(s)
| | | | | | - Nelly Mugo
- University of Washington.,Kenya Medical Research Institute
| | - Kenneth Ngure
- Jomo Kenyatta University of Agriculture and Technology
| | | | - Elizabeth A Bukusi
- University of Washington.,Kenya Medical Research Institute.,University of California, San Francisco; and for the Partners Demonstration Project and the Partners PrEP Study teams
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Kar P, Sengupta A. Synthetic therapeutics for the treatment of hepatitis B during pregnancy. Expert Opin Pharmacother 2018; 19:1771-1778. [PMID: 30273073 DOI: 10.1080/14656566.2018.1527313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Hepatitis B infection in pregnancy mandates careful monitoring and specialized management according to the phase of hepatitis B infection. Perinatal transmission may be prevented by antiviral therapy in mothers with high viral load and timely immunoprophylaxis of the infant. AREAS COVERED This review focuses on the current first-line therapies for treating hepatitis B in pregnancy, timing of therapy, and prevention of perinatal transmission. Strategies to manage disease at the various phases and potential emerging therapies in phase III of development are also covered. Medline/PubMed and Cochrane databases were searched systematically from 1990 to April 2018 with the relevant articles selected for the review. EXPERT OPINION Universal antenatal screening for hepatitis B and strict immunoprophylaxis for infants form the cornerstones to prevent hepatitis B virus (HBV) perinatal transmission. Tenofovir is the preferred drug for treatment in pregnancy in view of its good efficacy and high barrier to resistance. Most of the data on antivirals are from cohort studies which are prone to bias and more randomized controlled trials (RCTs) are needed to establish the benefits and safety of these drugs in pregnancy. Various novel drugs are in the pipeline which may pave the way for a cure in the near future.
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Affiliation(s)
- Premashis Kar
- a Department of Gastroenterology and Hepatology , Max Super Speciality Hospital, Vaishali , Ghaziabad , India
| | - Anando Sengupta
- a Department of Gastroenterology and Hepatology , Max Super Speciality Hospital, Vaishali , Ghaziabad , India
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Weight gain of HIV-exposed, uninfected children born before and after introduction of the 'Option B+' programme in Malawi. AIDS 2018; 32:2201-2208. [PMID: 30005013 DOI: 10.1097/qad.0000000000001942] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare birth weight and weight gain in HIV-exposed, uninfected (HEU) infants up to 24 months old, who enrolled in the Malawian national HIV care clinic (HCC) programme either before or after Option B+ (OB+) was implemented. DESIGN, SETTING AND PARTICIPANTS HIV-exposed infants enrol in the HCC programme as soon as possible after birth and are followed up to at least 24 months old. This analysis includes HEU infants with recorded birth weight, date of birth, gender and at least one follow-up weight measurement from 21 health facilities in central and southern Malawi (January 2010-December 2014). Weight-for-age z scores (WAZ) were derived and compared by birth period using linear regression at birth and mixed effects models for postnatal weight gain up to 24 months old. RESULTS Of 6845 HEU infants included in this study, 88.5% were born after OB+. The proportion of infants exposed in utero to combination antiretroviral therapy (ART) significantly increased after OB+ was implemented, and infants were exposed to ART for a longer time. There was no significant difference in WAZ at birth (P = 0.654) among HEU infants by birth period, but postnatal weight gain was faster among HEU infants born in the Option B+ period than infants born pre-Option B+. CONCLUSION Birth weight was not affected by longer exposure to ART during pregnancy after OB+ was introduced, when weight gain in HEU infants was faster, possibly because their mothers were in better health.
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Heffron R, Mugo N, Hong T, Celum C, Marzinke MA, Ngure K, Asiimwe S, Katabira E, Bukusi EA, Odoyo J, Tindimwebwa E, Bulya N, Baeten JM. Pregnancy outcomes and infant growth among babies with in-utero exposure to tenofovir-based preexposure prophylaxis for HIV prevention. AIDS 2018; 32:1707-1713. [PMID: 30001244 PMCID: PMC6086376 DOI: 10.1097/qad.0000000000001867] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Global guidelines recommend preexposure prophylaxis (PrEP) use by women at risk for HIV, including during pregnancy, a period with heightened HIV risk. However, data to support safety of PrEP use during pregnancy are limited, particularly from women using PrEP throughout pregnancy. METHODS In an open-label delivery study of PrEP integrated with ART for high-risk HIV serodiscordant couples in Kenya and Uganda (the Partners Demonstration Project), women who became pregnant while using PrEP were offered the option to continue PrEP throughout pregnancy. We compared pregnancy outcomes and 1-year infant growth from pregnancies with exposure to PrEP throughout pregnancy to those without any exposure, with data from the placebo arm of a prior efficacy trial of PrEP conducted in the same setting. RESULTS Outcomes from 30 women who elected to continue PrEP throughout pregnancy were compared with those from 96 pregnancies among PrEP-unexposed women. There were small nonsignificant decreases in the frequency of pregnancy loss [16.7% PrEP-exposed versus 23.5% PrEP-unexposed, adjusted odds ratio (aOR) = 0.59, P = 0.4] and preterm delivery [0 versus 7.7%, (aOR) = 0.54, exact P = 0.6]. No congenital anomalies occurred among PrEP-exposed infants. PrEP-exposed infants had slightly lower adjusted mean z-scores for length (-1.73 versus -0.79, P = 0.05) and head circumference (0.24 versus 1.07, P = 0.04) 1 month after birth but were comparable to PrEP-unexposed infants in these measurements 1 year after birth. CONCLUSION This first evaluation among women using PrEP throughout pregnancy indicates no greater frequency of adverse pregnancy outcomes or restricted infant growth; these findings support recommendations permitting PrEP use during pregnancy.
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Affiliation(s)
- Renee Heffron
- Department of Global Health
- Department of Epidemiology
| | - Nelly Mugo
- Department of Global Health
- Centres for Clinical Research
| | | | - Connie Celum
- Department of Global Health
- Department of Epidemiology
- Department of Medicine
| | - Mark A Marzinke
- Department of Pathology
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Kenneth Ngure
- Department of Global Health
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | - Elly Katabira
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Elizabeth A Bukusi
- Department of Global Health
- Department of Obstetrics & Gynecology, University of Washington, Seattle, USA
- Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Josephine Odoyo
- Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Nulu Bulya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Jared M Baeten
- Department of Global Health
- Department of Epidemiology
- Department of Medicine
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Rough K, Seage GR, Williams PL, Hernandez-Diaz S, Huo Y, Chadwick EG, Currier JS, Hoffman RM, Barr E, Shapiro DE, Patel K. Birth Outcomes for Pregnant Women with HIV Using Tenofovir-Emtricitabine. N Engl J Med 2018; 378:1593-1603. [PMID: 29694825 PMCID: PMC5984044 DOI: 10.1056/nejmoa1701666] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND In a previous trial of antiretroviral therapy (ART) involving pregnant women with human immunodeficiency virus (HIV) infection, those randomly assigned to receive tenofovir, emtricitabine, and ritonavir-boosted lopinavir (TDF-FTC-LPV/r) had infants at greater risk for very premature birth and death within 14 days after delivery than those assigned to receive zidovudine, lamivudine, and ritonavir-boosted lopinavir (ZDV-3TC-LPV/r). METHODS Using data from two U.S.-based cohort studies, we compared the risk of adverse birth outcomes among infants with in utero exposure to ZDV-3TC-LPV/r, TDF-FTC-LPV/r, or TDF-FTC with ritonavir-boosted atazanavir (ATV/r). We evaluated the risk of preterm birth (<37 completed weeks of gestation), very preterm birth (<34 completed weeks), low birth weight (<2500 g), and very low birth weight (<1500 g). Risk ratios with 95% confidence intervals were estimated with the use of modified Poisson models to adjust for confounding. RESULTS There were 4646 birth outcomes. Few infants or fetuses were exposed to TDF-FTC-LPV/r (128 [2.8%]) as the initial ART regimen during gestation, in contrast with TDF-FTC-ATV/r (539 [11.6%]) and ZDV-3TC-LPV/r (954 [20.5%]). As compared with women receiving ZDV-3TC-LPV/r, women receiving TDF-FTC-LPV/r had a similar risk of preterm birth (risk ratio, 0.90; 95% confidence interval [CI], 0.60 to 1.33) and low birth weight (risk ratio, 1.13; 95% CI, 0.78 to 1.64). As compared to women receiving TDF-FTC-ATV/r, women receiving TDF-FTC-LPV/r had a similar or slightly higher risk of preterm birth (risk ratio, 1.14; 95% CI, 0.75 to 1.72) and low birth weight (risk ratio, 1.45; 95% CI, 0.96 to 2.17). There were no significant differences between regimens in the risk of very preterm birth or very low birth weight. CONCLUSIONS The risk of adverse birth outcomes was not higher with TDF-FTC-LPV/r than with ZDV-3TC-LPV/r or TDF-FTC-ATV/r among HIV-infected women and their infants in the United States, although power was limited for some comparisons. (Funded by the National Institutes of Health and others.).
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Affiliation(s)
- Kathryn Rough
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - George R Seage
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Paige L Williams
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Sonia Hernandez-Diaz
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Yanling Huo
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Ellen G Chadwick
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Judith S Currier
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Risa M Hoffman
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Emily Barr
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - David E Shapiro
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
| | - Kunjal Patel
- From the Departments of Epidemiology (K.R., G.R.S., P.L.W., S.H.-D., K.P.) and Biostatistics (P.L.W., D.E.S.) and the Center for Biostatistics and AIDS Research (Y.H., D.E.S., K.P.), Harvard T.H. Chan School of Public Health, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (K.R.), Boston; the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago (E.G.C.); the Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles (J.S.C., R.M.H.); and the Department of Pediatrics, University of Colorado School of Medicine, Aurora (E.B.)
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Lumaca A, Galli L, de Martino M, Chiappini E. Paediatric HIV-1 infection: updated strategies of prevention mother-to-child transmission. J Chemother 2018; 30:193-202. [PMID: 29595094 DOI: 10.1080/1120009x.2018.1451030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION HIV-1 epidemiology is changing and prevention of mother-to-child transmission (PMTCT) strategies have been continuously optimized over time. However, the correct management of infected women during pregnancy is crucial for PMTCT and cases of vertical transmission continue to occur. OBJECTIVE To review the most recent evidence regarding the prevention of MTCT in resource-rich and resource-limited settings, focalizing on new possible approaches. RESULTS New issues regard the optimal antiretroviral therapy regimen for pregnant women with good immunological control, the use of intrapartum zidovudine (ZDV) in pregnant women with low viral load, the optimization of prophylaxis in the settings where breastfeeding is recommended and use of combined neonatal prophylaxis (CNP) in infants at high-risk for MTCT. Complete viral control, in recent years, has been achieved in most infected pregnant women, has led to change the recommended mode of delivery, since vaginal birth has become a safe option and is now largely recommended. Recent data reported a large use of CNP in preterm infants: this practice may be dangerous, due to the lack of safety data, and its efficacy and effectiveness is unproven. CONCLUSION Data are accumulating on efficacy, effectiveness and safety of different PMTCT strategies in various possible clinical scenarios, however further researches are needed in order to optimize the management of infants at extremely low risk for MTCT as well as in those presenting with high risk for infection.
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Affiliation(s)
- Alessandra Lumaca
- a Department of Health Sciences , Meyer University Hospital, University of Florence , Florence , Italy
| | - Luisa Galli
- a Department of Health Sciences , Meyer University Hospital, University of Florence , Florence , Italy
| | - Maurizio de Martino
- a Department of Health Sciences , Meyer University Hospital, University of Florence , Florence , Italy
| | - Elena Chiappini
- a Department of Health Sciences , Meyer University Hospital, University of Florence , Florence , Italy
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Toward a universal antiretroviral regimen: special considerations of pregnancy and breast feeding. Curr Opin HIV AIDS 2018; 12:359-368. [PMID: 28426519 DOI: 10.1097/coh.0000000000000386] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW As optimized antiretroviral therapy (ART) regimens are prepared for introduction in low-income and middle-income countries (LMIC), we consider the current evidence related to dosing, efficacy and safety during pregnancy and breastfeeding of next-generation first-line and second-line ART regimens proposed for imminent introduction in the global marketplace. RECENT FINDINGS Pregnancy pharmacokinetic considerations include potentially insufficient efavirenz exposure if dosed at 400 mg/day, the need for twice daily darunavir dosing and the paucity of data related to tenofovir alafenamide and dolutegravir dosing, safety and efficacy. Increasingly evidence suggests an association with adverse birth outcomes, particularly in women conceiving on ART, and with varying risk by drug and drug combination. Clinical trials and studies are in progress or planned that aim to determine dosing, safety and efficacy of several new antiretrovirals (ARVs). SUMMARY Having a universal, highly potent and safe ART regimen for all individuals living with HIV in LMIC including pregnant women is clearly the most beneficial strategy to keep mothers alive and healthy and to prevent transmission of HIV to their children. It will have to be determined whether the use of this next generation of optimized ARVs will also optimize health outcomes of pregnant women and their children.
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Heffron R, Pintye J, Matthews LT, Weber S, Mugo N. PrEP as Peri-conception HIV Prevention for Women and Men. Curr HIV/AIDS Rep 2017; 13:131-9. [PMID: 26993627 DOI: 10.1007/s11904-016-0312-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Daily oral tenofovir (TDF)-based pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy and recommended for men and women with substantial risk of HIV acquisition. The peri-conception period, the stage prior to pregnancy when condom use is necessarily reduced, has elevated HIV risk that can be mitigated by PrEP use. Data from a randomized trial suggest that peri-conception PrEP use by HIV-seronegative women does not increase the risk of pregnancy loss, birth defects or congenital anomalies, preterm birth, or infant growth faltering. Women considering PrEP use throughout pregnancy must weigh the known increased risk of HIV acquisition with unknown risks of drug effects on infant growth. PrEP has been used safely by HIV-seronegative men with HIV-seropositive female partners who have become pregnant. As an effective user-controlled HIV prevention strategy, PrEP offers autonomy and empowerment for HIV prevention and can be recommended alongside antiretroviral therapy, fertility screening, vaginal self-insemination, intercourse timed to peak fertility, medically assisted reproduction, and other safer conception strategies to provide multiple options. The integration of PrEP into safer conception programs is warranted and will safely reduce HIV transmission to women, men, and children during the peri-conception period.
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Affiliation(s)
- Renee Heffron
- Departments of Global Health and Epidemiology, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA.
| | - Jillian Pintye
- School of Nursing, University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA, 98104, USA
| | - Lynn T Matthews
- Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, 125 Nashua Street, Suite 722, Boston, MA, 02114, USA
| | - Shannon Weber
- University of California San Francisco, 1001 Potrero Ave, 6D-33, San Francisco, CA, 94110, USA
| | - Nelly Mugo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
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Pintye J, Beima-Sofie KM, Kimemia G, Ngure K, Trinidad SB, Heffron RA, Baeten JM, Odoyo J, Mugo N, Bukusi EA, Kelley MC, John-Stewart GC. "I Did Not Want to Give Birth to a Child Who has HIV": Experiences Using PrEP During Pregnancy Among HIV-Uninfected Kenyan Women in HIV-Serodiscordant Couples. J Acquir Immune Defic Syndr 2017; 76:259-265. [PMID: 28777265 PMCID: PMC5634917 DOI: 10.1097/qai.0000000000001516] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The perceptions, motivations, and beliefs of HIV-uninfected women about pre-exposure prophylaxis (PrEP) use during pregnancy can influence its uptake and adherence. This study elicited the views of HIV-uninfected women with personal experience taking PrEP during pregnancy. DESIGN Qualitative interviews were conducted with HIV-uninfected women who had personal experience taking PrEP while pregnant. METHODS Semistructured interviews were conducted with 21 HIV-uninfected Kenyan women in HIV-serodiscordant couples enrolled in an open-label PrEP demonstration project who became pregnant while using PrEP and continued PrEP through their pregnancy. Interviews were audio-recorded and transcribed into English. A qualitative descriptive analysis was performed, using a constant comparison approach to identify key themes related to PrEP use in pregnancy. RESULTS Desire to remain HIV uninfected and have an HIV-free infant were strong motivators influencing continued use of PrEP during pregnancy. Supporting HIV-infected partners and childbearing within an HIV-serodiscordant relationship were also motivators. Women had challenges distinguishing normal pregnancy symptoms from PrEP side effects and were concerned that observed side effects could be signs of danger for the infant related to PrEP exposure. Health care providers were important conduits of knowledge about PrEP, and continuity of PrEP providers throughout pregnancy facilitated adherence. CONCLUSIONS HIV-uninfected women in HIV-serodiscordant couples were motivated to use PrEP during pregnancy to remain HIV uninfected and to have an HIV-free child but had concerns about side effects. Health care providers will be important for PrEP messaging and adherence support in this unique population.
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Affiliation(s)
- Jillian Pintye
- Departments of *Global Health; and †Nursing, University of Washington, Seattle, WA; ‡Partners in Health Research and Development, Thika, Kenya; §Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya; Departments of ‖Bioethics and Humanities; ¶Epidemiology; and #Medicine, University of Washington, Seattle, WA; **Kenya Medical Research Institute, Nairobi, Kenya; and ††Nuffield Department of Population Health, The Ethox Centre, University of Oxford, Oxford, United Kingdom
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Safety of Tenofovir Disoproxil Fumarate-Based Antiretroviral Therapy Regimens in Pregnancy for HIV-Infected Women and Their Infants: A Systematic Review and Meta-Analysis. J Acquir Immune Defic Syndr 2017; 76:1-12. [PMID: 28291053 PMCID: PMC5553236 DOI: 10.1097/qai.0000000000001359] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: There are limited data on adverse effects of tenofovir disoproxil fumarate (TDF)-based antiretroviral therapy (ART) on pregnant women and their infants. Methods: We conducted a systematic review of studies published between January 1980 and January 2017 that compared adverse outcomes in HIV-infected women receiving TDF- vs. non–TDF-based ART during pregnancy. The risk ratio (RR) for associations was pooled using a fixed-effects model. Results: Seventeen studies met the study inclusion criteria. We found that the rate of preterm (<37 weeks gestation) delivery (RR = 0.90, 95% confidence interval [CI]: 0.81 to 0.99, I2 = 59%) and stillbirth (RR = 0.60, 95% CI: 0.43 to 0.84, I2 = 72.0%) were significantly lower in women exposed (vs. not) to TDF-based ART regimen. We found no increased risk in maternal severe (grade 3) or potentially life-threatening (grade 4) adverse events (RR = 0.62; 95% CI: 0.30 to 1.29), miscarriage (RR = 1.09; 95% CI: 0.80 to 1.48), very preterm (<34 weeks gestation) delivery (RR = 1.08, 95% CI: 0.72 to 1.62), small for gestational age (RR = 0.87, 95% CI: 0.67 to 1.13), low birth weight (RR = 0.91; 95% CI: 0.80 to 1.04), very low birth weight (RR = 3.18; 95% CI: 0.65 to 15.63), congenital anomalies (RR = 1.03; 95% CI: 0.83 to 1.28), infant adverse outcomes or infant mortality (age >14 days) (RR = 0.65; 95% CI: 0.23 to 1.85), but increased neonatal mortality (age <14 days) risk (RR = 5.64, 95% CI: 1.70 to 18.79) with TDR-based ART exposure. No differences were found for anthropomorphic parameters at birth; one study reported minor differences in z-scores for length and head circumference at age 1 year. Conclusions: TDF-based ART in pregnancy seems generally safe for women and their infants. However, data remain limited and further studies are needed, particularly to assess neonatal mortality and infant growth/bone effects.
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Offering pre-exposure prophylaxis for HIV prevention to pregnant and postpartum women: a clinical approach. J Int AIDS Soc 2017; 20:21295. [PMID: 28361503 PMCID: PMC5577744 DOI: 10.7448/ias.20.2.21295] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Introduction: HIV prevention during pregnancy and lactation is critical for both maternal and child health. Pregnancy provides a critical opportunity for clinicians to elicit women’s vulnerabilities to HIV and offer HIV testing, treatment and referral and/or comprehensive HIV prevention options for the current pregnancy, the postpartum period and safer conception options for future pregnancies. In this commentary, we review the safety of oral pre-exposure prophylaxis with tenofovir/emtricitabine in pregnant and lactating women and suggest opportunities to identify pregnant and postpartum women at substantial risk of HIV. We then describe a clinical approach to caring for women who both choose and decline pre-exposure prophylaxis during pregnancy and postpartum, highlighting areas for future research. Discussion: Evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine is safe in pregnancy and lactation. Identifying women vulnerable to HIV and eligible for pre-exposure prophylaxis is challenging in light of the myriad of individual, community, and structural forces impacting HIV acquisition. Validated risk calculators exist for specific populations but have not been used to screen and offer HIV prevention methods. Partner testing and engagement of men living with HIV are additional means of reaching at-risk women. However, women’s vulnerabilities to HIV change over time. Combining screening for HIV vulnerability with HIV and/or STI testing at standard intervals during pregnancy is a practical way to prompt providers to incorporate HIV screening and prevention counselling. We suggest using shared decision-making to offer women pre-exposure prophylaxis as one of multiple HIV prevention strategies during pregnancy and postpartum, facilitating open conversations about HIV vulnerabilities, preferences about HIV prevention strategies, and choosing a method that best meets the needs of each woman. Conclusion: Growing evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine during pregnancy and lactation is safe and effective. Shared decision-making provides one approach to identify at-risk women and offers pre-exposure prophylaxis but requires implementation research in diverse clinical settings. Including pregnant and breastfeeding women in future HIV prevention research is critical for the creation of evidence-driven public health policies and clinical guidelines.
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Tassiopoulos K, Huo Y, Braun J, Williams PL, Smith R, Aschengrau A, Nichols S, Hazra R, Meyer WA, Knapp K, Deygoo NS, Seage GR, for the Pediatric HIV/AIDS Cohort S. Blood lead levels and neurodevelopmental function in perinatally HIV-exposed, uninfected children in a US-based longitudinal cohort study. AIDS Res Hum Retroviruses 2017; 33:919-928. [PMID: 28322573 DOI: 10.1089/aid.2016.0265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND While children's exposure to environmental lead in the U.S. has decreased, areas of elevated levels remain. Because lead exposure is a risk factor for developmental delays, it should be considered when studying neurodevelopmental effects of in-utero antiretroviral medication (ARV) exposure in the growing population of perinatally HIV-exposed, uninfected children (PHEU). We compared blood lead levels (BPb) in PHEU children enrolled in the Surveillance Monitoring of ART Toxicities (SMARTT) Study to U.S. children, assessed associations with neurodevelopment, and explored whether associations between in-utero ARV and neurodevelopment are modified by BPb. METHODS Prevalence of elevated BPb (≥5 µg/dL) at ages 1-2 years was calculated by year and race/ethnicity and compared to that for children in the National Health and Nutrition Examination Survey (NHANES 2002-2010). Associations between elevated BPb and neurodevelopment at 1 and 3 years were assessed. Associations between ARVs (tenofovir disopropil fumarate [TDF]; atazanavir) and neurodevelopment were evaluated within BPb level (≥5 vs. <5 µg/dL). RESULTS Mean BPb in SMARTT decreased from 5.9 to 2.7 µg/dL between 1998-2014; prevalence of elevated BPb decreased from 50% to 4%. Both were consistently higher than in NHANES. Elevated BPb was associated with cognitive delay at age 3 (adjusted odds ratio: 1.64; 95% CI: 0.95, 2.90). At age 1, TDF was associated with delay only among those with elevated BPb. CONCLUSIONS PHEU children more often had elevated BPb than the general U.S. pediatric population. Exposure to environmental lead is one of several factors that may place these children at higher risk for neurodevelopmental delay.
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Affiliation(s)
- Katherine Tassiopoulos
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yanling Huo
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Joseph Braun
- Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Paige L. Williams
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Renee Smith
- Department of Pediatrics, University of Illinois, Chicago, Illinois
| | - Ann Aschengrau
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Sharon Nichols
- Department of Neurosciences, University of California, San Diego, California
| | - Rohan Hazra
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | | | - Katherine Knapp
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Nagamah S. Deygoo
- Department of Pediatrics, NYU School of Medicine, New York, New York
| | - George R. Seage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Health and survival of HIV perinatally exposed but uninfected children born to HIV-infected mothers. Curr Opin HIV AIDS 2017; 11:465-476. [PMID: 27716731 DOI: 10.1097/coh.0000000000000300] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The number of HIV-exposed but uninfected (HEU) infants exposed to both HIV and multiple antiretroviral drugs in utero and during prolonged breastfeeding is increasing in low-income countries where HIV prevalence is the highest. We review recent evidence on the effects of perinatal/postnatal exposure to maternal HIV and combined antiretroviral therapy (cART) on health outcomes of HEU children (mitochondrial and metabolic toxicity, adverse pregnancy outcomes, neurodevelopment, growth, infectious morbidity, and mortality). RECENT FINDINGS Several studies have reported ART-associated mitochondrial toxicity and metabolic disorders with conflicting results on adverse pregnancy outcomes, underscoring the need to conduct further investigations on these questions. Studies about congenital abnormalities report no significant differences between HEU exposed to ART and HIV-unexposed (HUU) children. Updated French data showed no significant difference in cancer incidence between HEU cART-exposed children and the general paediatric population. Furthermore, HEU children exposed to maternal cART have modest but significant impairment of development and a higher risk of growth impairment. Finally, HEU have higher risks of infections (mainly low respiratory tract infections and diarrhoea) and malaria than HUU children, particularly in children not breastfed or after early weaning. Higher mortality risk from infectious disease is reported in HEU compared to HUU children. SUMMARY As we move toward the elimination of mother-to-child transmission of HIV, HEU children are an emerging population whose health outcomes remain to be fully described. Future large cohorts of HEU children using careful comparison groups of HUU in the post-ART era are needed to better understand their long-term health outcomes.
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Mugwanya KK, John-Stewart G, Baeten J. Safety of oral tenofovir disoproxil fumarate-based HIV pre-exposure prophylaxis use in lactating HIV-uninfected women. Expert Opin Drug Saf 2017; 16:867-871. [PMID: 28571500 PMCID: PMC5581312 DOI: 10.1080/14740338.2017.1338271] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 05/31/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION In settings where HIV is prevalent in heterosexual populations, pregnancy and postpartum breastfeeding periods can be associated with substantial HIV acquisition risk. Pre-exposure prophylaxis (PrEP) with daily oral tenofovir disoproxil fumarate (TDF)/emtricitabine is an attractive HIV prevention option for women who are lactating but data are limited on its safety during the lactation period. Areas covered: We provide a concise synthesis and summary of current evidence on the safety of TDF-based PrEP during breastfeeding. We conducted a review, searching Pubmed database and major PrEP conferences for primary studies with TDF-based PrEP exposure during postpartum breastfeeding. Expert opinion: TDF-based oral PrEP is an effective female-controlled HIV prevention option. There is evidence supporting the safety of TDF use for infant outcomes during breastfeeding in antiretroviral treatment regimens for HIV and hepatitis B virus, and more limited, but consistently safe, data from use of TDF as PrEP. The potential for risk is arguably outweighed for at-risk individuals by HIV prevention benefits, including indirect protection to the infant as a result of preventing HIV in the breastfeeding mother. As PrEP delivery is scaled up in heterosexual populations in high HIV prevalence settings and for at-risk persons in other settings, implementation science studies can provide a framework to increase the accrual of safety, acceptability, and use data related to PrEP during lactation.
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Affiliation(s)
- Kenneth K. Mugwanya
- Department of Global Health, University of Washington, Seattle, USA
- Division of Disease Control, Makerere University, Kampala Uganda
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Pediatrics, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Jared Baeten
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
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Flash CA, Dale SK, Krakower DS. Pre-exposure prophylaxis for HIV prevention in women: current perspectives. Int J Womens Health 2017; 9:391-401. [PMID: 28615975 PMCID: PMC5459979 DOI: 10.2147/ijwh.s113675] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
There are ~900,000 new HIV infections among women every year, representing nearly half of all new HIV infections globally. In the US, nearly one-fifth of all new HIV infections occur among women, and women from racial and ethnic minority communities experience disproportionately high rates of new HIV infections. Thus, there is a need to develop and implement effective HIV prevention strategies for women in the US and internationally, with a specific need to advance strategies in minority communities. Previous studies have demonstrated that oral HIV pre-exposure prophylaxis (PrEP), the use of antiretroviral medications by HIV-uninfected persons to prevent HIV acquisition, can reduce HIV incidence among women who are adherent to PrEP. However, to date, awareness and uptake of PrEP among women have been very limited, suggesting a need for innovative strategies to increase the knowledge of and access to PrEP among women in diverse settings. This narrative review summarizes the efficacy and safety data of PrEP in women, discusses considerations related to medication adherence for women who use PrEP, and highlights behavioral, social, and structural barriers to maximize the effectiveness of PrEP in women. It also reviews novel modalities for PrEP in women which are being developed and tested, including topical formulations and long-acting injectable agents that may offer advantages as compared to oral PrEP and proposes a community-oriented, social networking framework to increase awareness of PrEP among women. If women are provided with access to PrEP and support to overcome social and structural barriers to adhere to PrEP, this prevention strategy holds great promise to impact the HIV epidemic among women in the US and globally.
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Affiliation(s)
- Charlene A Flash
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sannisha K Dale
- Massachusetts General Hospital.,Department of Psychiatry, Harvard Medical School, Boston, MA.,Department of Psychology, University of Miami, Coral Gables, FL
| | - Douglas S Krakower
- Department of Psychiatry, Harvard Medical School, Boston, MA.,Division of Infectious Diseases, Beth Israel Deaconess Medical Center.,The Fenway Institute, Boston, MA, USA
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Castillo E, Murphy K, van Schalkwyk J. N° 342-L'hépatite B et la grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:191-201. [DOI: 10.1016/j.jogc.2017.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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In-utero exposure to tenofovir is associated with impaired fetal and infant growth: need for follow-up studies in combination antiretroviral therapy/HIV-exposed infants: author's reply. AIDS 2017; 31:596-598. [PMID: 28118236 DOI: 10.1097/qad.0000000000001364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Osorio LE, Boechat MI, Mirochnick M, Kumwenda N, Kreitchmann R, Emel L, Pinto J, Joao E, Santos B, Swenson M, George K, Sato P, Mofenson L, Nielsen-Saines K. Bone Age and Mineral Density Assessments Using Plain Roentgenograms in Tenofovir-exposed Infants in Malawi and Brazil Enrolled in HIV Prevention Trials Network 057. Pediatr Infect Dis J 2017; 36:184-188. [PMID: 27798550 PMCID: PMC5233548 DOI: 10.1097/inf.0000000000001386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF) use during pregnancy has been increasing, and studies linking bone toxicity with exposure to TDF have raised concern for its use in infants. METHODS Hand/wrist and spine radiographs were obtained at 3 days and 12 weeks of age in infants born to HIV-infected pregnant women enrolled in the HIV Prevention Trials Network 057 pharmacokinetic study of TDF conducted in Malawi and Brazil assigned to 3 TDF dosing cohorts. In cohort 1, mothers received 600 mg of TDF during labor. In cohort 2, infants received 4 mg/kg dose on days 0, 3 and 5. In cohort 3, a 900 mg maternal dose was given during labor, followed by a 6 mg/kg infant dose on days 0, 3 and 5 of life. RESULTS Across all 3 cohorts, 89 infants had radiographs performed at either time point, and 85 had radiographs performed at both time points. Metaphyseal lucency was present in 1 case in Brazil and 2 in Malawi. Fifteen percent of infants from Brazil and 9% of infants from Malawi presented bone age discrepancies. No other abnormalities were identified in Brazil, whereas in Malawi, there were 7 more cases of wrist osteopenia, 2 of spine osteopenia and 3 other abnormalities. CONCLUSION Bone abnormalities were not uncommon in the overall cohort of HIV-exposed infants. Because of very limited study drug exposure at the time of birth, it is unlikely that TDF was associated with these findings. Untreated maternal HIV disease and/or maternal nutritional status could potentially be related to fetal bone development. This association should be explored in future cohort studies.
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Affiliation(s)
| | | | | | | | | | - Lynda Emel
- SCHARP Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jorge Pinto
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Esau Joao
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | | | - Molly Swenson
- SCHARP Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Paul Sato
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Lynne Mofenson
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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Jacobson DL, Patel K, Williams PL, Geffner ME, Siberry GK, Dimeglio LA, Crain MJ, Mirza A, Chen JS, McFarland EJ, Kacanek D, Silio M, Rich K, Borkowsky W, Van Dyke RB, Miller TL. Growth at 2 Years of Age in HIV-exposed Uninfected Children in the United States by Trimester of Maternal Antiretroviral Initiation. Pediatr Infect Dis J 2017; 36:189-197. [PMID: 27798548 PMCID: PMC5526594 DOI: 10.1097/inf.0000000000001387] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Abnormal childhood growth may affect future health. Maternal tenofovir (TFV) use was associated with lower body length and head circumference at 1 year of age in HIV-exposed uninfected (HEU) US children. METHODS We studied 509 HEU children in the US-based Surveillance Monitoring of Antiretroviral Therapy Toxicities cohort whose HIV-infected mothers were not using antiretrovirals at the last menstrual period and began combination antiretroviral therapy (cART) in pregnancy (cART initiators). We examined adjusted associations between antiretrovirals and Centers for Disease Control 2000 growth Z scores at 2 years of age within trimester of cART initiation: weight (weight Z score), length (length Z score), weight-for-length [weight-for-length Z score (WFLZ)], triceps skinfold Z score (TSFZ) and head circumference (head circumference Z score). RESULTS Mothers mean age was 28.6 years; 57% were black non-Hispanic and 19% delivered at <37 weeks gestation. At 2 years, mean weight Z score, length Z score, WFLZ and head circumference Z score were above average (P < 0.05), whereas TSFZ (P = 0.57) did not differ from average. WFLZ was >1.64 standard deviation (SD) (>95th percentile) in 13%. Among children of first-trimester cART initiators, TFV+emtricitabine-exposed children had slightly higher mean WFLZ (0.45 SD; 95% confidence interval: -0.10 to 1.00) and lower TSFZ (-0.55 SD; 95% confidence interval: -1.07 to -0.02) compared with zidovudine+lamivudine-exposed children. TSFZ was lower in those exposed to boosted protease inhibitors. In contrast, growth in children of second trimester cART initiators did not differ by antiretroviral exposures. CONCLUSION Growth was above average in HEU; 13% were obese. Maternal TFV use was not associated with lower length or head circumference at 2 years of age, as hypothesized, but may be related to greater weight among those exposed to cART early in pregnancy.
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Affiliation(s)
- Denise L. Jacobson
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston MA, USA
| | - Kunjal Patel
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston MA, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Paige L. Williams
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston MA, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Mitchell E. Geffner
- The Saban Research Institute, Children’s Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, USA
| | - George K. Siberry
- Maternal and Pediatric Infectious Disease (MPID) Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, USA
| | | | - Marilyn J. Crain
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, USA
| | | | - Janet S. Chen
- Drexel University College of Medicine, Philadelphia, USA
| | | | - Deborah Kacanek
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston MA, USA
| | | | | | | | | | - Tracie L. Miller
- Division of Pediatric Clinical Research, Department of Pediatrics, Miller School of Medicine at the University of Miami, Miami, USA
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Tenofovir disoproxil fumarate safety for women and their infants during pregnancy and breastfeeding. AIDS 2017; 31:213-232. [PMID: 27831952 DOI: 10.1097/qad.0000000000001313] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Pregnant/lactating women in some sub-Saharan Africa settings are at substantial risk of HIV acquisition and could benefit from preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate (TDF), but safety data in pregnancy/lactation are limited. DESIGN Systematic data review through August 2016. METHODS We reviewed research reports/conference abstracts with maternal/child adverse outcome data in HIV-infected and HIV-uninfected pregnant/lactating women receiving TDF alone or in combination with other drugs compared with non-TDF regimens. RESULTS In total, 26 articles in HIV-infected and seven in HIV-uninfected women were identified. No statistically significant differences were observed between TDF and comparison non-TDF regimens in pregnancy incidence, stillbirth/pregnancy loss, preterm delivery less than 37 weeks, low birth weight <2500/<1500 g, small for gestational age, birth defects, or infant (>14 days) or maternal mortality. One study reported significantly higher very preterm delivery (<34 weeks) and neonatal mortality with TDF versus non-TDF antiretroviral therapy (ART), but no significant difference between TDF ART and zidovudine/single-dose nevirapine. Most studies report normal infant linear growth; one study showed slightly lower, and one higher 1-year length-for-age z-score in TDF ART-exposed infants. No significant differences were reported in abnormal laboratory values or bone markers between TDF and non-TDF-exposed infants in four studies. Lower maternal bone mineral density was observed at 74 weeks postpartum in breastfeeding women on TDF ART compared with no ART in one study. CONCLUSION Given available safety data, there does not appear to be a safety-related rationale for prohibiting PrEP during pregnancy/lactation or for discontinuing PrEP in HIV-uninfected women receiving PrEP who become pregnant and are at continuing risk of HIV acquisition.
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Abstract
OBJECTIVE Tenofovir (TDF) affects bone health and is widely used in pregnancy but data are limited on the effects of TDF exposure in utero. We examined the association between duration of in-utero TDF exposure and linear growth in HIV-exposed, uninfected (HEU) infants. DESIGN A prospective cohort of pregnant women initiating TDF-containing regimens at primary care services in Cape Town, South Africa, were enrolled and followed with their breastfeeding infants through 12 months postpartum. METHODS Length-for-age z scores (LAZ) were calculated from infant lengths reported at birth and measured at 6, 12, 24, 36 and 48 weeks, using Fenton and WHO standards. Linear mixed-effects models were used to examine the association between duration of TDF exposure and LAZ over time. RESULTS In 464 singleton mother-infant pairs (median CD4 at ART initiation, 346 cells/μl; viral load (VL), 4.0 log10 copies/ml), the median duration of in-utero TDF exposure was 16.7 weeks (interquartile range, IQR 11.0-22.0) with 31, 44 and 25% of infants exposed to less than 12, 12-22 and more than 22 weeks of TDF, respectively. Overall, 12% of children were stunted (LAZ < -2) at 48 weeks. Duration of exposure was not associated with LAZ: adjusted mean difference for more than 22 vs less than 12 weeks, -0.12 (95% CI -0.47 to 0.23); 12-22 vs less than 12 weeks, -0.06 (95% CI -0.35 to 0.24). Mean LAZ was 0.15 lower per log increase in maternal VL at ART initiation (95% CI -0.29 to -0.0001). CONCLUSION These data suggest no association between duration of TDF exposure in utero and early linear growth.
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47
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Slogrove AL, Frigati L, Gray DM. Maternal HIV and Paediatric Lung Health. Paediatr Respir Rev 2017; 21:47-53. [PMID: 27665511 DOI: 10.1016/j.prrv.2016.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 08/11/2016] [Indexed: 10/21/2022]
Abstract
With improved prevention of mother to child transmission of HIV, paediatric HIV disease is less common. However, the number of HIV exposed but uninfected infants is growing. Exposure to maternal HIV impacts infant respiratory health through an increase in known risk factors such as increased preterm birth and low birth weight, suboptimal breastfeeding, increased psychosocial stressors and increased exposure to infective pathogens. Exposure to the HIV virus and altered maternal immune environment result in immunologic changes in the infant that may contribute to respiratory disease risk. HIV exposed infants are at increased risk for severe pneumonia with poorer outcomes compared to unexposed infants. Maternal ART and optimal nutrition, including breastfeeding in high infective disease burden settings, reduce morbidity and mortality in HIV exposed infants and should be prioritized. The impact of exposure to maternal HIV on normal lung growth and risk for chronic respiratory disease is unknown and warrants further investigation.
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Affiliation(s)
- A L Slogrove
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa.
| | - L Frigati
- Division of Paediatric Infectious Diseases, Department of Paediatrics and Child Health, Tygerberg Children's Hospital, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa.
| | - D M Gray
- Division Pulmonology, Department of Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Klipfontein Road, Cape Town, 7700, South Africa.
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48
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Abstract
PURPOSE OF REVIEW Chronic HIV infection and exposure to antiretroviral therapy compromises bone health in children and adolescents, potentially impacting their long-term quality of life. Thus, the purpose of this article is to review the most recent literature on this topic in HIV-infected children and adolescents. RECENT FINDINGS Recent studies continue to demonstrate bone abnormalities in HIV-infected children and adolescents, whether HIV is acquired perinatally or during adolescence. Researchers have employed new modalities, both high tech and those that can be utilized in resource-limited settings, to better assess bone health. New data suggest that this population may also be experiencing an increase incidence of fractures, and they may not acquire the same peak bone mass as their HIV-uninfected counterparts. Reassuringly, however, in-utero tenofovir exposure does not appear to have a significant impact on bone health in HIV-exposed, uninfected infants. SUMMARY HIV-infected children and adolescents are exposed to HIV and antiretroviral therapy for many decades starting early in life and during the most critical time for skeletal growth and bone mass accrual. Recent findings underscore the need for further research on bone in this population. Longitudinal studies are especially needed to evaluate long-term risk of osteoporosis and fracture.
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49
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Yin MT, Brown TT. HIV and Bone Complications: Understudied Populations and New Management Strategies. Curr HIV/AIDS Rep 2016; 13:349-358. [PMID: 27730445 DOI: 10.1007/s11904-016-0341-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The higher risk of osteoporosis and fracture associated with HIV infection and certain antiretrovirals has been well established and the need for risk stratification among older adults increasingly recognized. This review focuses upon emerging data on bone complications with HIV/HCV coinfection, in children and adolescents, and with pre-exposure prophylaxis (PrEP), as well as new management strategies to minimize the negative effects of ART on bone.
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Affiliation(s)
- Michael T Yin
- Division of Infectious Diseases, Columbia University Medical Center, 630 w168th street PH8-876, New York, NY, 10032, USA.
| | - Todd T Brown
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA
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50
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Seidman DL, Weber S, Timoney MT, Oza KK, Mullins E, Cohan DL, Wright RL. Use of HIV pre-exposure prophylaxis during the preconception, antepartum and postpartum periods at two United States medical centers. Am J Obstet Gynecol 2016; 215:632.e1-632.e7. [PMID: 27448959 DOI: 10.1016/j.ajog.2016.06.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/09/2016] [Accepted: 06/13/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Pregnancy may increase a woman's susceptibility to HIV. Maternal HIV acquisition during pregnancy and lactation is associated with increased perinatal and lactational HIV transmission. There are no published reports of preexposure prophylaxis use after the first trimester of pregnancy or during lactation. OBJECTIVE The purpose of this study was to report the use of preexposure prophylaxis and to identify gaps in HIV prevention services for women who were at substantial risk of HIV preconception and during pregnancy and lactation at 2 United States medical centers. STUDY DESIGN Chart review was performed on women who were identified as "at significant risk" for HIV acquisition preconception (women desiring pregnancy) and during pregnancy and lactation at 2 medical centers in San Francisco and New York from 2010-2015. Women were referred to specialty clinics for women who were living with or were at substantial risk of HIV. RESULTS Twenty-seven women who were identified had a median age of 27 years. One-half of the women had unstable housing, 22% of the women had ongoing intimate partner violence, and 22% of the women had active substance use. Twenty-six women had a male partner living with HIV, and 1 woman had a male partner who had sex with men. Of the partners who were living with HIV, 73% (19/26) were receiving antiretroviral therapy, and 42% (11/26) had documented viral suppression. Thirty-nine percent (10/26) of partners had known detectable virus, and 19% (5/26) had unknown viral loads. Women were identified by clinicians, health educators, and health departments. Approximately one-third of the women were identified preconception (8/27); the majority of the women were identified during pregnancy (18/27) with a median gestational age of 20 weeks (interquartile range, 11-23), and 1 woman was identified in the postpartum period. None of the pregnant referrals had received safer conception counseling to reduce HIV transmission. Twenty-six percent of all women (7/27) were eligible for postexposure prophylaxis at referral, of whom 57% (4/7) were offered postexposure prophylaxis. In 30% (8/27), the last HIV exposure was not assessed and postexposure prophylaxis was not offered. The median time from identification as "at substantial risk" to consultation was 30 days (interquartile range, 2-62). Two women were lost to follow up before consultation. One woman who was identified as "at significant risk" was not referred because of multiple pregnancy complications. She remained in obstetrics care and was HIV-negative at delivery but was lost to follow up until 10 months after delivery when she was diagnosed with HIV. No other seroconversions were identified. Of referrals who presented and were offered preexposure prophylaxis, 67% women (16/24) chose to take it, which was relatively consistent whether the women were preconception (5/8), pregnant (10/15), or after delivery (1/1). Median length of time on preexposure prophylaxis was 30 weeks (interquartile range, 20-53). One-half of women (10/20) who were in care at delivery did not attend a postpartum visit. CONCLUSION Women at 2 United States centers frequently chose to use preexposure prophylaxis for HIV prevention when it was offered preconception and during pregnancy and lactation. Further research and education are needed to close critical gaps in screening for women who are at risk of HIV for pre- and postexposure prophylaxis eligibility and gaps in care linkage before and during pregnancy and lactation. Postpartum women are particularly vulnerable to loss-to-follow-up and miss opportunities for safe and effective HIV prevention.
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