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Safety of in-utero antiretroviral exposure: neurologic outcomes in children who are HIV-exposed but uninfected. AIDS 2020; 34:1377-1387. [PMID: 32310900 DOI: 10.1097/qad.0000000000002550] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether there is an increased risk of neurologic diagnoses in children who are HIV-exposed but uninfected (CHEU) exposed in utero to specific antiretroviral medications. DESIGN Prospective cohort study of CHEU enrolled from 2007 to 2017. METHODS We evaluated children for neurologic case status, including microcephaly, febrile seizures, seizure disorders, ophthalmologic disorders, and other neurologic disorders. Adjusted relative risks (aRRs) were estimated for the association between in-utero antiretroviral exposure and neurologic case using log-binomial regression, accounting for potential confounders. Sensitivity analyses were conducted to evaluate robustness of findings. RESULTS Among 3747 eligible CHEU, 231 (6.2%) met neurologic case criteria (95% CI 5.4--7%). Most eligible children (86%) were exposed in utero to combination antiretroviral regimens. In adjusted models, children exposed to efavirenz at any time during pregnancy had higher risk of neurologic case status (aRR = 1.53, 95% CI 0.94--2.51). This association was stronger when comparing efavirenz exposure at conception to no exposure during pregnancy (aRR = 1.92, 95% CI 1.09--3.36) and considering follow-up and case diagnosis only through age 2 (aRR = 2.14, 95% CI 1.11--4.12). Children exposed to didanosine at conception and during the first trimester had increased risk of neurologic case status (aRR = 2.28, 95% CI 1.07--4.87 and aRR = 2.02, 95% CI 1.01--4.04, respectively), compared with didanosine-unexposed children. Children with dolutegravir exposure had some suggestion of increased risk of neurologic case (aRR = 2.43, 95% CI 0.75--7.84), which was observed consistently across several sensitivity analyses. CONCLUSION Efavirenz and didanosine exposure during pregnancy were associated with higher risk of neurologic abnormalities in CHEU, and dolutegravir exposure showed some suggestive associations, which warrant further monitoring.
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Disclosing in utero HIV/ARV exposure to the HIV-exposed uninfected adolescent: is it necessary? J Int AIDS Soc 2016; 19:21099. [PMID: 27741954 PMCID: PMC5065689 DOI: 10.7448/ias.19.1.21099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 09/06/2016] [Accepted: 09/14/2016] [Indexed: 01/04/2023] Open
Abstract
Introduction The tremendous success of antiretroviral therapy has resulted in a diminishing population of perinatally HIV-infected children on the one hand and a mounting number of HIV-exposed uninfected (HEU) children on the other. As the oldest of these HEU children are reaching adolescence, questions have emerged surrounding the implications of HEU status disclosure to these adolescents. This article outlines the arguments for and against disclosure of a child's HEU status. Discussion Disclosure of a child's HEU status, by definition, requires disclosure of maternal HIV status. It is necessary to weigh the benefits and harms which could occur with disclosure in each of the following domains: psychosocial impact, long-term physical health of the HEU individual and the public health impact. Does disclosure improve or worsen the psychological health of the HEU individual and extended family unit? Do present data on the long-term safety of in utero HIV/ARV exposure reveal potential health risks which merit disclosure to the HEU adolescent? What research and public health programmes or systems need to be in place to afford monitoring of HEU individuals and which, if any, of these require disclosure? Conclusions At present, it is not clear that there is sufficient evidence on whether long-term adverse effects are associated with in utero HIV/ARV exposures, making it difficult to mandate universal disclosure. However, as more countries adopt electronic medical record systems, the HEU status of an individual should be an important piece of the health record which follows the infant not only through childhood and adolescence but also adulthood. Clinicians and researchers should continue to approach the dialogue around mother–child disclosure with sensitivity and a cogent consideration of the evolving risks and benefits as new information becomes available while also working to maintain documentation of an individual's perinatal HIV/ARV exposures as a vital part of his/her medical records. As more long-term adult safety data on in utero HIV/ARV exposures become available these decisions may become clearer, but at this time, they remain complex and multi-faceted.
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Spaulding AB, Yu Q, Civitello L, Mussi-Pinhata MM, Pinto J, Gomes IM, Alarcón JO, Siberry GK, Harris DR, Hazra R. Neurologic Outcomes in HIV-Exposed/Uninfected Infants Exposed to Antiretroviral Drugs During Pregnancy in Latin America and the Caribbean. AIDS Res Hum Retroviruses 2016; 32:349-56. [PMID: 26879281 DOI: 10.1089/aid.2015.0254] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
To evaluate antiretroviral (ARV) drug exposure and other factors during pregnancy that may increase the risk of neurologic conditions (NCs) in HIV-exposed/uninfected (HEU) infants. A prospective cohort study was conducted at 24 clinical sites in Latin America and the Caribbean. Data on maternal demographics, health, HIV disease status, and ARV use during pregnancy were collected. Infant data included measurement of head circumference after birth and reported medical diagnoses at birth, 6-12 weeks, and 6 months. Only infants with maternal exposure to combination ARV therapy (cART) (≥3 drugs from ≥2 drug classes) during pregnancy were included. Microcephaly, defined as head circumference for age z-score less than -2, and NC were evaluated for their association with covariates, including individual ARVs, using bivariable and logistic regression analyses. From 2002 to 2009, 1,400 HEU infants met study inclusion criteria. At least one NC was reported in 134 (9.6%; 95% confidence interval [CI]: 8.1-11.2), microcephaly in 105 (7.5%; 95% CI: 6.2-9.0), and specific neurologic diagnoses in 33 (2.4%; 95% CI: 1.6-3.3) HEU infants. Microcephaly and NC were not significantly associated with any specific ARV analyzed (p > 0.05). Covariates associated with increased odds of NC included male sex (odds ratio [OR] = 1.9; 95% CI: 1.3-2.8), birth weight <2.5 kg (OR = 3.1; 95% CI: 2.1-4.8), 1-min Apgar score <7 (OR = 2.5; 95% CI: 1.4-4.4), and infant infections (OR = 2.5; 95% CI: 1.5-4.1). No ARV investigated was associated with adverse neurologic outcomes. Continued investigation of such associations may be warranted as new ARVs are used during pregnancy and cART exposure during the first trimester becomes increasingly common.
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Affiliation(s)
| | | | - Lucy Civitello
- Department of Neurology, Children's National Medical Center, Washington, District of Columbia
| | - Marisa M. Mussi-Pinhata
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Jorge Pinto
- Division of Immunology, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Jorge O. Alarcón
- Instituto de Medicine Tropical “Daniel Alcides Carrion,” University of San Marcos, Lima, Peru
| | - George K. Siberry
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | | | - Rohan Hazra
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Abstract
BACKGROUND During the last decades remarkable scientific advances have been made toward the prevention of HIV mother-to-child transmission, in particular in developed nations. The aim of this review was to analyze the latest findings and available international recommendations on the prevention of HIV mother-to-child transmission in high-income countries. METHODS We performed a literature search of the Cochrane Library, MEDLINE by PubMed and EMBASE from database inception through June 2014, using the following terms: HIV, mother-to-child transmission and mother-to-child-transmission prevention. All types of articles in the English language were included. US and available European guidelines were searched and included in the analysis. RESULTS One hundred fifty articles were selected for inclusion in this review. CONCLUSIONS Global epidemiology of HIV infection is rapidly evolving, in particular in high-resource countries. The interpretation of clinical and epidemiological studies is crucial for the development of evidence-based recommendations to guide the management of HIV mother-to-child transmission. Although significant progress has been made, heterogeneity between countries in specific interventions still exists, which may address future research.
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Abstract
BACKGROUND Despite a wide body of literature supporting the use of antenatal antiretrovirals (ARV) for the prevention of mother-to-child transmission, there remains a need for continued monitoring as the intrauterine interval is a critical period during which fetal programming influences the future health and development of the child. METHODS We conducted a systematic review of the current literature addressing potential metabolic complications of in utero HIV and ARV exposure. We describe studies evaluating metabolic outcomes such as intrauterine and early postnatal growth, bone health and mitochondrial toxicity. RESULTS Overall, infants exposed to HIV/ARV do not appear to exhibit vastly compromised intrauterine or early postnatal growth. However, some studies on the effect of combination antiretroviral therapy on small for gestational age and low birth weight outcomes in low-middle income countries show a risk for small for gestational age/low birth weight while those in the United States do not. Postnatal growth to 1 year does not appear to be affected by intrauterine tenofovir exposure in African studies, but a US study found statistically significant differences in length for age z scores (LAZ) at 1 year. Little data exists on long-term bone health. Mitochondrial toxicity including abnormal mitochondrial morphology and DNA content, as well as neurologic deficits and death, have been demonstrated in HIV/ARV-exposed infants. CONCLUSION Although gross measures of metabolic well-being appear to be reassuring, careful vigilance of even small risks for potential serious adverse effects to infants exposed to intrauterine HIV/ARVs is warranted as intrauterine fetal metabolic programming may substantially impact the future health of the child.
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Antiretroviral drugs for preventing mother-to-child transmission of HIV: a review of potential effects on HIV-exposed but uninfected children. J Acquir Immune Defic Syndr 2011; 57:290-6. [PMID: 21602695 DOI: 10.1097/qai.0b013e318221c56a] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The provision of antiretroviral drugs for the prevention of mother-to-child HIV transmission has been rising sharply in low- and middle-income countries. Changes to the World Health Organization guidelines support further extension of these programs. The result will be a greatly expanded population of HIV-exposed but uninfected children with substantial exposure to antiretroviral drugs, both in utero and while breastfeeding. There are limited data on possible toxicities in this burgeoning population, and the large number of confounding factors limits any conclusions. Although the evidence on birth defects and mitochondrial toxicity remains equivocal, considerable data link protease inhibitors to preterm delivery and low birth-weight. Transient hematologic toxicities are also likely. The drug impact later in life is an open question. Larger and longer cohort studies are necessary to properly balance the risks and benefits of large-scale infant exposure to antiretroviral agents.
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Karim QA, Banegura A, Cahn P, Christie CDC, Dintruff R, Distel M, Hankins C, Hellmann N, Katabira E, Lehrman S, Montaner J, Purdon S, Rooney JF, Wood R, Heidari S. Asking the right questions: developing evidence-based strategies for treating HIV in women and children. BMC Public Health 2011; 11:388. [PMID: 21612633 PMCID: PMC3118247 DOI: 10.1186/1471-2458-11-388] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 05/25/2011] [Indexed: 11/10/2022] Open
Abstract
In July 2010, the World Health Organization (WHO) issued formal revisions of its guidelines on the use of highly active antiretroviral therapy for HIV. The new guidelines greatly expand eligibility for treatment of adults and children, as well as for pregnant women seeking prophylaxis for vertical HIV transmission. WHO's new recommendations bring the guidelines closer to practices in developed countries, and its shift to earlier treatment alone will increase the number of treatment-eligible people by 50% or more.Scaling up access to HIV treatment is revealing important gaps in our understanding of how best to provide for all those in need. This knowledge gap is especially significant in developing countries, where women and children comprise a majority of those living with HIV infection. Given the magnitude and significance of these populations, the International AIDS Society, through its Industry Liaison Forum, prioritized HIV treatment and prophylaxis of women and children. In March 2010, the International AIDS Society and 15 partners launched a Consensus Statement outlining priority areas in which a relative lack of knowledge impedes delivery of optimal prevention of mother to child transmission (PMTCT) and treatment to women and children.The Consensus Statement, "Asking the Right Questions: Advancing an HIV Research Agenda for Women and Children", makes a special appeal for a more gender-sensitive approach to HIV research at all stages, from conception to design and implementation. It particularly emphasizes research to enhance the understanding of sex-based differences and paediatric needs in treatment uptake and response. In addition to clinical issues, the statement focuses on programmatic research that facilitates access and adherence to antiretroviral regimens. Better coordination of HIV management with sexual and reproductive healthcare delivery is one such approach.We discuss here our knowledge gaps concerning effective, safe PMTCT and treatment for women and children in light of the expansion envisioned by WHO's revised guidelines. The guideline's new goals present an opportunity for advancing the women and children's agenda outlined in the Consensus Statement.
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Affiliation(s)
- Quarraisha Abdool Karim
- Department of Epidemiology, Columbia University, New York, USA
- Prevention and Epidemiology, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | | | - Pedro Cahn
- Direccion Cientifica, Fundacion Huesped, Buenos Aires, Argentina
| | - Celia DC Christie
- Department of Pediatrics, University of the West Indies, Kingston, Jamaica
| | | | - Manuel Distel
- Medical Affairs, Boehringer Ingelheim GmbH, Ingelheim, Germany
| | - Catherine Hankins
- Office of the Deputy Executive Director, UNAIDS, Geneva, Switzerland
| | - Nicholas Hellmann
- Medical and Scientific Affairs, Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - Elly Katabira
- Department of Research, Makerere Medical School, Kampala, Uganda
| | - Sandra Lehrman
- Scientific Affairs - Infectious Diseases, Office of the Chief Medical Officer, Merck & Co, Upper Gwynedd, Pennsylvania, USA
| | - Julio Montaner
- AIDS Research and Head of Division of AIDS, University of British Columbia, Vancouver, Canada
| | - Scott Purdon
- Access and Government Affairs, ViiV Healthcare, Middlesex, UK
| | - James F Rooney
- Medical Affairs, Gilead Sciences, Foster City, California, USA
| | - Robin Wood
- Institute of Infectious Disease and Molecular Medicine, Desmond Tutu HIV Centre, University of Cape Town, South Africa
| | - Shirin Heidari
- Research Promotion, International AIDS Society, Geneva, Switzerland
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