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Eniayewu O, Akinloye A, Shenkoya B, Azuka U, Bolaji O, Adejuyigbe E, Owen A, Olagunju A. Prenatal efavirenz exposure is independently associated with maternal, but not fetal CYP2B6 genotype. Pharmacogenet Genomics 2024:01213011-990000000-00068. [PMID: 38934229 DOI: 10.1097/fpc.0000000000000542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
OBJECTIVES Understanding the influence of fetal and maternal genetics on prenatal drug exposure could potentially improve benefit-risk evaluation. In this study, we investigated the impact of two functional polymorphisms in CYP2B6 on prenatal exposure to efavirenz. METHODS Dried blood spot (DBS) samples were collected from HIV-positive pregnant women (n = 112) and their newborns (n = 107) at delivery. They were genotyped for single nucleotide polymorphisms in CYP2B6. Efavirenz was quantified by liquid chromatography-tandem mass spectrometry (LC-MS/MS). RESULTS Significant correlations were observed in efavirenz concentration between maternal and newborn (r = 0.46, R2 = 0.21, P < 0.001), and maternal and cord (r = 0.83, R2 = 0.68, P < 0.001) samples. Median (interquartile range) newborn plasma-to-maternal plasma and cord-to-maternal plasma ratios were 0.85 (0.03-3.49) and 0.78 (0.23-1.96), respectively. Newborn efavirenz concentration in DBS varied significantly based on composite maternal CYP2B6 genotype: fast (CYP2B6 516GG and 983TT, n = 26), 747 ng/ml (602-1060); intermediate (CYP2B6 516GT or 983TC n = 50), 1177 ng/ml (898-1765); and slow (CYP2B6 516GT and 983TC or 516TT or 983CC, n = 14), 3094 ng/ml (2126-3812). Composite newborn CYP2B6 genotype was, however, not significantly associated with prenatal exposure. Efavirenz concentration in newborn stratified as fast (n = 25), intermediate (n = 36), and slow metabolizers (n = 19) from prenatal exposure was 999.7 (774-1285), 1240 (709-1984), and 1792 ng/ml (1201-3188), respectively. CONCLUSION The clinical relevance of the observed influence of maternal genetics on prenatal efavirenz exposure requires further investigation.
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Affiliation(s)
- Oluwasegun Eniayewu
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife
- Department of Pharmaceutical and Medicinal Chemistry, University of Ilorin, Ilorin
| | | | - Babajide Shenkoya
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife
| | - Uche Azuka
- Department of Obstetrics and Gynaecology, Federal Medical Centre, Makurdi
| | - Oluseye Bolaji
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife
| | - Ebunoluwa Adejuyigbe
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Andrew Owen
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Adeniyi Olagunju
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
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Short CES, Byrne L, Hagan-Bezgin A, Quinlan RA, Anderson J, Brook G, De Alwis O, de Ruiter A, Farrugia P, Fidler S, Hamlyn E, Hartley A, Murphy S, Noble H, Oomeer S, Roedling S, Rosenvinge M, Rubinstein L, Shah R, Singh S, Thorne E, Toby M, Wait B, Sarner L, Taylor GP. Pregnancy Management in HIV Viral Controllers: Twenty Years of Experience. Pathogens 2024; 13:308. [PMID: 38668263 PMCID: PMC11054990 DOI: 10.3390/pathogens13040308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/30/2024] [Accepted: 04/03/2024] [Indexed: 04/29/2024] Open
Abstract
(1) Background: The evidence base for the management of spontaneous viral controllers in pregnancy is lacking. We describe the management outcomes of pregnancies in a series of UK women with spontaneous HIV viral control (<100 copies/mL 2 occasions before or after pregnancy off ART). (2) Methods: A multi-centre, retrospective case series (1999-2021) comparing pre- and post-2012 when guidelines departed from zidovudine-monotherapy (ZDVm) as a first-line option. Demographic, virologic, obstetric and neonatal information were anonymised, collated and analysed in SPSS. (3) Results: A total of 49 live births were recorded in 29 women, 35 pre-2012 and 14 post. HIV infection was more commonly diagnosed in first reported pregnancy pre-2012 (15/35) compared to post (2/14), p = 0.10. Pre-2012 pregnancies were predominantly managed with ZDVm (28/35) with pre-labour caesarean section (PLCS) (24/35). Post-2012 4/14 received ZDVm and 10/14 triple ART, p = 0.002. Post-2012 mode of delivery was varied (5 vaginal, 6 PLCS and 3 emergency CS). No intrapartum ZDV infusions were given post-2012 compared to 11/35 deliveries pre-2012. During pregnancy, HIV was detected (> 50 copies/mL) in 14/49 pregnancies (29%) (median 92, range 51-6084). Neonatal ZDV post-exposure prophylaxis was recorded for 45/49 infants. No transmissions were reported. (4) Conclusion: UK practice has been influenced by the change in guidelines, but this has had little impact on CS rates.
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Affiliation(s)
- Charlotte-Eve S. Short
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- Imperial College NIHR BRC, Imperial College London, London W2 1NY, UK
- Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Laura Byrne
- School of Medicine, St Georges, University of London, London SW17 0RE, UK
- St. George’s University Hospitals NHS Trust, London SW17 0RE, UK
| | - Aishah Hagan-Bezgin
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- School of Medicine, University of Liverpool, Liverpool L69 3GE, UK
| | - Rachael A. Quinlan
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- Imperial College NIHR BRC, Imperial College London, London W2 1NY, UK
| | - Jane Anderson
- Homerton Healthcare NHS Foundation Trust, London E9 6SR, UK
- London North West University Healthcare NHS Trust, Harrow HA1 3UJ, UK
| | - Gary Brook
- London North West University Healthcare NHS Trust, Harrow HA1 3UJ, UK
| | | | - Annemiek de Ruiter
- Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
- ViiV Healthcare, Brentford TW8 9GS, UK
| | - Pippa Farrugia
- Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Sarah Fidler
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- Imperial College NIHR BRC, Imperial College London, London W2 1NY, UK
- Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Eleanor Hamlyn
- Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Anna Hartley
- Barts Health NHS Trust, London E1 1BB, UK
- Leeds University Teaching Hospital NHS Trust, Leeds LS1 3EX, UK
| | - Siobhan Murphy
- London North West University Healthcare NHS Trust, Harrow HA1 3UJ, UK
| | | | - Soonita Oomeer
- Imperial College Healthcare NHS Trust, London W2 1NY, UK
- Central and North West London NHS Foundation Trust, London NW1 3AX, UK
| | - Sherie Roedling
- Central and North West London NHS Foundation Trust, London NW1 3AX, UK
| | | | | | - Rimi Shah
- Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | | | - Elizabeth Thorne
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | | | - Brenton Wait
- Homerton Healthcare NHS Foundation Trust, London E9 6SR, UK
| | | | - Graham P. Taylor
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- Imperial College NIHR BRC, Imperial College London, London W2 1NY, UK
- Imperial College Healthcare NHS Trust, London W2 1NY, UK
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Paulsen FW, Tetens MM, Vollmond CV, Gerstoft J, Kronborg G, Johansen IS, Larsen CS, Wiese L, Dalager-Pedersen M, Lunding S, Nielsen LN, Weis N, Obel N, Omland LH, Lebech AM. Incidence of Childbirth, Pregnancy, Spontaneous Abortion, and Induced Abortion Among Women With Human Immunodeficiency Virus in a Nationwide Matched Cohort Study. Clin Infect Dis 2023; 76:1896-1902. [PMID: 36718956 DOI: 10.1093/cid/ciad053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/22/2023] [Accepted: 01/25/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Reproductive health in women with human immunodeficiency virus (HIV) (WWH) has improved in recent decades. We aimed to investigate incidences of childbirth, pregnancy, spontaneous abortion, and induced abortion among WWH in a nationwide, population-based, matched cohort study. METHODS We included all WWH aged 20-40 years treated at an HIV healthcare center in Denmark from 1995 to 2021 and a matched comparison cohort of women from the general population (WGP). We calculated incidence rates per 1000 person-years and used Poisson regression to calculate adjusted incidence rate ratios (aIRRs) of childbirth, pregnancy, spontaneous abortion, and induced abortion stratified according to calendar periods (1995-2001, 2002-2008, and 2009-2021). RESULTS We included 1288 WWH and 12 880 WGP; 46% of WWH were of African origin, compared with 1% of WGP. Compared with WGP, WWH had a decreased incidence of childbirth (aIRR, 0.6 [95% confidence interval, .6-.7]), no difference in the incidence of pregnancy (0.9 [.8-1.0]) or spontaneous abortion (0.9 [.8-1.0]), but an increased incidence of induced abortion (1.9 [1.6-2.1]) from 1995 to 2021. The aIRRs for childbirth, pregnancy, and spontaneous abortion increased from 1995-2000 to 2009-2021, while the aIRR for induced abortion remained increased across all time periods for WWH. CONCLUSIONS From 1995 to 2008, the incidences of childbirth, pregnancy, and spontaneous abortion were decreased among WWH compared with WGP. From 2009 to 2021, the incidence of childbirth, pregnancy, and spontaneous abortion no longer differed among WWH compared with WGP. The incidence of induced abortions remains increased compared with WGP.
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Affiliation(s)
- Fie W Paulsen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Malte M Tetens
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Cecilie V Vollmond
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jan Gerstoft
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Gitte Kronborg
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
| | - Isik S Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Carsten S Larsen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Lothar Wiese
- Department of Infectious Diseases, Zealand University Hospital, Roskilde, Denmark
| | - Michael Dalager-Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Suzanne Lunding
- Department of Internal Medicine, Copenhagen University Hospital, Herlev, Herlev, Denmark
| | - Lars N Nielsen
- Department of Infectious Diseases, Copenhagen University Hospital, North Zealand Hospital, Hillerød, Denmark
| | - Nina Weis
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars H Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Abstract
Objective: To investigate the characteristics and outcomes of people who initiated different antiretroviral therapy (ART) regimens during the era of integrase strand transfer inhibitors (INSTIs). Design: UK-based observational cohort study. Methods: UK Collaborative HIV Cohort study participants were included if they had started ART between 1 January 2012 and 30 June 2017. Virological failure was defined as the first of two consecutive plasma HIV RNA more than 50 copies/ml, at least 6 months after starting ART. Follow-up was censored at ART discontinuation, class switch or death. The risk of virological failure among those on INSTI, protease inhibitor or nonnucleoside reverse transcriptase inhibitor (NNRTI) regimens was compared using Kaplan–Meier and Cox regression methods. Results: Of 12 585 participants, 45.6% started a NNRTI, 29.0% a protease inhibitor and 25.4% an INSTI regimen. Over a median follow-up of 20.3 months (interquartile range 7.9–38.9), 7.5% of participants experienced virological failure. Compared with those starting an NNRTI regimen, people receiving INSTIs or protease inhibitors were more likely to experience virological failure: INSTI group adjusted hazard ratio 1.52, 95% confidence interval 1.19–1.95, P = 0.0009; protease inhibitor group adjusted hazard ratio 2.70, 95% confidence interval 2.27–3.21, P less than 0.0001, likelihood ratio test P less than 0.0001. Conclusion: First-line INSTI regimens were associated with a lower risk of virological failure than protease inhibitor regimens but both groups were more likely to experience virological failure than those initiating treatment with a NNRTI. There is likely to be residual channelling bias resulting from selected use of INSTIs and protease inhibitors in specific clinical contexts, including in those with a perceived risk of poor adherence.
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Tulloch KJ, Dodin P, Tremblay‐Racine F, Elwood C, Money D, Boucoiran I. Cabergoline: a review of its use in the inhibition of lactation for women living with HIV. J Int AIDS Soc 2019; 22:e25322. [PMID: 31183987 PMCID: PMC6558502 DOI: 10.1002/jia2.25322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 05/22/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION In developed countries, breastfeeding is not recommended for women living with human immunodeficiency virus (WLWH). However, lactation symptoms can be distressing for women who choose not to breastfeed. There is currently no universal guideline on the most appropriate options for prevention or reduction of lactation symptoms amongst WLWH. This review describes the evidence base for using cabergoline, a dopaminergic agonist, for the post-partum inhibition of lactation for WLWH. METHODS A scoping review of post-partum pharmaceutical lactation inhibition specific for WLWH was conducted using searches in PubMed, Medline Ovid, EBM Reviews Ovid, Embase, Web of Science and Scopus until 2019. A narrative review of cabergoline pharmacologic properties, therapeutic efficacy, tolerability data and drug interaction data relevant to lactation inhibition was then conducted. RESULTS AND DISCUSSION Among 1366 articles, the scoping review identified 13 relevant publications. Eight guidelines providing guidance regarding lactation inhibition for WLWH and two surveys of medical practice on this topic in UK have been published. Three studies have evaluated the use of pharmaceutical agents in WLWH. Two of these studies evaluated cabergoline and reported it to be an effective method of lactation inhibition in this population. The third study evaluated ethinyl estradiol and bromocriptine use and showed poor efficacy. Cabergoline is a long-acting dopamine D2 agonist and ergot derivative that inhibits prolactin secretion and suppresses physiologic lactation when given as a single oral dose of 1 mg after delivery. Cabergoline is at least as effective as bromocriptine for lactation inhibition with success rates between 78% and 100%. Transient, mild to moderate adverse events to cabergoline are described in clinical trials. Few drug interactions exist as cabergoline is neither a substrate nor an inducer/inhibitor of hepatic cytochrome P450 isoenzymes. There are no reported clinically significant drug-drug interactions between cabergoline and any antiretroviral medications including protease inhibitors. CONCLUSIONS Cabergoline is a safe and effective pharmacologic option for the prevention of physiological lactation and associated physical symptoms in non-breastfeeding women. Future studies should focus on its safety, efficacy and acceptability among WLWH.
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Affiliation(s)
- Karen J Tulloch
- Department of PharmacyBC Women's Hospital and Health CentreVancouverBCCanada
- Women's Health Research InstituteVancouverBCCanada
| | | | | | - Chelsea Elwood
- Women's Health Research InstituteVancouverBCCanada
- Department of Obstetrics and GynaecologyUniversity of British ColumbiaVancouverBCCanada
| | - Deborah Money
- Women's Health Research InstituteVancouverBCCanada
- Department of Obstetrics and GynaecologyUniversity of British ColumbiaVancouverBCCanada
| | - Isabelle Boucoiran
- Department of Obstetrics and GynecologyCHU Sainte‐JustineUniversité de MontréalMontrealQCCanada
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Thai national guidelines for the prevention of motherto- child transmission of HIV: March 2010. ASIAN BIOMED 2018. [DOI: 10.2478/abm-2010-0067] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Thailand has been one of the leading developing countries to implement a national program to prevent mother-to-child transmission (MTCT) of HIV. Although the recent transmission rate has been low, the goal is to eliminate MTCT altogether. The Thai National HIV Guidelines Working Group issued treatment guidelines to prevent MTCT in Thailand in March 2010. These guidelines will be implemented nationwide within a year. The most important aspects of these new guidelines are as follows: Treatment in HIV-infected pregnant women who have not been on antiretroviral treatment prior to pregnancy. Antepartum treatment is recommended for all pregnant women regardless of CD4 count with highly active antiretroviral therapy (HAART) containing zidovudine (AZT) + lamivudine (3TC) + lopinavir/ritonavir (LPV/r). Treatment should be started immediately irrespective of gestational age in women with CD4 count <350 cells/ mm3, and as early as 14 weeks of gestation in those with CD4 count >350 cells/mm3. After delivery, women with baseline CD4 count <350 cells/mm3 are referred for long-term care and HAART according to the National Adult HIV Treatment and Care Guidelines 2010. Women with CD4 count >350 cells/mm3 do not need HAART and can stop all drugs after delivery. The treatment in infants includes AZT syrup for four weeks and exclusive formula feeding. Treatment in HIV-infected pregnant women who conceive while on HAART. Women who are stable on HAART should continue the treatment during the whole period of pregnancy. Those who are taking efavirenz (EFV) and present during the first trimester should have EFV switched to another drug. Whenever possible, AZT should be used during pregnancy. Treatment in infants is similar to the above scenario. Treatment in women who present in labor without antenatal care. Single-dose nevirapine (SD-NVP) 200 mg must be given immediately along with oral AZT 300 mg every three hours until delivery, or oral AZT 600 mg given as a single dose. The tail therapy of AZT + 3TC + LPV/r for four weeks should be given unless these women have a CD4 count of <350 cells/mm3 and therefore require life-long HAART. SD-NVP should not be given if the women are to deliver within two hours. The infants in this situation should receive AZT + 3TC + NVP for four weeks. Treatment during delivery and mode of delivery. During labor, oral AZT 300 mg every three hours or oral AZT 600 mg given as a single dose is recommended regardless of antepartum antiretroviral (ARV) regimen or the woman’s history of AZT resistance. Elective caesarean section is suggested in women who did not receive HAART (including those without antenatal care), received HAART for less than four weeks prior to delivery, had poor adherence, or had incomplete viral suppression at 36 weeks of gestation.
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Williams PL, Huo Y, Rutstein R, Hazra R, Rough K, Van Dyke RB, Chadwick EG, for the Pediatric HIV/AIDS Cohort S. Trends in Neonatal Prophylaxis and Predictors of Combination Antiretroviral Prophylaxis in US Infants from 1990 to 2015. AIDS Patient Care STDS 2018; 32:48-57. [PMID: 30346801 DOI: 10.1089/apc.2017.0295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Postnatal antiretroviral (ARV) prophylaxis for infants born to women with HIV is a critical component of perinatal HIV transmission prevention. However, variability in prophylaxis regimens remains and consistency with guidelines has not been evaluated in the United States. We evaluated trends over time in prophylaxis regimens among 6386 HIV-exposed uninfected (HEU) infants using pooled data spanning two decades from three US-based cohorts: the Women and Infants Transmission Study (WITS, 1990-2007), Pediatric AIDS Clinical Trials Group (PACTG) 219C (1993-2007), and the PHACS Surveillance Monitoring of ART Toxicities (SMARTT) study (2007-2015). We also identified maternal and infant risk factors for use of combination prophylaxis regimens (≥2 ARVs) and examined consistency with US perinatal guidelines. We found that receipt of combination prophylaxis between 1996 and 2015 ranged from 2% to 15%, with a consistent median duration of 6 weeks. Infants whose mothers had lower CD4 T-cell counts, higher viral load (VL), no antepartum ARVs, age <20 years at delivery, and Cesarean delivery had significantly higher rates of combination prophylaxis, while infants born 2006-2010 (vs. 2011-2015), who were Hispanic or with lower maternal education levels, had significantly lower rates. Predictors for combination prophylaxis varied over time, with the strongest associations of maternal VL in later birth cohorts. While use of combination prophylaxis increased over time, only 50% of high-risk infants received such regimens in 2011-2015. In conclusion, HEU infants at higher risk of HIV acquisition are more likely to receive combination neonatal prophylaxis, consistent with US guidelines. However, substantial variability remains, and infants at higher risk often fail to receive combination prophylaxis.
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Affiliation(s)
- Paige L. Williams
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- 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
| | - Richard Rutstein
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rohan Hazra
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Kathryn Rough
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Russell B. Van Dyke
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana
| | - Ellen G. Chadwick
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Ørbaek M, Thorsteinsson K, Helleberg M, Moseholm E, Katzenstein TL, Storgaard M, Johansen IS, Pedersen G, Weis N, Lebech AM. Assessment of mode of delivery and predictors of emergency caesarean section among women living with HIV in a matched-pair setting with women from the general population in Denmark, 2002-2014. HIV Med 2017; 18:736-747. [PMID: 28544321 DOI: 10.1111/hiv.12519] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We aimed to assess mode of delivery and predictors of emergency caesarean section (EmCS) in women living with HIV (WLWH) in a matched-pair setting with women from the general population (WGP) in Denmark. Further, we analysed birth plan in WLWH. METHODS All WLWH giving birth to live-born children from 2002 to 2014 were included in the study. Data were retrieved from medical records and national registries. WLWH were matched 1:5 by age, birth year, parity and ethnicity to WGP. Multivariate logistic regression was used to estimate predictors. RESULTS We included 389 WLWH and 1945 WGP in the study. At delivery, all WLWH were on antiretroviral therapy and 85.6% had HIV RNA <40 HIV-1 RNA copies/mL. Mean age was 32.7 years [95% confidence interval (CI) 32.1-33.2 years]. Mode of delivery differed significantly between WLWH and WGP [vaginal delivery, 33.4% versus 73.3%, respectively; elective caesarean section (ECS), 40.6% versus 9.7%, respectively; EmCS, 26% versus 17%, respectively; P < 0.0001]. Age > 40 years [adjusted odds ratio (aOR) 2.3; 95% CI 1.5-3.5], asphyxia (aOR 3.2; 95% CI 2.4-4.1), delivery during the evening and at night [aOR 2.3 (95% CI 1.7-3.0) and aOR 2.0 (95% CI 1.5-2.7), respectively], preterm delivery (aOR 3.8; 95% CI 2.6-5.6) and premature rupture of membranes (aOR 3.0; 95% CI 2.1-4.4) predicted EmCS. WLWH had a higher risk of EmCS compared with WGP [2002-2006, aOR 2.0 (95% CI 1.2-3.3); 2007-2008, aOR 2.9 (95% CI 1.4-5.9); 2009-2014, aOR 2.6 (95% CI 1.7-3.9)]. After 2007, more than half of WLWH planned to deliver vaginally. Prior caesarean section was associated with ECS (aOR 11.0; 95% CI 4.5-26.8). No mother-to-child transmission occurred. CONCLUSIONS Increasing numbers of WLWH deliver vaginally. Despite virological suppression, more WLWH plan and deliver by ECS than WGP. WLWH had a twofold higher risk of EmCS compared with WGP.
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Affiliation(s)
- M Ørbaek
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
| | - K Thorsteinsson
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
| | - M Helleberg
- Department of Infectious Diseases, The National University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - E Moseholm
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
| | - T L Katzenstein
- Department of Infectious Diseases, The National University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - M Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Denmark
| | - I S Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - G Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - N Weis
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - A-M Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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French CE, Thorne C, Byrne L, Cortina‐Borja M, Tookey PA. Presentation for care and antenatal management of HIV in the UK, 2009-2014. HIV Med 2017; 18:161-170. [PMID: 27476457 PMCID: PMC5298001 DOI: 10.1111/hiv.12410] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Despite very low rates of vertical transmission of HIV in the UK overall, rates are higher among women starting antenatal antiretroviral therapy (ART) late. We investigated the timing of key elements of the care of HIV-positive pregnant women [antenatal care booking, HIV laboratory assessment (CD4 count and HIV viral load) and antenatal ART initiation], to assess whether clinical practice is changing in line with recommendations, and to investigate factors associated with delayed care. METHODS We used the UK's National Study of HIV in Pregnancy and Childhood for 2009-2014. Data were analysed by fitting logistic regression and Cox proportional hazards models. RESULTS A total of 5693 births were reported; 79.5% were in women diagnosed with HIV prior to that pregnancy. Median gestation at antenatal booking was 12.1 weeks [interquartile range (IQR) 10.0-15.6 weeks] and booking was significantly earlier during 2012-2014 vs. 2009-2011 (P < 0.001), although only in previously diagnosed women. Overall, 42.2% of pregnancies were booked late (≥ 13 gestational weeks). Among women not already on treatment, antenatal ART commenced at a median of 21.4 (IQR18.1-24.5) weeks and started significantly earlier in the most recent time period (P < 0.001). Compared with previously diagnosed women, those newly diagnosed during the current pregnancy booked later for antenatal care and started antenatal ART later (both P < 0.001). Multivariable analyses revealed demographic variations in access to or uptake of care, with groups including migrants and parous women initiating care later. CONCLUSIONS Although women are accessing antenatal and HIV care earlier in pregnancy, some continue to face barriers to timely initiation of antenatal care and ART.
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Affiliation(s)
- CE French
- Population, Policy and Practice ProgrammeUCL Institute of Child HealthUniversity College LondonLondonUK
| | - C Thorne
- Population, Policy and Practice ProgrammeUCL Institute of Child HealthUniversity College LondonLondonUK
| | - L Byrne
- Population, Policy and Practice ProgrammeUCL Institute of Child HealthUniversity College LondonLondonUK
| | - M Cortina‐Borja
- Population, Policy and Practice ProgrammeUCL Institute of Child HealthUniversity College LondonLondonUK
| | - PA Tookey
- Population, Policy and Practice ProgrammeUCL Institute of Child HealthUniversity College LondonLondonUK
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Eke AC, Eleje GU, Eke UA, Xia Y, Liu J. Hepatitis B immunoglobulin during pregnancy for prevention of mother-to-child transmission of hepatitis B virus. Cochrane Database Syst Rev 2017; 2:CD008545. [PMID: 28188612 PMCID: PMC6464495 DOI: 10.1002/14651858.cd008545.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatitis is a viral infection of the liver. It is mainly transmitted between people through contact with infected blood, frequently from mother to baby in-utero. Hepatitis B poses significant risk to the fetus and up to 85% of infants infected by their mothers at birth develop chronic hepatitis B virus (HBV) infection. Hepatitis B immunoglobulin (HBIG) is a purified solution of human immunoglobulin that could be administered to the mother, newborn, or both. HBIG offers protection against HBV infection when administered to pregnant women who test positive for hepatitis B envelope antigen (HBeAg) or hepatitis B surface antigen (HBsAg), or both. When HBIG is administered to pregnant women, the antibodies passively diffuse across the placenta to the child. This materno-fetal diffusion is maximal during the third trimester of pregnancy. Up to 1% to 9% infants born to HBV-carrying mothers still have HBV infection despite the newborn receiving HBIG plus active HBV vaccine in the immediate neonatal period. This suggests that additional intervention such as HBIG administration to the mother during the antenatal period could be beneficial to reduce the transmission rate in utero. OBJECTIVES To determine the benefits and harms of hepatitis B immunoglobulin (HBIG) administration to pregnant women during their third trimester of pregnancy for the prevention of mother-to-child transmission of hepatitis B virus infection. SEARCH METHODS We searched the The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, Science Citation Index Expanded (Web of Science), SCOPUS, African Journals OnLine, and INDEX MEDICUS up to June 2016. We searched ClinicalTrials.gov and portal of the WHO International Clinical Trials Registry Platform (ICTRP) in December 2016. SELECTION CRITERIA We included randomised clinical trials comparing HBIG versus placebo or no intervention in pregnant women with HBV. DATA COLLECTION AND ANALYSIS Two authors extracted data independently. We analysed dichotomous outcome data using risk ratio (RR) and continuous outcome data using mean difference (MD) with 95% confidence intervals (CI). For meta-analyses, we used a fixed-effect model and a random-effects model, along with an assessment of heterogeneity. If there were statistically significant discrepancies in the results, we reported the more conservative point estimate. If the two estimates were equal, we used the estimate with the widest CI as our main result. We assessed bias control using the Cochrane Hepato-Biliary Group suggested bias risk domains and risk of random errors using Trial Sequential Analysis (TSA). We assessed the quality of the evidence using GRADE. MAIN RESULTS All 36 included trials originated from China and were at overall high risk of bias. The trials included 6044 pregnant women who were HBsAg, HBeAg, or hepatitis B virus DNA (HBV-DNA) positive. Only seven trials reported inclusion of HBeAg-positive mothers. All 36 trials compared HBIG versus no intervention. None of the trials used placebo.Most of the trials assessed HBIG 100 IU (two trials) and HBIG 200 IU (31 trials). The timing of administration of HBIG varied; 30 trials administered three doses of HBIG 200 IU at 28, 32, and 36 weeks of pregnancy. None of the trials reported all-cause mortality or other serious adverse events in the mothers or babies. Serological signs of hepatitis B infection of the newborns were reported as HBsAg, HBeAg, and HBV-DNA positive results at end of follow-up. Twenty-nine trials reported HBsAg status in newborns (median 1.2 months of follow-up after birth; range 0 to 12 months); seven trials reported HBeAg status (median 1.1 months of follow-up after birth; range 0 to 12 months); and 16 trials reported HBV-DNA status (median 1.2 months of follow-up; range 0 to 12 months). HBIG reduced mother-to-child transmission (MTCT) of HBsAg when compared with no intervention (179/2769 (6%) with HBIG versus 537/2541 (21%) with no intervention; RR 0.30, TSA-adjusted CI 0.20 to 0.52; I2 = 36%; 29 trials; 5310 participants; very low quality evidence). HBV-DNA reduced MTCT of HBsAg (104/1112 (9%) with HBV-DNA versus 382/1018 (38%) with no intervention; RR 0.25, TSA-adjusted CI 0.22 to 0.27; I2 = 84%; 16 trials; 2130 participants; low quality evidence). TSA supported both results. Meta-analysis showed that maternal HBIG did not decrease HBeAg in newborns compared with no intervention (184/889 (21%) with HBIG versus 232/875 (27%) with no intervention; RR 0.68, TSA-adjusted CI 0.04 to 6.37; I2 = 90%; 7 trials; 1764 participants; very low quality evidence). TSA could neither support nor refute this observation as data were too sparse. None of the trials reported adverse events of the immunoglobulins on the newborns, presence of local and systemic adverse events on the mothers, or cost-effectiveness of treatment. AUTHORS' CONCLUSIONS Due to very low to low quality evidence found in this review, we are uncertain of the effect of benefit of antenatal HBIG administration to the HBV-infected mothers on newborn outcomes, such as HBsAg, HBV-DNA, and HBeAg compared with no intervention. The results of the effects of HBIG on HBsAg and HBeAg are surrogate outcomes (raising risk of indirectness), and we need to be critical while interpreting the findings. We found no data on newborn mortality or maternal mortality or both, or other serious adverse events. Well-designed randomised clinical trials are needed to determine the benefits and harms of HBIG versus placebo in prevention of MTCT of HBV.
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Affiliation(s)
- Ahizechukwu C Eke
- Johns Hopkins University School of MedicineDivision of Maternal Fetal Medicine, Department of Gynecology and Obstetrics600 N Wolfe StreetPhipps 228BaltimoreMarylandUSA21287‐1228
| | - George U Eleje
- Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Nnewi CampusEffective Care Research Unit, Department of Obstetrics and GynaecologyPMB 5001, NnewiAnambra StateNigeria
| | - Uzoamaka A Eke
- University of Connecticut Health CenterDepartment of Infectious Diseases263 Farmington AvenueFarmingtonConnecticutUSA06053
| | - Yun Xia
- Beijing University of Chinese Medicine Subsidiary Dongfang HospitalScience of EducationNo.6 District 1 Fangxingyuan, Fangzhuang, Fengtai DistrictBeijingChina100078
| | - Jiao Liu
- Beijing University of Chinese Medicine Subsidiary Dongfang HospitalNo.6 District 1 Fangxingyuan, Fangzhuang, Fengtai DistrictBeijingChina100078
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Abstract
In this article we investigate the way in which viral load assays are used to assess the viruses of Human Immunodeficiency Virus (HIV)-positive pregnant women who are cared for in an HIV-specialist antenatal clinic in London. One of the viral load assays has been made more sensitive to subtypes of the virus that are considered to be local, possibly reading the viruses of those who have ‘foreign’ subtypes as undetectable. Consequently, the patient might not be offered the kind of care needed to prevent transmission of HIV, as her body is not recognised as sufficiently debilitated. Thus, being identified as a debilitated body in this setting facilitates the prevention of vertical transmission of HIV and the management of the HIV-positive pregnant patient's virus. Further to this, we argue that in our example, having a debilitated body as constructed by the viral load assay is thus a ‘privilege’ that is accorded to HIV-positive persons depending on the geographic origin of their virus. Using Karen Barad's agential realism, we argue that the manner in which HIV is read through the viral load assay constructs a specific woman/foetus/HIV phenomenon. The specificity of this phenomenon directly impacts on the course of care, opening up or foreclosing the possibility of her child having a future free from HIV.
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12
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Abstract
The objective of this study is to assess the risk of viral rebound in postpartum women on suppressive combination antiretroviral therapy (cART).
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de Ruiter A, Taylor GP, Clayden P, Dhar J, Gandhi K, Gilleece Y, Harding K, Hay P, Kennedy J, Low-Beer N, Lyall H, Palfreeman A, O'Shea S, Tookey P, Tosswill J, Welch S, Wilkins E. British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review). HIV Med 2015; 15 Suppl 4:1-77. [PMID: 25604045 DOI: 10.1111/hiv.12185] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Renet S, Closon A, Brochet MS, Bussières JF, Boucher M. Increase in transaminase levels following the use of raltegravir in a woman with a high HIV viral load at 35 weeks of pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 35:68-72. [PMID: 23343800 DOI: 10.1016/s1701-2163(15)31051-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite the efficacy of raltegravir in reducing viral load in HIV-infected patients, evidence for its safety in late pregnancy is lacking. A high rate of placental transfer was recently demonstrated. CASE A treatment-naïve 34-year-old HIV-1-positive woman of African origin began treatment with zidovudine/lamivudine, lopinavir/ritonavir, and raltegravir at 35 weeks of pregnancy. After 11 days of treatment with raltegravir, a substantial reduction in viral load was achieved. Concurrently, she had a 23-fold increase in serum alanine aminotransferase and a 10-fold increase in serum aspartate aminotransferase, both of which returned to normal when raltegravir treatment was discontinued. A healthy boy was delivered at term. The infant's tests for HIV were negative at five months, and he had no health problems at eight months. CONCLUSION This is the first case report, to our knowledge, of increased maternal serum transaminase levels following the use of raltegravir in a woman at a late stage of pregnancy.
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Affiliation(s)
- Sophie Renet
- Pharmacy Practice Research Unit (PPRU), CHU Sainte-Justine, Montreal QC, Pharmacy Department, Paris-Descartes University, Paris, France
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15
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Abstract
OBJECTIVES To analyze mother-to-child HIV transmission (MTCT) rates over time in light of changes in management, demographic, and pregnancy characteristics. DESIGN Population-based surveillance data on diagnosed HIV-positive women and their infants are routinely collected in the UK and Ireland. METHODS A total of 12486 singleton pregnancies delivered in 2000-2011 were analyzed. HIV infection status was available for 11515 infants (92.2%). RESULTS The rate of MTCT declined from 2.1% (17/816) in 2000-2001 to 0.46% (nine of 1975, 95% confidence interval: 0.21-0.86%) in 2010-2011 (trend, P=0.01), because of a combination of factors including earlier initiation of antenatal combination antiretroviral therapy (cART). Excluding 63 infants who were breastfed or acquired HIV postnatally, MTCT risk was significantly higher for all modes of delivery in women with viral load of 50-399 copies/ml (1.0%, 14/1349), compared with viral load of less than 50 copies/ml (0.09%, six of 6347, P<0.001). Among the former (viral load 50-399 copies/ml), the risk of MTCT was 0.26% (two of 777) following elective cesarean section and 1.1% (two of 188) following planned vaginal delivery (P=0.17), excluding in-utero transmissions. MTCT probability declined rapidly with each additional week of treatment initially, followed by a slower decline up to about 15 weeks of cART, with substantial differences by baseline viral load. CONCLUSION MTCT rates in the UK and Ireland have continued to decline since 2006, reaching an all-time low of 5 per 1000 in 2010-2011. This was primarily because of a reduction in transmissions associated with late initiation or nonreceipt of antenatal cART, and an increase in the proportion of women on cART at conception.
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16
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Randomized clinical trial comparing the pharmacokinetics of standard- and increased-dosage lopinavir-ritonavir coformulation tablets in HIV-positive pregnant women. Antimicrob Agents Chemother 2014; 58:2884-93. [PMID: 24614377 DOI: 10.1128/aac.02599-13] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A lopinavir-ritonavir (LPV/r)-based regimen is recommended during pregnancy to reduce the risk of HIV mother-to-child transmission, but the appropriate dose is controversial. We compared the pharmacokinetics of standard and increased LPV/r doses during pregnancy. This randomized, open-label prospective study enrolled 60 pregnant women between gestational weeks 14 and 30. The participants received either the standard dose (400/100 mg twice a day [BID]) or increased dose (600/150 mg BID) of LPV/r tablets during pregnancy and the standard dose for 6 weeks after childbirth. Pharmacokinetics analysis was performed using a high-performance liquid chromatography-tandem mass spectrometry method. Adherent participants who received the standard dose presented minimum LPV concentrations of 4.4, 4.3, and 6.1 μg/ml in the second and third trimesters and postpartum, respectively. The increased-dose group exhibited values of 7.9, 6.9, and 9.2 μg/ml at the same three time points. Although LPV exposure was significantly higher in the increased-dose group, the standard dose produced therapeutic levels of LPV against wild-type virus in all adherent participants, except one patient in the third trimester; 50%, 37.5%, and 25%, and 0%, 15%, and 0% of the participants in the standard- and increased-dose groups failed to achieve therapeutic levels against resistant viruses during the second and third trimesters and after childbirth, respectively. After 12 weeks of treatment and after childbirth, all adherent participants achieved undetectable HIV viral loads, and their babies (49/54) were uninfected. No serious drug-related adverse events were observed. We conclude that the standard dose is appropriate for use during pregnancy and that an increased dose may be necessary for women harboring resistant HIV. (This study has been registered at ClinicalTrials.gov under registration no. NCT00605098.).
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[Consensus statement on monitoring of HIV: pregnancy, birth, and prevention of mother-to-child transmission]. Enferm Infecc Microbiol Clin 2014; 32:310.e1-310.e33. [PMID: 24484733 DOI: 10.1016/j.eimc.2013.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 12/02/2013] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The main objective in the management of HIV-infected pregnant women is prevention of mother-to-child transmission; therefore, it is essential to provide universal antiretroviral treatment, regardless of CD4 count. All pregnant women must receive adequate information and undergo HIV serology testing at the first visit. METHODS We assembled a panel of experts appointed by the Secretariat of the National AIDS Plan (SPNS) and the other participating Scientific Societies, which included internal medicine physicians with expertise in the field of HIV infection, gynecologists, pediatricians and psychologists. Four panel members acted as coordinators. Scientific information was reviewed in publications and conference reports up to November 2012. In keeping with the criteria of the Infectious Diseases Society of America, 2levels of evidence were applied to support the proposed recommendations: the strength of the recommendation according to expert opinion (A, B, C), and the level of empirical evidence (I, II, III). This approach has already been used in previous documents from SPNS. RESULTS AND CONCLUSIONS The aim of this paper was to review current scientific knowledge, and, accordingly, develop a set of recommendations regarding antiretroviral therapy (ART), regarding the health of the mother, and from the perspective of minimizing mother-to-child transmission (MTCT), also taking into account the rest of the health care of pregnant women with HIV infection. We also discuss and evaluate other strategies to reduce the MTCT (elective Cesarean, child's treatment…), and different aspects of the topic (ARV regimens, their toxicity, monitoring during pregnancy and postpartum, etc.).
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Briand N, Jasseron C, Sibiude J, Azria E, Pollet J, Hammou Y, Warszawski J, Mandelbrot L. Cesarean section for HIV-infected women in the combination antiretroviral therapies era, 2000-2010. Am J Obstet Gynecol 2013; 209:335.e1-335.e12. [PMID: 23791563 DOI: 10.1016/j.ajog.2013.06.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 05/05/2013] [Accepted: 06/12/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Elective cesarean section (CS) is a proven method to prevent mother-to-child transmission (MTCT), but is no longer recommended for women with antiretroviral therapy resulting in a low viral load (VL): <400 copies/mL in French and <1000 copies/mL in US guidelines. We sought to describe mode of delivery practices in human immunodeficiency virus (HIV)-infected women and their association with MTCT and postpartum complications. STUDY DESIGN All deliveries from HIV-1-infected women in the French Perinatal Cohort (Agence Nationale de Recherches sur le Sida/Enquête Périnatale Française) 2000 through 2010 (N = 8977) were analyzed, with additional details for 2005 through 2010 (n = 4717). RESULTS Vaginal deliveries increased from 25% in 2000 to 53% in 2010. Over 2005 through 2010, 4300 women had VL before delivery <400 copies/mL; among them only 49.3% delivered vaginally, 22.0% had nonelective CS, and 28.7% had elective CS. Elective CS were performed for scarred uterus in 45.4%, other obstetrical indications in 37.1%, and solely because of HIV in 15.7%. Of the 417 women with VL ≥400 copies/mL, 48.9% had elective CS as recommended, 25.9% had nonelective CS, and 25.2% had vaginal delivery. The MTCT rate did not differ according to the mode of delivery in term deliveries (≥37 gestational weeks) in 2000 through 2010: 0.3% after both vaginal delivery and elective CS with VL <50 copies/mL, 4.0% vs 5.3%, respectively, with VL ≥10,000 copies/mL. In case of preterm delivery, MTCT rates tended to be higher with vaginal delivery. Postpartum complications were more frequent following CS than vaginal deliveries (6.5% vs 2.9, P < .01). CONCLUSION Our findings suggest that HIV-infected women on antiretroviral therapy with low VL can safely opt for vaginal delivery in the absence of obstetrical risk factors.
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Affiliation(s)
- Nelly Briand
- Inserm, Center for Research in Epidemiology and Population Health U1018, Le Kremlin-Bicêtre, France; Université Paris-Sud, Le Kremlin-Bicêtre, France
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Short CES, Douglas M, Smith JH, Taylor GP. Preterm delivery risk in women initiating antiretroviral therapy to prevent HIV mother-to-child transmission. HIV Med 2013; 15:233-8. [DOI: 10.1111/hiv.12083] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2013] [Indexed: 11/29/2022]
Affiliation(s)
- C-ES Short
- Section of Infectious Diseases; Imperial College; London UK
- St Mary's Hospital; Imperial College Healthcare NHS Trust; London UK
| | - M Douglas
- St Mary's Hospital; Imperial College Healthcare NHS Trust; London UK
| | - JH Smith
- St Mary's Hospital; Imperial College Healthcare NHS Trust; London UK
| | - GP Taylor
- Section of Infectious Diseases; Imperial College; London UK
- St Mary's Hospital; Imperial College Healthcare NHS Trust; London UK
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20
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Monforte AD, Anderson J, Olczak A. What do we know about antiretroviral treatment of HIV in women? Antivir Ther 2013; 18 Suppl 2:27-34. [PMID: 23784804 DOI: 10.3851/imp2647] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2012] [Indexed: 10/26/2022]
Abstract
As the number of women living with HIV continues to increase, the lack of sex-specific data on responses to antiretroviral therapy (ART) becomes increasingly problematic. Establishing the specific needs of women has been hampered by a strong male bias of study populations in clinical trials resulting in a lack of female-specific data for ART. The limited data currently available make it difficult to draw conclusions about the pharmacokinetic profile and clinical efficacy of ART in women. Data relating to the safety and tolerability profiles of ART in women are more plentiful, with indications that women may experience adverse event profiles distinct from those experienced by men. This, in turn, may be a factor in the generally higher rates of discontinuation of ART observed in women. Psychological and social aspects of HIV infection are particularly pertinent for women and girls, presenting potential barriers to diagnosis, access and adherence to therapy. Understanding these factors, in conjunction with an increase in clinical trial and real-world data specific to women with HIV is required to provide clearer guidance on optimum ART options for women.
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Pilotto JH, Grinsztejn B, Veloso VG, Velasque LS, Friedman RK, Moreira RI, Rodrigues-Pedro A, Oliveira SM, Currier JS, Morgado MG. Moderate prevalence of transmitted drug resistance mutations among antiretroviral-naive HIV-infected pregnant women in Rio de Janeiro, Brazil. AIDS Res Hum Retroviruses 2013; 29:681-6. [PMID: 23259924 DOI: 10.1089/aid.2011.0333] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Transmission of drug-resistant HIV-1 strains has been gaining attention and is becoming a growing problem throughout the world. The aim of this study was to determine the prevalence of transmitted drug resistance mutations (TDRM) among antiretroviral (ARV)-naive HIV-infected pregnant women in Rio de Janeiro, Brazil. ARV-naive pregnant women were recruited at Hospital Geral de Nova Iguacu (HGNI), Rio de Janeiro, from 2005 to 2008. HIV genotyping was carried out using ViroSeq (Abbott v. 2.0). TDRM were detected using the Calibrated Population Resistance Tool-CPR v. 6.0.The prevalence of mutations associated with resistance in the protease and reverse transcriptase regions of the HIV genome were assessed in samples collected prior to initiation of ARV prophylaxis or treatment. Among 238 eligible specimens that were collected, 197 samples were successfully amplified using reverse transcription polymerase chain reaction. Eighty-one percent of women were infected with HIV subtype B, 10% with subtype F1 viruses, 1.0% with subtype C virus, and 8.0% with recombinant forms of the virus. The prevalence of HIV TDRM was 5.6% for nucleoside reverse transcriptase inhibitors, 2.0% for nonnucleoside reverse transcriptase inhibitors, and 3.0% for protease inhibitors. The overall prevalence of any drug resistance was 10.7%. There were no multiclass resistant strains identified in the analyzed samples. The prevalence of HIV TDRM among the pregnant women in our cohort was moderate. Resistance testing should be encouraged in Rio de Janeiro, among other locations, for all HIV-infected pregnant women prior to prevention of mother-to-child transmission of HIV.
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Affiliation(s)
- José H. Pilotto
- Instituto Oswaldo Cruz/FIOCRUZ, AIDS and Molecular Immunology Laboratory, Rio de Janeiro, Brazil
- Hospital Geral de Nova Iguaçu (HGNI), HIV Family Care Clinic (HHFCC), Rio de Janeiro, Brazil
| | - Beatriz Grinsztejn
- Fundação Oswaldo Cruz, Instituto de Pesquisa Clínica Evandro Chagas/IPEC, Rio de Janeiro, Brazil
| | - Valdilea G. Veloso
- Fundação Oswaldo Cruz, Instituto de Pesquisa Clínica Evandro Chagas/IPEC, Rio de Janeiro, Brazil
| | - Luciane S. Velasque
- Fundação Oswaldo Cruz, Instituto de Pesquisa Clínica Evandro Chagas/IPEC, Rio de Janeiro, Brazil
- Department of Mathematics and Statistics, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Ruth K. Friedman
- Fundação Oswaldo Cruz, Instituto de Pesquisa Clínica Evandro Chagas/IPEC, Rio de Janeiro, Brazil
| | - Ronaldo I. Moreira
- Fundação Oswaldo Cruz, Instituto de Pesquisa Clínica Evandro Chagas/IPEC, Rio de Janeiro, Brazil
| | - Adriana Rodrigues-Pedro
- Instituto Oswaldo Cruz/FIOCRUZ, AIDS and Molecular Immunology Laboratory, Rio de Janeiro, Brazil
| | - Sandra M. Oliveira
- Hospital Geral de Nova Iguaçu (HGNI), HIV Family Care Clinic (HHFCC), Rio de Janeiro, Brazil
| | - Judith S. Currier
- David Geffen School of Medicine at UCLA, Division of Infectious Diseases and Center for Clinical AIDS Research and Education, University of California, Los Angeles, California
| | - Mariza G. Morgado
- Instituto Oswaldo Cruz/FIOCRUZ, AIDS and Molecular Immunology Laboratory, Rio de Janeiro, Brazil
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Use of combination neonatal prophylaxis for the prevention of mother-to-child transmission of HIV infection in European high-risk infants. AIDS 2013; 27:991-1000. [PMID: 23211776 DOI: 10.1097/qad.0b013e32835cffb1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate use of combination neonatal prophylaxis (CNP) in infants at high risk for mother-to-child transmission (MTCT) of HIV in Europe and investigate whether CNP is more effective in preventing MTCT than single drug neonatal prophylaxis (SNP). DESIGN Individual patient-data meta-analysis across eight observational studies. METHODS Factors associated with CNP receipt and with MTCT were explored by logistic regression using data from nonbreastfed infants, born between 1996 and 2010 and at high risk for MTCT. RESULTS In 5285 mother-infant pairs, 1463 (27.7%) had no antenatal or intrapartum antiretroviral prophylaxis, 915 (17.3%) had only intrapartum prophylaxis and 2907 (55.0%) mothers had detectable delivery viral load despite receiving antenatal antiretroviral therapy. Any neonatal prophylaxis was administered to 4623 (87.5%) infants altogether; 1105 (23.9%) received CNP. Factors significantly associated with the receipt of CNP were later calendar birth year, no elective caesarean section, maternal CD4 cell count less than 200 cells/μl, maternal delivery viral load more than 1000 copies/ml, no antenatal antiretroviral therapy, receipt of intrapartum single-dose nevirapine and cohort. After adjustment, absence of neonatal prophylaxis was associated with higher risk of MTCT compared to neonatal prophylaxis [adjusted odds ratio (aOR) 2.29; 95% confidence interval (95% CI) 1.46-2.59; P < 0.0001]. Further, there was no association between CNP and MTCT compared to SNP (aOR 1.41; 95% CI 0.97-2.5; P = 0.07). CONCLUSION In this European population, CNP use is increasing and associated with presence of MTCT risk factors. The finding of no observed difference in MTCT risk between one drug and CNP may reflect residual confounding or the fact that CNP may be effective only in a subgroup of infants rather than the whole population of high-risk infants.
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Abstract
OBJECTIVES In contrast to HIV-1 infection, little is known about the natural disease course of HIV-2 and its response to antiretrovirals (ARVs). We describe a cohort of HIV-2-infected patients, focusing on the method of diagnosis, ARV treatment and complications. METHODS Through a retrospective review of medical records at our centre, we identified 12 patients with HIV-2 infection in our clinic population (1400 active patients) who received care between 2002 and 2011. We summarized clinical characteristics, ARV treatment and outcomes. RESULTS Seven of the patients were male and five were female. All patients were born in West African countries. The mode of transmission was heterosexual intercourse in 11 patients, and injecting drug use in one patient. The median CD4 count at the time of diagnosis was 668 cells/μL (range 23 to 1546 cells/μL). HIV-2 quantitative viral load measurements were not uniformly available to clinicians. Four patients were treated with protease inhibitor-based regimens, with a mean increase in CD4 count of 183 cells/μL (range 43 to 341 cells/μL). The other eight patients have been observed off ARVs. Two patients experienced complications from HIV, one patient had HIV encephalopathy and molluscom contagiosum, and another had microsporidiosis infection in the setting of AIDS. CONCLUSION Our results support those of previous studies indicating that HIV-2 has a more indolent disease course than HIV-1, with a spectrum of disease ranging from asymptomatic to AIDS. Development of a reliable quantitative HIV-2 viral load assay to guide management is needed. Further research studies are needed to establish the best time to start ARV treatment in HIV-2-infected patients.
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Affiliation(s)
- B L Hollenbeck
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
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Neubert J, Pfeffer M, Borkhardt A, Niehues T, Adams O, Bolten M, Reuter S, Stannigel H, Laws HJ. Risk adapted transmission prophylaxis to prevent vertical HIV-1 transmission: effectiveness and safety of an abbreviated regimen of postnatal oral zidovudine. BMC Pregnancy Childbirth 2013; 13:22. [PMID: 23347580 PMCID: PMC3568057 DOI: 10.1186/1471-2393-13-22] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 01/17/2013] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Antiretroviral drugs including zidovudine (ZDV) are effective in reducing HIV mother to child transmission (MTCT), however safety concern remains. The optimal duration of postnatal ZDV has not been established in clinical studies and there is a lack of consensus regarding optimal management. The objective of this study was to investigate the effectiveness and safety of a risk adapted two week course of oral postnatal ZDV as part of a combined intervention to reduce MTCT. METHODS 118 mother infant pairs were treated according to the German-Austrian recommendations for HIV therapy in pregnancy and in HIV exposed newborns between 2000-2010. In the absence of factors associated with an increased HIV-1 transmission risk, children were assigned to the low risk group and treated with an abbreviated postnatal regimen with oral ZDV for 2 weeks. In the presence of risk factors, postnatal ZDV was escalated accordingly. RESULTS Of 118 mother-infant pairs 79 were stratified to the low risk group, 27 to the high risk group and 11 to the very high risk group for HIV-1 MTCT. 4 children were lost to follow up. Overall Transmission risk in the group regardless of risk factors and completion of prophylaxis was 1.8% (95% confidence interval (CI) 0.09-6.6). If transmission prophylaxis was complete, transmission risk was 0.9% (95% CI 0.01-5.7). In the low risk group receiving two week oral ZDV transmission risk was 1.4% (95% CI 0.01-8.4) CONCLUSION These data demonstrate the effectiveness of a short neonatal ZDV regimen in infants of women on stable ART and effective HIV-1 suppression. Further evaluation is needed in larger studies.
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Affiliation(s)
- Jennifer Neubert
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, medical faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Maren Pfeffer
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, medical faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Arndt Borkhardt
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, medical faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Tim Niehues
- Department of Pediatrics, Helios Clinic Krefeld, Lutherplatz 40, 47805, Krefeld, Germany
| | - Ortwin Adams
- Institut of Virology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Mareike Bolten
- Department of Obstetrics and Gynaecology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Stefan Reuter
- Department of Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Hans Stannigel
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, medical faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Hans-Juergen Laws
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, medical faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
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Johnson M, Afonina L, Haanyama O. The challenges of testing for HIV in women: experience from the UK and other European countries. Antivir Ther 2013; 18 Suppl 2:19-25. [DOI: 10.3851/imp2637] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2012] [Indexed: 10/26/2022]
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Miralles C, Mardarescu M, Sherr L. What do we know about the situation of women living with HIV in Europe? Antivir Ther 2013; 18 Suppl 2:11-7. [DOI: 10.3851/imp2646] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2012] [Indexed: 10/26/2022]
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Haberl A, Johnson M, Dominguez S, Miralles C, d’Arminio Monforte A, Anderson J. The need for data on women living with HIV in Europe. Antivir Ther 2013; 18 Suppl 2:1-10. [DOI: 10.3851/imp2640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2013] [Indexed: 10/26/2022]
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28
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Buchholz B, Hien S, Baumann U. Verhinderung der vertikalen HIV1-Transmission. Monatsschr Kinderheilkd 2012. [DOI: 10.1007/s00112-012-2817-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Prevention on parent to child transmission of HIV - what is new? Indian J Pediatr 2012; 79:1491-500. [PMID: 23080266 DOI: 10.1007/s12098-012-0887-5] [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] [Received: 10/18/2011] [Accepted: 09/11/2012] [Indexed: 10/27/2022]
Abstract
Prevention of Mother-To-Child Transmission (PMTCT) of HIV has been at the forefront of research in the field of HIV/AIDS since the PACTG 076 proved successful in 1994. This was followed by many trials with single, dual, or triple Anti Retroviral Therapy (ART), with or without breast-feeding, with different modes of delivery. These trials aimed and promised to find a relatively simple, low-cost intervention that could virtually eliminate the risk of HIV transmission from mother to child, cutting across all geographic boundaries. However, translation of the findings from most of these research studies into successful national PMTCT programs and health policies has not been optimal. In the west, parent to child transmission of HIV has been virtually eliminated due to universal coverage, screening, planned conception wherever possible, thorough evaluation and appropriate antenatal, intranatal and postnatal interventions. In contrast, in resource limited settings where the magnitude of the problem is the greatest accounting for more than 95 % of all vertical transmissions of HIV, there is a constant struggle dealing with the birth of an infected infant every minute. It is time to make optimal choices to prevent the transmission of HIV from an infected mother to her child and virtually eliminate this largely preventable scourge in children.
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30
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An audit of the management of HIV-positive pregnant women and their babies: are we already meeting the 2012 BHIVA guidelines? J Int AIDS Soc 2012. [DOI: 10.7448/ias.15.6.18240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Eleventh International Congress on Drug Therapy in HIV Infection. J Int AIDS Soc 2012. [DOI: 10.7448/ias.15.6.18447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Low rates of mother-to-child transmission of HIV-1 and risk factors for infection in Spain: 2000-2007. Pediatr Infect Dis J 2012; 31:1053-8. [PMID: 22926219 DOI: 10.1097/inf.0b013e31826fe968] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The objective of the study was to describe temporal patterns in the management of HIV-1 infected women and their newborns and the changes over time in the mother-to-child transmission (MTCT) rates and risk factors. METHODS A multicenter prospective observational study was performed in Madrid, Spain, from 2000 to 2007. Cohort period 1 (CP1) included births in 2000-2003 and cohort period 2 (CP2) included births in 2004-2007. RESULTS Of the 803 HIV-infected women and their infants, 427 were in the CP1 and 376 in CP2. Almost all CP2 women received highly active antiretroviral therapy. More women in CP2 received antiretroviral treatment for ≥16 weeks during pregnancy (72.0% in CP1 vs. 84.8% in CP2; P < 0.001). Overall, no differences in trends in mode of delivery were observed. The proportion of women with vaginal deliveries who had undetectable viral loads increased from 31.1% in CP1 to 42.7% in CP2 (P = 0.02). Thirteen children (1.6%, 95% confidence interval: 0.68-2.55) were HIV-1 infected by MTCT. No changes in the rates of infection were observed over time. All the cases of MTCT occurred when antiretroviral treatment was not given or was given for <16 weeks during pregnancy. CONCLUSIONS Low MTCT rates were observed over time. Lack of timely provision of antiretroviral drugs was the main limitation to develop all preventive interventions available nowadays. Nonsustained control of viral load could be associated with residual transmission.
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Jones AB, Hughes A, Barton S. Guidance on Occupational-Related HIV Post-Exposure Prophylaxis (PEP) in the Intensive Care Setting. J Intensive Care Soc 2012. [DOI: 10.1177/175114371201300413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ann-Britt Jones
- Specialist Registrar in Genito-urinary Medicine, Chelsea and Westminster Hospital NHS Foundation Trust
| | - Amelia Hughes
- Specialist Registrar in Genito-urinary Medicine, Chelsea and Westminster Hospital NHS Foundation Trust
| | - Simon Barton
- Clinical Director HIV, GUM and Dermatology, Chelsea and Westminster Hospital NHS Foundation Trust
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Anderson EJ, Yogev R. The glory of guidelines and the twilight of reality: controversies and challenges in the prevention and treatment of HIV in children. Expert Rev Anti Infect Ther 2012; 10:761-74. [PMID: 22943400 DOI: 10.1586/eri.12.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since the discovery of HIV 30 years ago, we have learned much about HIV in children and adolescents. Dramatic declines have occurred in mother-to-child transmission of HIV in resource-rich countries. Resource-poor countries struggle with improving prevention of mother-to-child transmission due to the lack of universal antiretroviral treatment for pregnant and nursing mothers. In children infected with HIV, pharmacokinetic, safety and efficacy data have been determined for many of the older drugs. Data are lacking for the newer, safer and more effective currently available drugs, resulting in the pediatric guidelines lagging behind adult recommendations. Although guidelines for prevention and treatment are helpful, the way they are created causes them to lag behind new scientific evidence, and in some situations they will be confusing or only based on expert opinion. Improving prevention of HIV infection in adolescents and young adults and in treating those who become HIV infected is crucially important. The next 10 years hold tremendous opportunities for improvements in prevention and treatment of HIV in children, adolescents and young adults.
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Affiliation(s)
- Evan J Anderson
- Department of Pediatrics and Medicine, Emory University School of Medicine, 2015 Uppergate Drive, Atlanta, GA, USA.
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35
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11.0 References. HIV Med 2012. [DOI: 10.1111/j.1468-1293.2012.1030_12.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Quinn KJ, McCarty EJ, Dinsmore WM, Quah SP. Clinical care versus ethical obligations: HIV-1 and -2 co-infection with hepatitis B in a pregnant Jehovah's Witness. Int J STD AIDS 2012; 23:e5-6. [PMID: 22844019 DOI: 10.1258/ijsa.2009.009457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Co-infection with HIV-1 and -2 is rare, even in west Africa. We present the case of a 38-year-old pregnant Jehovah's Witness presenting late in pregnancy with triple infection with HIV-1, HIV-2 and hepatitis B virus. There was a successful outcome in averting vertical transmission despite objections to management based on religious and cultural beliefs.
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Affiliation(s)
- K J Quinn
- Department of Genito-Urinary and HIV Medicine, Royal Victoria Hospital Belfast, Belfast, UK.
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37
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Huntington SE, Bansi LK, Thorne C, Anderson J, Newell ML, Taylor GP, Pillay D, Hill T, Tookey PA, Sabin CA. Using two on-going HIV studies to obtain clinical data from before, during and after pregnancy for HIV-positive women. BMC Med Res Methodol 2012; 12:110. [PMID: 22839414 PMCID: PMC3475121 DOI: 10.1186/1471-2288-12-110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 07/18/2012] [Indexed: 12/04/2022] Open
Abstract
Background The UK Collaborative HIV Cohort (UK CHIC) is an observational study that collates data on HIV-positive adults accessing HIV clinical care at (currently) 13 large clinics in the UK but does not collect pregnancy specific data. The National Study of HIV in Pregnancy and Childhood (NSHPC) collates data on HIV-positive women receiving antenatal care from every maternity unit in the UK and Ireland. Both studies collate pseudonymised data and neither dataset contains unique patient identifiers. A methodology was developed to find and match records for women reported to both studies thereby obtaining clinical and treatment data on pregnant HIV-positive women not available from either dataset alone. Results Women in UK CHIC receiving HIV-clinical care in 1996–2009, were found in the NSHPC dataset by initially ‘linking’ records with identical date-of-birth, linked records were then accepted as a genuine ‘match’, if they had further matching fields including CD4 test date. In total, 2063 women were found in both datasets, representing 23.1% of HIV-positive women with a pregnancy in the UK (n = 8932). Clinical data was available in UK CHIC following most pregnancies (92.0%, 2471/2685 pregnancies starting before 2009). There was bias towards matching women with repeat pregnancies (35.9% (741/2063) of women found in both datasets had a repeat pregnancy compared to 21.9% (1502/6869) of women in NSHPC only) and matching women HIV diagnosed before their first reported pregnancy (54.8% (1131/2063) compared to 47.7% (3278/6869), respectively). Conclusions Through the use of demographic data and clinical dates, records from two independent studies were successfully matched, providing data not available from either study alone.
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Affiliation(s)
- Susie E Huntington
- Research Department of Infection & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
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38
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8.0 Neonatal management. HIV Med 2012. [DOI: 10.1111/j.1468-1293.2012.1030_9.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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39
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Taylor GP, Clayden P, Dhar J, Gandhi K, Gilleece Y, Harding K, Hay P, Kennedy J, Low-Beer N, Lyall H, Palfreeman A, Tookey P, Welch S, Wilkins E, de Ruiter A. British HIV Association guidelines for the management of HIV infection in pregnant women 2012. HIV Med 2012. [DOI: 10.1111/j.1468-1293.2012.01030.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- GP Taylor
- Communicable Diseases; Section of Infectious Diseases; Imperial College London; UK
| | - P Clayden
- UK Community Advisory Board representative/HIV treatment advocates network; London; UK
| | - J Dhar
- Genitourinary Medicine; University Hospitals of Leicester NHS Trust; Leicester; UK
| | - K Gandhi
- Heart of England NHS Foundation Trust; Birmingham; UK
| | | | - K Harding
- Guy's and St Thomas′ Hospital NHS Foundation Trust; London; UK
| | - P Hay
- St George's Healthcare NHS Trust; London; UK
| | - J Kennedy
- Homerton University Hospital NHS Foundation Trust; London; UK
| | - N Low-Beer
- Chelsea and Westminster Hospital NHS Foundation Trust; London; UK
| | - H Lyall
- Imperial College Healthcare NHS Trust; London; UK
| | - A Palfreeman
- Genitourinary Medicine; University Hospitals of Leicester NHS Trust; Leicester; UK
| | - P Tookey
- UCL Institute of Child Health; London; UK
| | - S Welch
- Paediatric Infectious Diseases; Heart of England NHS Foundation Trust; Birmingham; UK
| | - E Wilkins
- Infectious Diseases and Director of the HIV Research Unit; North Manchester General Hospital; Manchester; UK
| | - A de Ruiter
- Genitourinary Medicine; Guy's and St Thomas' NHS Foundation Trust; London; UK
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40
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5.0 Use of antiretroviral therapy in pregnancy. HIV Med 2012. [DOI: 10.1111/j.1468-1293.2012.1030_6.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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41
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Ambulatory obstetric care. Clin Obstet Gynecol 2012; 55:714-21. [PMID: 22828104 DOI: 10.1097/grf.0b013e3182577251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prenatal care is focused on improving the health of women and babies. Traditional models of prenatal care focus on individual provider-patient interactions. Newer models, including group prenatal care and specialty clinics, may be useful models in certain situations.
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Ammassari A, Cicconi P, Ladisa N, Di Sora F, Bini T, Trotta MP, D'Ettorre G, Cattelan AM, Vichi F, d'Arminio Monforte A. Induced first abortion rates before and after HIV diagnosis: results of an Italian self-administered questionnaire survey carried out in 585 women living with HIV. HIV Med 2012; 14:31-9. [DOI: 10.1111/j.1468-1293.2012.01032.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2012] [Indexed: 11/29/2022]
Affiliation(s)
- A Ammassari
- Department of Infectious Diseases; INMI; L Spallanzani; Rome; Italy
| | - P Cicconi
- Institute of Infectious and Tropical Diseases; Department of Medicine; Surgery and Dentistry; San Paolo University Hospital; Milan; Italy
| | - N Ladisa
- Institute of Infectious Diseases; University of Bari; Bari; Italy
| | - F Di Sora
- Department of Infectious Diseases; Hospital San Giovanni Addolorata; Rome; Italy
| | - T Bini
- Institute of Infectious and Tropical Diseases; Department of Medicine; Surgery and Dentistry; San Paolo University Hospital; Milan; Italy
| | - MP Trotta
- Department of Infectious Diseases; INMI; L Spallanzani; Rome; Italy
| | - G D'Ettorre
- Institute of Infectious Diseases; Policlinico Umberto I; Rome; Italy
| | - AM Cattelan
- Department of Infectious Diseases; Hospital of Rovigo; Rovigo; Italy
| | - F Vichi
- Department of Infectious Diseases; Hospital SS Annunziata, bagno a Ripoli; Florence; Italy
| | - A d'Arminio Monforte
- Institute of Infectious and Tropical Diseases; Department of Medicine; Surgery and Dentistry; San Paolo University Hospital; Milan; Italy
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Tong Leung VK, Lao TT, Suen SSH, Chan OK, Singh Sahota D, Lau TK, Yeung Leung T. Breastfeeding initiation: is this influenced by maternal hepatitis B infection? J Matern Fetal Neonatal Med 2012; 25:2390-4. [PMID: 22694367 DOI: 10.3109/14767058.2012.697941] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To elucidate the effect of hepatitis B virus (HBV) infection on breastfeeding uptake in Chinese mothers in an endemic region. PATIENTS AND METHODS A retrospective cohort study on 63 885 consecutive pregnant delivered between January 1997 and June 2008, were extracted from computerized database to examine the relationship between breastfeeding uptake and maternal HBV status, adjusted for demographic factors. RESULTS A total of 6593 (10.3%) women were hepatitis B surface antigen (HBsAg)-positive, with an annual prevalence of around 10%. In the study period, 29 869 (46.8%) practised breastfeeding, and its prevalence ranged from 35.4 to 54.8% with an increasing trend throughout the years (p < 0.001). HBsAg-positive mothers had a significantly lower rate of breastfeeding (39.2 vs. 47.6% p < 0.001). Multiparas had higher incidence of HBV infection (10.9 vs. 9.8%, p < 0.001) and lower breastfeeding rate (42.2% versus 51.0%, p < 0.001) when compared with primiparas. Among those factors, maternal HBV infection had the strongest negative association with breastfeeding (adjusted odd ratio (aOR) = 0.726, 95% confidence interval (CI): 0.689-0.765). CONCLUSIONS Our results suggested maternal HBV infection was one of the factors for the persistently low breastfeeding rate in Hong Kong over the past decades. To promote breastfeeding, it is necessary to generate definitive data on its safety regarding to mother-to-child transmission (MTCT) of HBV in order to allay the fear and anxiety in HBsAg-positive mothers.
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Affiliation(s)
- Viola Kit Tong Leung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, P R China.
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Riordan A. North West England Perinatal and Paediatric HIV Network review of local guidelines used to manage infants born to HIV-positive women. HIV Med 2012; 13:384-5. [PMID: 22651669 DOI: 10.1111/j.1468-1293.2012.00997.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Esker S, Albano J, Uy J, Arikan D, Jimenez-Exposito MJ, Seekins D, Tilson H. Monitoring the risk of birth defects associated with atazanavir exposure in pregnancy. AIDS Patient Care STDS 2012; 26:307-11. [PMID: 22404239 DOI: 10.1089/apc.2011.0444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Stephen Esker
- Bristol-Myers Squibb Company, Plainsboro, New Jersey
| | | | - Jonathan Uy
- Bristol-Myers Squibb Company, Plainsboro, New Jersey
| | - Dilek Arikan
- Bristol-Myers Squibb Company, Hopewell, New Jersey
| | | | | | - Hugh Tilson
- University of North Carolina, Gillings School of Global Public Health, Chapel Hill, North Carolina
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When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery? AIDS 2012; 26:1095-103. [PMID: 22441248 DOI: 10.1097/qad.0b013e3283536a6c] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND HAART dramatically reduces mother-to-child transmission of HIV allowing vaginal delivery if the viral load is low. This study provides data for the optimum timing of short-term HAART in pregnancy. METHODS Retrospective multicentre cohort study of pregnant women commencing HAART in London and Brighton, UK. Demographics, gestation, drug class, CD4 cell count, and viral load results were collated. Survival curves for reaching a viral load less than 50 copies/ml were stratified by initial HIV viral load. Cox's proportional hazards regression model was adjusted for demographics and immunovirological parameters. RESULTS Viral load was less than 50 copies/ml in 292 of 378 pregnancies (77.2%) by delivery. Pretreatment viral load was associated with the time taken, and the proportion achieving a viral load less than 50 copies/ml at (P≤0.001). When baseline viral load was less than 10 ,000 copies/ml, gestational age at HAART initiation did not affect success up to 26.3 weeks gestation. When viral load was more than 10 ,000 copies/ml, deferring HAART past 20.4 weeks reduced the probability of reaching less than 50 copies/ml by delivery (P=0.011). When baseline viral load was more than 100, 000 copies/ml the likelihood of reaching a viral load of less than 50 copies/ml was low (37%: hazard ratio 0.31), and dependent on the length of time on HAART. The hazard ratio for a nonnucleoside reverse transcriptase inhibitor regimen achieving a viral load less than 50 copies/ml compared with a protease inhibitor was 0.7 (95% confidence interval 0.52-0.94). CONCLUSION With a viral load more than 10, 000 copies/ml and especially with a viral load more than 100 ,000 copies/ml, the probability of achieving either less than 50 copies/ml by the time of delivery is compromised by delaying initiation of short-term highly active antiretroviral therapy beyond 20.4 weeks gestation. Current UK and other guidelines for when to commence START may therefore limit the chance of vaginal delivery.
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Else LJ, Taylor S, Back DJ, Khoo SH. Pharmacokinetics of antiretroviral drugs in anatomical sanctuary sites: the fetal compartment (placenta and amniotic fluid). Antivir Ther 2012; 16:1139-47. [PMID: 22155898 DOI: 10.3851/imp1918] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
HIV resides within anatomical 'sanctuary sites' where local drug exposure and viral dynamics may differ significantly from the systemic compartment. Widespread implementation of antiretroviral therapy has seen a significant decline in the incidence of mother-to-child transmission (MTCT) of HIV. In addition to suppression of maternal plasma/genital viral loads, antiretroviral agents that cross the placenta and achieve adequate concentrations in the fetal compartment may exert a greater prophylactic effect. Penetration of antiretrovirals in the fetal compartment is expressed by accumulation ratios derived from the measurement of drug concentrations in paired maternal plasma and umbilical cord samples. The nucleoside analogues and nevirapine accumulate extensively in cord blood and in the surrounding amniotic fluid, whereas the protease inhibitors (PIs) exhibit low-to-moderate placental accumulation. Early data suggest that high placental/neonatal concentrations are achieved with raltegravir, but to a lesser extent with etravirine and maraviroc (rank order of accumulation: raltegravir/nucleoside reverse transcriptase inhibitor [tenofovir > zidovudine/lamivudine/emtricitabine/stavudine/abacavir] > non-nucleoside reverse transcriptase inhibitor [nevirapine > etravirine] > PI > maraviroc/enfuvirtide). More comprehensive in vivo pharmacokinetic data are required to justify the potential use of these agents as safe and effective options during pregnancy.
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Affiliation(s)
- Laura J Else
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.
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Ndirangu J, Newell ML, Bland RM, Thorne C. Maternal HIV infection associated with small-for-gestational age infants but not preterm births: evidence from rural South Africa. Hum Reprod 2012; 27:1846-56. [PMID: 22442245 PMCID: PMC3357196 DOI: 10.1093/humrep/des090] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) is prevalent in many countries where small-for-gestational age (SGA) and premature delivery are also common. However, the associations between maternal HIV, preterm delivery and SGA infants remain unclear. We estimate the prevalence of SGA and preterm (<37 weeks) births, their associations with antenatal maternal HIV infection and their contribution to infant mortality, in a high HIV prevalent, rural area in South Africa. METHODS Data were collected, in a non-randomized intervention cohort study, on all women attending antenatal clinics (2001–2004), before the availability of antiretroviral treatment. Newborns were weighed and gestational age was determined (based on last menstrual period plus midwife assessment antenatally). Poisson regression with robust variance assessed risk factors for preterm and SGA birth, while Cox regression assessed infant mortality and associated factors. RESULTS Of 2368 live born singletons, 16.6% were SGA and 21.4% were preterm. HIV-infected women (n= 1189) more commonly had SGA infants than uninfected women (18.1 versus 15.1%; P = 0.051), but percentages preterm were similar (21.8 versus 20.9%; P = 0.621). After adjustment for water source, delivery place, parity and maternal height, the SGA risk in HIV-infected women was higher [adjusted relative risk (aRR) 1.28, 95% confidence interval (CI): 1.06–1.53], but the association between maternal HIV infection and preterm delivery remained weak and not significant (aRR: 1.07, 95% CI: 0.91–1.26). In multivariable analyses, mortality under 1 year of age was significantly higher in SGA and severely SGA than in appropriate-for-gestational-age infants [adjusted hazard ratio (aHR): 2.12, 95% CI: 1.18–3.81 and 2.77, 95% CI: 1.56–4.91], but no difference in infant mortality was observed between the preterm and term infants (aHR: 1.18 95% CI: 0.79–1.79 for 34–36 weeks and 1.31, 95% CI: 0.58–2.94 for <34 weeks). CONCLUSIONS Maternal HIV infection increases the risk of SGA, but not preterm births, in this cohort.
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Affiliation(s)
- James Ndirangu
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, South Africa.
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Noguera Julian A, De José MI. [Recommendations issued by the Spanish Society of Pediatric Infectious Diseases for the follow-up of the child exposed to the human immunodeficiency virus and to antiretroviral drugs during pregnancy and the neonatal period]. An Pediatr (Barc) 2012; 76:360.e1-9. [PMID: 22406157 DOI: 10.1016/j.anpedi.2012.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 01/05/2012] [Indexed: 10/28/2022] Open
Abstract
Human immunodeficiency virus vertical transmission in developed countries has dramatically decreased to less than 2% over the last 15 years due to the consecutive implementation of different prophylactic measures, including the use of antiretrovirals, elective cesarean section and refraining from breastfeeding. The follow-up of these otherwise healthy children is, by far, the most common situation related to HIV infection that general pediatricians currently face in routine clinical care in Spain. These recommendations issued by the Spanish Society of Pediatric Infectious Diseases attempt to summarize the main aspects of this follow-up, including birth management, type of feeding, neonatal antiretroviral prophylaxis, HIV infection diagnosis, common early comorbidities, short- and mid-term toxicities, vaccination and other prophylactic measures and long-term follow-up.
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Affiliation(s)
- A Noguera Julian
- Unitat d'Infectologia, Servei de Pediatria, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain.
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French CE, Cortina-Borja M, Thorne C, Tookey PA. Incidence, patterns, and predictors of repeat pregnancies among HIV-infected women in the United Kingdom and Ireland, 1990-2009. J Acquir Immune Defic Syndr 2012; 59:287-93. [PMID: 22227490 PMCID: PMC3378493 DOI: 10.1097/qai.0b013e31823dbeac] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To explore the pattern of repeat pregnancies among diagnosed HIV-infected women in the United Kingdom and Ireland, estimate the rate of these sequential pregnancies, and investigate the demographic and clinical characteristics of women experiencing them. DESIGN Diagnosed HIV-infected pregnant women are reported through an active confidential reporting scheme to the National Study of HIV in Pregnancy and Childhood. METHODS Pregnancies occurring during 1990-2009 were included. Multivariable analyses were conducted fitting Cox proportional hazards models. RESULTS There were 14,096 pregnancies in 10,568 women; 2737 (25.9%) had 2 or more pregnancies reported. The rate of repeat pregnancies was 6.7 (95% confidence interval: 6.5 to 7.0) per 100 woman-years. The proportion of pregnancies in women who already had at least 1 pregnancy reported increased from 20.3% (32 of 158) in 1997 to 38.6% (565 of 1465) in 2009 (P < 0.001). In multivariable analysis, the probability of repeat pregnancy significantly declined with increasing age at first pregnancy. Parity was also inversely associated with repeat pregnancy. Compared with women born in the United Kingdom or Ireland, those from Europe, Eastern Africa, and Southern Africa were less likely to have a repeat pregnancy, whereas women from Middle Africa and Western Africa were more likely to. Maternal health at first pregnancy was not associated with repeat pregnancy. CONCLUSIONS The number of diagnosed HIV-infected women in the United Kingdom and Ireland experiencing repeat pregnancies is increasing. Variations in the probability of repeat pregnancies, according to demographic and clinical characteristics, are an important consideration when planning reproductive health services and HIV care for people living with HIV.
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Affiliation(s)
- Clare E French
- MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, London, UK.
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