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Dadabhai S, Chou VB, Pinilla M, Chinula L, Owor M, Violari A, Moodley D, Stranix-Chibanda L, Matubu TA, Chareka GT, Theron G, Kinikar AA, Mubiana-Mbewe M, Fairlie L, Bobat R, Mmbaga BT, Flynn PM, Taha TE, McCarthy KS, Browning R, Mofenson LM, Brummel SS, Fowler MG. Effects of preterm birth, maternal ART and breastfeeding on 24-month infant HIV-free survival in a randomized trial. AIDS 2024; 38:1304-1313. [PMID: 38427596 PMCID: PMC11211053 DOI: 10.1097/qad.0000000000003878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/30/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND IMPAACT 1077BF/FF (PROMISE) compared the safety/efficacy of two HIV antiretroviral therapy (ART) regimens to zidovudine (ZDV) alone during pregnancy for HIV prevention. PROMISE found an increased risk of preterm delivery (<37 weeks) with antepartum triple ART (TDF/FTC/LPV+r or ZDV/3TC/LPV+r) compared with ZDV alone. We assessed the impact of preterm birth, breastfeeding, and antepartum ART regimen on 24-month infant survival. METHODS We compared HIV-free and overall survival at 24 months for liveborn infants by gestational age, time-varying breastfeeding status, and antepartum ART arm at 14 sites in Africa and India. Kaplan-Meier survival probabilities and Cox proportional hazards ratios were estimated. RESULTS Three thousand four hundred and eighty-two live-born infants [568 (16.3%) preterm and 2914 (83.7%) term] were included. Preterm birth was significantly associated with lower HIV-free survival [0.85; 95% confidence interval (CI) 0.82-0.88] and lower overall survival (0.89; 95% CI 0.86-0.91) versus term birth (0.96; 95% CI 0.95-0.96). Very preterm birth (<34 weeks) was associated with low HIV-free survival (0.65; 95% CI 0.54-0.73) and low overall survival (0.66; 95% CI 0.56-0.74). Risk of HIV infection or death at 24 months was higher with TDF-ART than ZDV-ART (adjusted hazard ratio 2.37; 95% CI 1.21-4.64). Breastfeeding initiated near birth decreased risk of infection or death at 24 months (adjusted hazard ratio 0.05; 95% CI 0.03-0.08) compared with not breastfeeding. CONCLUSION Preterm birth and antepartum TDF-ART were associated with lower 24-month HIV-free survival compared with term birth and ZDV-ART. Any breastfeeding strongly promoted HIV-free survival, especially if initiated close to birth. Reducing preterm birth and promoting infant feeding with breastmilk among HIV/antiretroviral drug-exposed infants remain global health priorities.
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Affiliation(s)
- Sufia Dadabhai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
- Kamuzu University of Health Sciences-Johns Hopkins Research Project, Blantyre, Malawi
| | - Victoria B. Chou
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mauricio Pinilla
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Lameck Chinula
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- University of North Carolina Project Malawi, Tidziwe Centre, Lilongwe, Malawi
| | - Maxensia Owor
- MU-JHU Research Collaboration; Upper Mulago Hill Road, Kampala, Uganda
| | - Avy Violari
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Soweto
| | - Dhayendre Moodley
- Centre for the AIDS Programme of Research in South Africa and School of Clinical Medicine, University of KwaZulu Natal, Congella, South Africa
| | - Lynda Stranix-Chibanda
- Child, Adolescent and Women's Health Department, Faculty of Medicine and Health Sciences, University of Zimbabwe, Avondale
- University of Zimbabwe Clinical Trials Research Centre, Belgravia, Harare, Zimbabwe
| | - Taguma Allen Matubu
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Gerhard Theron
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | | | - Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Raziya Bobat
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Blandina Theophil Mmbaga
- Kilimanjaro Christian Medical Centre, Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College/Kilimanjaro CRS, Moshi, Tanzania
| | | | - Taha E. Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | | | - Renee Browning
- National Institute of Allergy and Infectious Diseases/NIH, Rockville, MD
| | | | - Sean S. Brummel
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
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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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Ajibola G, Mdluli C, Bennett K, Sakoi M, Batlang O, Makhema J, Lockman S, Shapiro R, Myer L, Powis K. No increased in utero and peripartum HIV acquisition risk in HIV-exposed preterm infants. South Afr J HIV Med 2023; 24:1509. [PMID: 37928500 PMCID: PMC10623649 DOI: 10.4102/sajhivmed.v24i1.1509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/13/2023] [Indexed: 11/07/2023] Open
Abstract
Background Limited data exist on the differential risk of HIV acquisition between infants born preterm versus those born at term to women living with HIV (WLHIV). With a reported increase in preterm delivery among pregnant WLHIV, understanding the risk of vertical transmission of HIV in preterm infants can inform strategies to optimise the timing of diagnostic testing, antiretroviral prophylaxis, and infant feeding. Objectives To describe the prevalence and timing of HIV acquisition, in utero versus perinatal, among infants with perinatal HIV exposure born prior to 37 weeks completed gestation age compared to those born at term in the Botswana-based Mpepu study and explore predictors of infant HIV acquisition. Method Using data extracted from the Mpepu study, we describe the prevalence, timing and risk factors for HIV acquisition in infants born preterm versus those born at term. Fisher exact testing was used to test for differences in prevalence and timing of HIV and a multivariable logistic regression model was used to assess risk factors for infant HIV acquisition. Results 2866 infants born to WLHIV were included in this secondary analysis. 532 (19%) were born preterm. There was no observed difference in the prevalence of HIV acquisition among infants born preterm versus at term overall (0.8% vs 0.6%, P = 0.54), at birth (0.2% vs 0.3%, P = 1.00) or between 14 and 34 days post-delivery (0.6% vs 0.3%, P = 0.41). The absence of maternal antiretroviral use during pregnancy significantly predicted infant HIV acquisition, with the risk of HIV acquisition reduced by 96% among infants whose mothers were taking antiretroviral treatment (ART) during pregnancy (adjusted odds ratio: 0.003, confidence interval: 0.01-0.02, P < 0.001). Conclusion There was no observed increase of in utero and peripartum HIV acquisition among infants born preterm following foetal exposure to HIV compared to those born at term.
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Affiliation(s)
| | | | - Kara Bennett
- Bennett Statistical Consulting Inc, New York, United States of America
| | - Maureen Sakoi
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
| | - Oganne Batlang
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
| | - Joseph Makhema
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
| | - Shahin Lockman
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
- Department of Infectious Diseases, Brigham and Womens Hospital, Boston, United States of America
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Roger Shapiro
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Landon Myer
- Department of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kathleen Powis
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, United States of America
- Department of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, United States of America
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Murray C, Portwood C, Sexton H, Kumarendran M, Brandon Z, Kirtley S, Hemelaar J. Adverse perinatal outcomes attributable to HIV in sub-Saharan Africa from 1990 to 2020: Systematic review and meta-analyses. COMMUNICATIONS MEDICINE 2023; 3:103. [PMID: 37481594 PMCID: PMC10363130 DOI: 10.1038/s43856-023-00331-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 06/30/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Maternal HIV infection and antiretroviral drugs (ARVs) are associated with increased risks of adverse perinatal outcomes. The vast majority of pregnant women living with HIV (WLHIV) reside in sub-Saharan Africa. We aimed to determine the burden of adverse perinatal outcomes attributable to HIV and ARVs in sub-Saharan Africa between 1990 and 2020. METHODS We conduct a systematic review of studies on the association of pregnant WLHIV with adverse perinatal outcomes in sub-Saharan Africa. We perform random-effects meta-analyses to determine the risk difference (attributable risk, AR) of perinatal outcomes among WLHIV receiving no ARVs, monotherapy, or combination antiretroviral therapy (cART) initiated antenatally or preconception, compared to HIV-negative women. We estimate numbers of perinatal outcomes attributable to HIV and ARVs by combining the AR values with numbers of WLHIV receiving different ARV regimens in each country in sub-Saharan Africa annually between 1990 and 2020. RESULTS We find that WLHIV receiving no ARVs or cART initiated antenatally or preconception, but not monotherapy, have an increased risk of preterm birth (PTB), low birthweight (LBW) and small for gestational age (SGA), compared to HIV-negative women. Between 1990 and 2020, 1,921,563 PTBs, 2,119,320 LBWs, and 2,049,434 SGAs are estimated to be attributable to HIV and ARVs in sub-Saharan Africa, mainly among WLHIV receiving no ARVs, while monotherapy and preconception and antenatal cART averted many adverse outcomes. In 2020, 64,585 PTBs, 58,608 LBWs, and 61,112 SGAs were estimated to be attributable to HIV and ARVs, the majority among WLHIV receiving preconception cART. CONCLUSIONS As the proportion of WLHIV receiving preconception cART increases, the burden of adverse perinatal outcomes among WLHIV in sub-Saharan Africa is likely to remain high. SYSTEMATIC REVIEW REGISTRATION NUMBER CRD42021248987.
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Affiliation(s)
- Claudia Murray
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Clara Portwood
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Harriet Sexton
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
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Portwood C, Sexton H, Kumarendran M, Brandon Z, Johnson B, Kirtley S, Hemelaar J. Perinatal outcomes associated with combination antiretroviral therapy compared with monotherapy. AIDS 2023; 37:489-501. [PMID: 36695359 DOI: 10.1097/qad.0000000000003432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Increasing numbers of women living with HIV (WLHIV) worldwide receive combination antiretroviral therapy (cART) during pregnancy. We aimed to assess the risk of adverse perinatal outcomes in pregnant WLHIV receiving cART compared with pregnant WLHIV receiving zidovudine monotherapy. DESIGN Systematic review and meta-analysis. METHODS We searched four electronic literature databases (PubMed, CINAHL, Global Health, EMBASE) for studies published between 1 January 1980 and 20 April 2020 using a comprehensive search strategy. Studies reporting data on WLHIV receiving cART compared with WLHIV receiving monotherapy for 11 adverse perinatal outcomes were sought: preterm birth (PTB), very PTB, spontaneous PTB, low birthweight (LBW), very LBW, preterm and term LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Random-effects meta-analyses were conducted to calculate relative risk (RR) and 95% confidence intervals (95% CI). RESULTS We included 30 studies reporting on 317 101 pregnant women in 27 countries. WLHIV receiving cART were at increased risk of PTB (RR 1.32, 95% CI 1.18-1.46), LBW (1.35, 1.19-1.53), SGA (1.32, 1.13-1.53), VSGA (1.64, 1.34-2.02), and stillbirth (2.41, 1.83-3.17) compared to WLHIV receiving monotherapy. The significance of these results was maintained in subgroup analyses for studies conducted in low and middle-income countries and average quality studies. Additionally, WLHIV receiving nonnucleoside reverse transcriptase inhibitor-based cART were associated with increased risk of PTB, LBW, and stillbirth, while WLHIV receiving protease inhibitor-based cART were associated with increased risk of PTB, compared with WLHIV receiving monotherapy. CONCLUSION Pregnant WLHIV receiving cART are associated with increased risk of adverse perinatal outcomes, compared with WLHIV receiving monotherapy.
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Affiliation(s)
- Clara Portwood
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Harriet Sexton
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Bradley Johnson
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
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Portwood C, Sexton H, Kumarendran M, Brandon Z, Kirtley S, Hemelaar J. Adverse perinatal outcomes associated with antiretroviral therapy in women living with HIV: A systematic review and meta-analysis. Front Med (Lausanne) 2023; 9:924593. [PMID: 36816720 PMCID: PMC9935588 DOI: 10.3389/fmed.2022.924593] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 12/20/2022] [Indexed: 02/05/2023] Open
Abstract
Background Maternal HIV infection is associated with an increased risk of adverse perinatal outcomes. The World Health Organization (WHO) recommends immediate initiation of lifelong antiretroviral therapy (ART) for all people living with HIV, including pregnant women living with HIV (WLHIV). We aimed to assess the risk of adverse perinatal outcomes in WLHIV receiving ART compared to ART-naïve WLHIV and HIV-negative women. Materials and methods We conducted a systematic literature review by searching PubMed, CINAHL, Global Health, and EMBASE for studies published between Jan 1, 1980, and April 20, 2020. Two investigators independently selected relevant studies and extracted data from studies reporting on the association of pregnant WLHIV receiving ART with adverse perinatal outcomes. Perinatal outcomes examined were preterm birth (PTB), very PTB, spontaneous PTB (sPTB), low birth weight (LBW), very LBW (VLBW), term LBW, preterm LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Random-effects meta-analyses examined the risk of adverse perinatal outcomes in WLHIV receiving ART compared to ART-naïve WLHIV and HIV-negative women. Subgroup and sensitivity analyses were performed based on country income status and study quality, and adjustment for confounding factors assessed. Results Of 94,594 studies identified, 73 cohort studies, including 424,277 pregnant women, met the inclusion criteria. We found that WLHIV receiving ART are associated with a significantly decreased risk of PTB (relative risk 0.79, 95% CI 0.67-0.93), sPTB (0.46, 0.32-0.66), LBW (0.86, 0.79-0.93), and VLBW (0.62, 0.39-0.97) compared to ART-naïve WLHIV. However, WLHIV receiving ART are associated with a significantly increased risk of PTB (1.42, 1.28-1.57), sPTB (2.20, 1.32-3.67), LBW (1.58, 1.36-1.84), term LBW (1.88, 1.23-2.85), SGA (1.69, 1.32-2.17), and VSGA (1.22, 1.10-1.34) compared to HIV-negative women. Conclusion ART reduces the risk of adverse perinatal outcomes in pregnant WLHIV, but the risk remains higher than in HIV-negative women. Our findings support the WHO recommendation of immediate initiation of lifelong ART for all people living with HIV, including pregnant WLHIV. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42021248987.
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Affiliation(s)
- Clara Portwood
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Harriet Sexton
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom,*Correspondence: Joris Hemelaar,
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Brandon O, Chakravarti S, Hemelaar J. Trends in management and outcomes of pregnant women living with HIV between 2008–2013 and 2014–2019: A retrospective cohort study. Front Med (Lausanne) 2022; 9:970175. [DOI: 10.3389/fmed.2022.970175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDespite major advances in the care of pregnant women living with HIV (WLHIV), they remain at increased risk of adverse pregnancy outcomes. This study assesses recent developments in management and outcomes of pregnant WLHIV at a tertiary obstetric unit in the United Kingdom.MethodsWe conducted a retrospective cohort study of WLHIV delivering at the John Radcliffe Hospital, Oxford, during 2008–2019. Detailed data was collected for maternal, virological, obstetric, and perinatal characteristics. To determine changes over time, data from the periods 2008–13 and 2014–19 were compared.ResultsWe identified 116 pregnancies in 94 WLHIV. Between 2008–2013 and 2014–2019, the rate of preconception HIV diagnosis increased from 73 to 90% (p = 0.021) and the proportion of WLHIV on combination ART (cART) at conception increased from 54 to 84% (p = 0.001). The median gestation at which cART was initiated antenatally decreased from 22+1 to 17+1 weeks (p = 0.003). In 2014-2019, 41% of WLHIV received non-nucleoside reverse transcriptase inhibitor-based cART, 37% protease inhibitor-based cART, and 22% of cART regimens contained an integrase inhibitor. The proportion of WLHIV with a viral load <50 copies/mL at delivery rose from 87 to 94% (p = 0.235). Sixty-six percent of WLHIV delivered by Cesarean section, with a significant decrease over time in the rate of both planned (62–39%, p = 0.016) and actual (49–31%, p = 0.044) elective Cesarean. Perinatal outcomes included one case of perinatal HIV transmission (0.86%), 11% preterm birth, 15% small-for-gestational-age, and 2% stillbirth. There was an association between a viral load >50 copies/mL at delivery and preterm delivery (p = 0.0004).ConclusionVirological, obstetric, and perinatal outcomes of WLHIV improved during the study period. Implementation of national guidance has led to an increase in preconception diagnosis and treatment, earlier initiation of antenatal treatment, a reduction in the number of women with a detectable viral load at delivery, and an increase in vaginal deliveries.
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Sherr L, Haag K, Steventon Roberts KJ, Cluver LD, Wittesaele C, Saliwe B, Tolmay J, Langwenya N, Jochim J, Saal W, Zhou S, Marlow M, Chen-Charles JJ, Toska E. The development of children born to young mothers with no, first- or second-generation HIV acquisition in the Eastern Cape province, South Africa: a cross-sectional study. BMJ Open 2022; 12:e058340. [PMID: 36229140 PMCID: PMC9562751 DOI: 10.1136/bmjopen-2021-058340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 10/03/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The intergenerational effects of HIV require long-term investigation. We compared developmental outcomes of different generations impacted by HIV-children of mothers not living with HIV, the 'second generation' (ie, with recently infected mothers) and the 'third generation' (ie, children of perinatally infected mothers). METHODS A cross-sectional community sample of N=1015 young mothers (12-25 years) and their first children (2-68 months, 48.2% female), from South Africa's Eastern Cape Province. 71.3% (n=724) of children were born to mothers not living with HIV; 2.7% (n=27; 1 living with HIV) were third-generation and 26.0% (n=264; 11 living with HIV) second-generation children. Child scores on the Mullen Scales of Early Learning (MSEL), the WHO Ten Questions Screen for Disability and maternal demographics were compared between groups using χ2 tests and univariate approach, analysis of variance analysis. Hierarchical linear regressions investigated predictive effects of familial HIV infection patterns on child MSEL composite scores, controlling for demographic and family environment variables. RESULTS Second-generation children performed poorer on gross (M=47.0, SD=13.1) and fine motor functioning (M=41.4, SD=15.2) and the MSEL composite score (M=90.6, SD=23.0) than children with non-infected mothers (gross motor: M=50.4, SD=12.3; fine motor: M=44.4, SD=14.1; composite score: M=94.1, SD=20.7). The third generation performed at similar levels to non-exposed children (gross motor: M=52.4, SD=16.1; fine motor: M=44.3, SD=16.1, composite score: M=94.7, SD=22.2), though analyses were underpowered for definite conclusions. Hierarchical regression analyses suggest marginal predictive effects of being second-generation child compared with having a mother not living with HIV (B=-3.3, 95% CI=-6.8 to 0 .1) on MSEL total scores, and non-significant predictive effects of being a third-generation child (B=1.1, 5% CI=-7.5 to 9.7) when controlling for covariates. No group differences were found for disability rates (26.9% third generation, 27.7% second generation, 26.2% non-exposed; χ2=0.02, p=0.90). CONCLUSION Recently infected mothers and their children may struggle due to the disruptiveness of new HIV diagnoses and incomplete access to care/support during pregnancy and early motherhood. Long-standing familial HIV infection may facilitate care pathways and coping, explaining similar cognitive development among not exposed and third-generation children. Targeted intervention and fast-tracking into services may improve maternal mental health and socioeconomic support.
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Affiliation(s)
- Lorraine Sherr
- Institute for Global Health, University College London, London, UK
| | | | - Kathryn J Steventon Roberts
- Institute for Global Health, University College London, London, UK
- Department of Social Policy & Intervention, University of Oxford, Oxford, UK
| | - Lucie Dale Cluver
- Department of Social Policy & Intervention, University of Oxford, Oxford, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Camille Wittesaele
- Department of Social Policy & Intervention, University of Oxford, Oxford, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Bongiwe Saliwe
- Centre for Social Science Research, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Janke Tolmay
- Centre for Social Science Research, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Nontokozo Langwenya
- Department of Social Policy & Intervention, University of Oxford, Oxford, UK
| | - Janina Jochim
- Department of Social Policy & Intervention, University of Oxford, Oxford, UK
| | - Wylene Saal
- School of Humanities, Sol Plaatje University, Kimberly, South Africa
| | - Siyanai Zhou
- Centre for Social Science Research, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Marguerite Marlow
- Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Stellenbosch, Western Cape, South Africa
| | | | - Elona Toska
- Department of Social Policy & Intervention, University of Oxford, Oxford, UK
- Centre for Social Science Research, University of Cape Town, Rondebosch, Western Cape, South Africa
- Department of Sociology, University of Cape Town, Rondebosch, Western Cape, South Africa
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9
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Jones AJ, Eke UA, Eke AC. Prediction and prevention of preterm birth in pregnant women living with HIV on antiretroviral therapy. Expert Rev Anti Infect Ther 2022; 20:837-848. [PMID: 35196941 PMCID: PMC9133156 DOI: 10.1080/14787210.2022.2046463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/22/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The rate of spontaneous preterm-birth among pregnant women living with HIV on antiretroviral therapy (ART) is 3- to 4-fold higher when compared to HIV-negative women. The pathophysiology of preterm-birth related to HIV or ART remains unknown, especially as women living with HIV are often excluded from preterm birth studies. AREAS COVERED This review discusses the currently available evidence on the prediction and prevention of preterm-birth in pregnant women living with HIV. A review of the literature was conducted of primary articles between 2005 and 2021 measuring the association or lack thereof between combination ART and preterm birth, as well as of other predisposing factors to preterm birth in women living with HIV, including cervical length, vaginal microbiome, and cervico-vaginal biomarkers. EXPERT OPINION Further research into the effect of ART exposure on preterm-birth risk is critical, and development of preterm-birth predictive tools in this population should be a priority. Vaginal progesterone supplementation deserves further investigation as a therapeutic option to prevent recurrent preterm birth in pregnant women living with HIV. The ProSPAR study, a multicenter randomized controlled trial studying progesterone supplementation in pregnant women on protease inhibitor-based regimens, has been designed but is not yet recruiting patients.
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Affiliation(s)
| | - Uzoamaka A Eke
- Division of Infectious Diseases and Institute of Human Virology, Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, United States of America
| | - Ahizechukwu C Eke
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore
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10
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Adverse perinatal outcomes associated with HAART and monotherapy: systematic review and meta-analysis. AIDS 2022; 36:1409-1427. [PMID: 35608111 DOI: 10.1097/qad.0000000000003248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Assess adverse perinatal outcomes in women living with HIV (WLHIV) receiving HAART or zidovudine (ZDV) monotherapy, compared with antiretroviral therapy (ART)-naive WLHIV and HIV-negative women. DESIGN Systematic review and meta-analysis. METHODS We conducted a systematic literature review by searching PubMed, CINAHL, Global Health, and EMBASE for studies published during 1 January 1980 to 20 April 2020. We included studies reporting on the association of pregnant WLHIV receiving HAART or ZDV monotherapy with 11 perinatal outcomes: preterm birth (PTB), very PTB, spontaneous PTB (sPTB), low birth weight (LBW), very LBW, term LBW, preterm LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Random-effects meta-analyses were conducted. RESULTS Sixty-one cohort studies assessing 409 781 women were included. WLHIV receiving ZDV monotherapy were associated with a decreased risk of PTB [relative risk 0.70, 95% confidence interval (CI) 0.62-0.79] and LBW (0.77, 0.67-0.88), and comparable risk of SGA, compared with ART-naive WLHIV. WLHIV receiving ZDV monotherapy had a comparable risk of PTB and LBW, and an increased risk of SGA (1.16, 1.04-1.30) compared with HIV-negative women. In contrast, WLHIV receiving HAART were associated with a comparable risk of PTB and LBW, and increased risk of SGA (1.38, 1.09-1.75), compared with ART-naive WLHIV. WLHIV receiving HAART were associated with an increased risk of PTB (1.55, 1.38-1.74), sPTB (2.09, 1.48-2.96), LBW (1.79, 1.51-2.13), term LBW (1.88, 1.23-2.85), SGA (1.80,1.34-2.40), and VSGA (1.22, 1.10-1.34) compared with HIV-negative women. CONCLUSION Pregnant WLHIV receiving HAART have an increased risk of a wide range of perinatal outcomes compared with HIV-negative women.
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11
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Moseholm E, Katzenstein TL, Pedersen G, Johansen IS, Wienecke LS, Storgaard M, Obel N, Weis N. Use of antiretroviral therapy in pregnancy and association with birth outcome among women living with HIV in Denmark: A nationwide, population-based cohort study. HIV Med 2022; 23:1007-1018. [PMID: 35388607 PMCID: PMC9545374 DOI: 10.1111/hiv.13304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/25/2022] [Accepted: 03/12/2022] [Indexed: 11/28/2022]
Abstract
Objective To describe antiretroviral therapy (ART) regimens during pregnancy among women living with HIV (WLWH) in Denmark and to examine the association between ART use in pregnancy and adverse birth outcomes. Methods A population‐based cohort study including all pregnancies among WLWH in Denmark between 2000 and 2019. Data were collected through national registries. Temporal trends of ART use in pregnancy were evaluated. Logistic regression models were used to examine the association of ART use in pregnancy and other risk factors with adverse birth outcomes. Results In total, 589 pregnancies were included. Combination treatment with a nucleoside reverse transcriptase inhibitor (NRTI) and a protease inhibitor (PI) was the most common ART regimen (96%). ART regimen, PI use in pregnancy and timing of ART initiation were not significantly associated with increased odds of preterm birth, small for gestational age or low birth weight. First‐trimester initiation of ART was significantly associated with increased odds of intrauterine growth restriction in the multivariate analysis [adjusted odds ratio (aOR) = 3.78, 95% confidence interval (CI): 1.23–11.59], while first trimester PI use was associated with increased odds of IUGR in the univariate analysis only [OR = 3.24, 95% CI: 1.13–9.30]. Smoking, comorbidity, and maternal HIV RNA ≥ 50 copies/mL were independently associated with increased odds of adverse birth outcomes. Conclusions Pregnant WLWH living in Denmark are generally well treated with HIV RNA < 50 copies/mL at delivery and NRTI + PI as the most common ART regimen used in pregnancy. Initiation of ART in the first trimester may be associated with poor fetal growth. The association between ART use in pregnancy and adverse birth outcomes may partly be explained by maternal risk factors.
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Affiliation(s)
- Ellen Moseholm
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark.,Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Terese Lea Katzenstein
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Gitte Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nina Weis
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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12
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Mdletshe N, Thobakgale C, Malaba TR, Madlala H, Myer L, Muema DM, Mogeni P, Gray CM, Altfeld M, Newell ML, Ndung'u T. Low immune activation in early pregnancy is associated with preterm but not small-for-gestational age delivery in HIV infected women initiating antiretroviral therapy in pregnancy: a PIMS case-control study in Cape Town, South Africa. Clin Infect Dis 2021; 73:2205-2216. [PMID: 33606024 PMCID: PMC8677566 DOI: 10.1093/cid/ciab151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Indexed: 12/24/2022] Open
Abstract
Background Mechanisms underlying an association between human immunodeficiency virus (HIV) or antiretroviral therapy (ART) during pregnancy with risk of preterm delivery (PTD) and small-for-gestational-age (SGA) remain unclear. We explored the association between cellular immune activation and PTD or SGA in women with HIV initiating ART during or before pregnancy. Methods Women with HIV enrolled at median 15 weeks’ gestation, were analyzed for immune markers, and matched on ART initiation timing (15 women initiated pre- and 15 during pregnancy). There were 30 PTD (delivery <37 weeks), 30 SGA (weight for age ≤10th percentile) cases, and 30 controls (term, weight for gestational age >25th percentile) as outcomes. Lymphocytes, monocytes, and dendritic cell populations and their activation status or functionality were enumerated by flow cytometry. Results PTD cases initiating ART in pregnancy showed decreased CD8+ T cell, monocyte, and dendritic cell activation; increased classical (CD14+CD16–) and intermediate (CD14+CD16+) monocyte frequencies; and decreased inflammatory monocytes (CD14dimCD16+) compared with SGA cases and term controls (all P < .05). Allowing for baseline viral load, the immune markers remained significantly associated with PTD but only in women initiating ART in pregnancy. Lower monocyte activation was predictive of PTD. TLR ligand-induced interferon-α and macrophage inflammatory protein-1β levels in monocytes were significantly lower in PTD women initiating ART in pregnancy. Conclusion Low immune activation, skewing toward anti-inflammatory monocytes, and lower monocyte cytokine production in response to TLR ligand stimulation were associated with PTD but not SGA among women initiating ART in, but not before, pregnancy, suggesting immune anergy to microbial stimulation as a possible underlying mechanism for PTD in women initiating ART in pregnancy.
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Affiliation(s)
- Nontlantla Mdletshe
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal (UKZN), Durban, South Africa
| | - Christina Thobakgale
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal (UKZN), Durban, South Africa.,School of Pathology, National Institute for Communicable Diseases and the University of the Witwatersrand, Johannesburg, South Africa
| | - Thokozile R Malaba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Hlengiwe Madlala
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Polycarp Mogeni
- Africa Health Research Institute, Durban, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,KwaZulu-Natal Innovation and Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, South Africa
| | - Clive M Gray
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Marcus Altfeld
- Department of Viral Immunology, Heinrich-Pette-Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany
| | - Marie-Louise Newell
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thumbi Ndung'u
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal (UKZN), Durban, South Africa.,Africa Health Research Institute, Durban, South Africa.,Max Planck Institute for Infection Biology, Berlin, Germany.,Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts, USA.,Division of Infection and Immunity, University College London, London, United Kingdom
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13
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Management of Viral Complications of Pregnancy: Pharmacotherapy to Reduce Vertical Transmission. Obstet Gynecol Clin North Am 2021; 48:53-74. [PMID: 33573790 DOI: 10.1016/j.ogc.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Viral infections are common complications of pregnancy. Although some infections have maternal sequelae, many viral infections can be perinatally transmitted to cause congenital or chronic infection in fetuses or infants. Treatments of such infections are geared toward reducing maternal symptoms and complications and toward preventing maternal-to-child transmission of viruses. The authors review updates in the treatment of herpes simplex virus, cytomegalovirus, hepatitis B and C viruses, human immunodeficiency virus, and COVID-19 during pregnancy.
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14
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Michaelis IA, Krägeloh-Mann I, Manyisane N, Mazinu MC, Jordaan ER. Prospective cohort study of mortality in very low birthweight infants in a single centre in the Eastern Cape province, South Africa. BMJ Paediatr Open 2021; 5:e000918. [PMID: 33665373 PMCID: PMC7893654 DOI: 10.1136/bmjpo-2020-000918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 11/25/2022] Open
Abstract
Background Neonatal mortality is a major contributor worldwide to the number of deaths in children under 5 years of age. The primary objective of this study was to assess the overall mortality rate of babies with a birth weight equal or below 1500 g in a neonatal unit at a tertiary hospital in the Eastern Cape Province, South Africa. Furthermore, different maternal-related and infant-related factors for higher mortality were analysed. Methods This is a prospective cohort study which included infants admitted to the neonatal wards of the hospital within their first 24 hours of life and with a birth weight equal to or below 1500 g. Mothers who consented answered a questionnaire to identify factors for mortality. Results 173 very low birth weight (VLBW) infants were recruited in the neonatal department between November 2017 and December 2018, of whom 55 died (overall mortality rate 32.0%). Twenty-three of the 44 infants (53,5%) with a birth weight below 1000 g died during the admission. One hundred and sixty-one mothers completed the questionnaire and 45 of their babies died.Main factors associated with mortality were lower gestational age and lower birth weight. Need for ventilator support and sepsis were associated with higher mortality, as were maternal factors such as HIV infection and age below 20 years. Conclusion This prospective study looked at survival of VLBW babies in an underprivileged part of the Eastern Cape of South Africa. Compared with other public urban hospitals in the country, the survival rate remains unacceptably low. Further research is required to find the associated causes and appropriate ways to address these.
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Affiliation(s)
- Isabel A Michaelis
- Paediatrics, Walter Sisulu University, Mthatha, Eastern Cape, South Africa
| | - Ingeborg Krägeloh-Mann
- Children's Hospital, Neuropaediatrics, Developmental Neurology, Social Paediatrics, Eberhard Karls University Tübingen Faculty of Medicine, Tübingen, Baden-Württemberg, Germany
| | - Ncomeka Manyisane
- Paediatrics, Walter Sisulu University, Mthatha, Eastern Cape, South Africa
| | - Mikateko C Mazinu
- Biostatistics unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
| | - Esme R Jordaan
- Biostatistics unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
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15
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Elenga N, Djossou F, Nacher M. Association between maternal human immunodeficiency virus infection and preterm birth: A matched case-control study from a pregnancy outcome registry. Medicine (Baltimore) 2021; 100:e22670. [PMID: 33530154 PMCID: PMC7850744 DOI: 10.1097/md.0000000000022670] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 09/10/2020] [Indexed: 01/05/2023] Open
Abstract
This study aimed to evaluate the relationships between different types of antiretroviral therapy (ART) and preterm birth.Preterm birth was studied among all singleton pregnancies and compared between human immunodeficiency virus (HIV)-infected and uninfected women.We performed a matched case-control study from the pregnancy outcome registry of Cayenne Hospital. HIV-infected and uninfected women who delivered in the maternity ward of Cayenne Hospital from January 1, 2013 to December 31, 2015 were studied. We conducted an initial analysis to determine the risk factors for preterm birth among HIV-infected pregnant women. We also evaluated associations between exposure to antiretroviral therapy (ART) and preterm birth.There were 8682 deliveries; of these, 117 involved HIV-infected women, representing a prevalence of 1.34%. There were 470 controls. The sociodemographic characteristics were comparable. HIV-infected women were more likely to experience preterm birth (adjusted odds ratio [AOR] = 3.9, 95% confidence interval [CI] 1.5-9.9). Overall, 95.73% of the women received antiretroviral therapy before becoming pregnant, and they were in good clinical condition. The median CD4 count at the beginning of pregnancy was 500 cells/mm3 (357-722). Additionally, 53% of HIV-infected women had an undetectable viral load count (<20 copies/mL). Their median haemoglobin level was 120 g/L (100-120). There were 2 human immunodeficiency virus-infected babies. A higher rate of preterm birth was associated with protease inhibitor-based ART than a reverse transcriptase inhibitor-based ART regimen. The sample size being small this result would be considered with caution.The preterm birth rate among HIV-infected pregnant women was twice that of the general population; this trend was not explained by sociodemographic characteristics. Preterm birth was independently associated with combination ART, especially with ritonavir-boosted protease inhibitor therapy during pregnancy.
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Affiliation(s)
| | | | - Mathieu Nacher
- Centre d’Investigation Clinique Antilles-Guyane, Inserm 1424, Andrée Rosemon Regional Hospital, Rue des flamboyants, Cayenne Cedex, French Guiana
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16
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Bhengu BS, Tomita A, Mashaphu S, Paruk S. The Role of Adverse Childhood Experiences on Perinatal Substance Use Behaviour in KwaZulu-Natal Province, South Africa. AIDS Behav 2020; 24:1643-1652. [PMID: 31542877 DOI: 10.1007/s10461-019-02661-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The role of risky sexual behaviour has been widely investigated across the sub-Saharan African HIV hyperendemic setting, with few studies having focused on the behaviour attributed to the deep-rooted, neurodevelopmentally-driven adverse childhood experiences (ACE) that sustain the endemic. We investigated the role of ACE on perinatal substance use outcomes in KwaZulu-Natal Province, South Africa, with 223 women being interviewed within one-week post-partum at a general hospital. Our secondary outcome was the occurrence of preterm birth delivery, which is understood to be linked to ACE. Study results suggest that the most common perinatal substance use was alcohol (n = 27, 12.11%), followed by tobacco (n = 18, 8.07%), with the prevalence of preterm birth delivery being 8.97% (n = 20, 8.97%). Regression analyses indicated increased ACE being significantly associated with perinatal alcohol (aOR = 1.45, 95% CI 1.22-1.72), tobacco use (aOR = 1.56, 95% CI 1.23-1.97) and preterm birth delivery (aOR = 1.21, 95% CI 1.03-1.43), independent of socio-economic status. When the model was further adjusted by HIV status, suppressed viral load was more significantly associated with lower odds of preterm birth delivery (aOR = 0.06, 95% CI: 0.01-0.24) than an unsuppressed status. Risk-behaviour reduction strategies should address the role of ACE on substance use and viral load, and hence possibly ART adherence, in HIV hyperendemic settings.
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17
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Liff I, Zash R, Mingochi D, Gaonakala FT, Diseko M, Mayondi G, Johnson K, James K, Makhema J, Shapiro R, Wylie BJ. Mid-trimester cervical length not associated with HIV status among pregnant women in Botswana. PLoS One 2020; 15:e0229500. [PMID: 32160214 PMCID: PMC7065819 DOI: 10.1371/journal.pone.0229500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 02/09/2020] [Indexed: 11/21/2022] Open
Abstract
Objective HIV-infected women on antiretroviral therapy have a higher risk of preterm birth than HIV-uninfected women in Botswana. To better understand the mechanism for preterm birth among HIV-infected women, we evaluated whether mid-trimester cervical length differed by HIV status as cervical shortening is associated with an increased risk for preterm birth. Methods We conducted a prospective cohort study among pregnant women receiving care at the Scottish Livingstone Hospital in Molepolole, Botswana. Consecutive women referred for routine obstetrical ultrasound were consented and enrolled if between 22w0d and 24w6d by ultrasound biometry. Blinded to maternal HIV status, an obstetrician measured transvaginal cervical length using standardized criteria. Cervical length, as well as the proportion of women with a short cervix (<25mm), were compared among HIV-infected and HIV-uninfected women. The acceptability of transvaginal ultrasound was also evaluated. Results Between April 2016 and April 2017, 853 women presenting for obstetric ultrasound were screened, 187 (22%) met eligibility criteria, and 179 (96%) were enrolled. Of those enrolled, 50 (28%) were HIV-infected (86% on antiretroviral therapy), 127 (71%) were HIV-uninfected, and 2 (1%) had unknown HIV status. There was no significant difference in mean cervical length between HIV-infected and HIV-uninfected women (32mm vs 31mm, p = 0.21), or in the proportion with a short cervix (10% vs 14%, p = 0.44). Acceptability data was available for 115 women who underwent a transvaginal ultrasound exam. Of these, 112 of 115 (97%) women deemed the transvaginal scan acceptable. Conclusions The increased risk of preterm birth observed among HIV-infected women receiving antiretroviral therapy in Botswana is unlikely associated with mid-trimester cervical shortening. Further research is needed to understand the underlying mechanism for preterm birth among HIV-infected women.
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Affiliation(s)
- Ingrid Liff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
- * E-mail:
| | - Rebecca Zash
- Department of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | - Modiegi Diseko
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Gloria Mayondi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Katherine Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Kaitlyn James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Roger Shapiro
- Department of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Blair J. Wylie
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
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18
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Use of Antiretroviral Therapy During Pregnancy and Adverse Birth Outcomes Among Women Living With HIV-1 in Low- and Middle-Income Countries: A Systematic Review. J Acquir Immune Defic Syndr 2019; 79:1-9. [PMID: 29847475 DOI: 10.1097/qai.0000000000001770] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Worldwide, nearly 18 million women of reproductive age are living with HIV-1. Although increased access to antiretroviral therapy (ART) during pregnancy has significantly reduced HIV-1 mother-to-child transmission (MTCT), a similarly robust reduction in preterm birth (PTB) and low birthweight (LBW) among infants born to women living with HIV has not been observed. This study was designed to identify associations between classes of ART regimens and risk of PTB or LBW. SETTING Low- and middle-income countries. METHODS We conducted a systematic review of randomized and observational studies that assessed the effect of ART regimen on the risk of PTB (≤37 completed weeks of gestation) or LBW (<2500 g at birth) among pregnant women in low- and middle-income countries living with HIV-1. We searched Medline, COCHRANE, Web of Science, SCOPUS, and CPCI-S for included studies. RESULTS When compared to monotherapy, both nonnucleoside reverse transcriptase inhibitor- and protease inhibitor-based regimens had a consistent, harmful association with LBW. There is mixed evidence suggesting both potential harm and potential benefit for most other regimens on risk of LBW and PTB, and the harmful or protective effects of certain regimens varies depending on the drug backbone. CONCLUSIONS Although the benefits of ART during pregnancy for prevention of MTCT are undisputed, this systematic review indicates that ART regimens vary substantially in their association with LBW and PTB. Although challenging, optimization of ART regimens could simultaneously promote maternal health, prevent MTCT, and also minimize risks of PTB and LBW.
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Balogun KA, Guzman Lenis MS, Papp E, Loutfy M, Yudin MH, MacGillivray J, Walmsley SL, Silverman M, Serghides L. Elevated Levels of Estradiol in Human Immunodeficiency Virus-Infected Pregnant Women on Protease Inhibitor-Based Regimens. Clin Infect Dis 2019; 66:420-427. [PMID: 29020282 DOI: 10.1093/cid/cix761] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/21/2017] [Indexed: 01/30/2023] Open
Abstract
Background Human immunodeficiency virus (HIV)-infected pregnant women on protease inhibitor (PI)-based combination antiretroviral therapy (cART) have a greater risk for adverse birth outcomes, and an association with steroid hormone levels has been implicated. The objective of this study was to investigate the association between PI-cART and estradiol levels in pregnancy. Methods Fifty-five HIV-infected and 49 HIV-uninfected Canadian pregnant women were followed prospectively throughout gestation. All HIV-infected women were on a PI-based cART regimen. Maternal plasma samples were collected at 12-18 weeks, 24-28 weeks, 34-38 weeks, at delivery, and from the cord. Birth outcomes were recorded. Levels of estradiol, dehydroepiandrosterone sulfate (DHEAS), sex hormone-binding globulin (SHBG), cortisol, and adrenocorticotropic hormone (ACTH) were quantified by enzyme-linked immunosorbent assay. Results (median [interquartile range] for cord estradiol: 23.9 ng/mL [16.4-36.4] for HIV-infected exposed to PI-cART and 15.7 ng/mL [12.2-21.2] for HIV-negative; P = .0025). HIV-infected women had higher DHEAS levels in cord plasma that correlated with cord and maternal delivery estradiol levels. Cortisol and ACTH levels did not differ between groups. In the HIV-infected women, cord estradiol levels correlated negatively with birth weight centile (r = -0.47, P = .0016). Conclusions Our data suggest that PI-cART exposure in pregnancy is associated with elevated levels of estradiol, likely driven by higher fetal DHEAS production. Cord estradiol levels were inversely correlated with birth weight centile in infants born to PI-cART-exposed women, suggesting that fetal exposure to high estradiol levels may be contributing to cART-associated fetal growth restriction.
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Affiliation(s)
- Kayode A Balogun
- Toronto General Research Institute, University Health Network, Canada
| | | | - Eszter Papp
- Toronto General Research Institute, University Health Network, Canada
| | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital, Canada.,Department of Medicine, University of Toronto, Canada.,St Michael's Hospital, Canada
| | - Mark H Yudin
- Department of Medicine, University of Toronto, Canada.,St Michael's Hospital, Canada.,Department of Obstetrics and Gynaecology, University of Toronto, Canada
| | | | - Sharon L Walmsley
- Toronto General Research Institute, University Health Network, Canada.,Department of Medicine, University of Toronto, Canada
| | | | - Lena Serghides
- Toronto General Research Institute, University Health Network, Canada.,Women's College Research Institute, Women's College Hospital, Canada.,Department of Immunology and Institute of Medical Sciences, University of Toronto, Canada
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20
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Abstract
Viral infections are common complications of pregnancy. Although some infections have maternal sequelae, many viral infections can be perinatally transmitted to cause congenital or chronic infection in fetuses or infants. Treatments of such infections are geared toward reducing maternal symptoms and complications and toward preventing maternal-to-child transmission of viruses. This article reviews the treatment of herpes simplex virus, cytomegalovirus, hepatitis B and C viruses, and human immunodeficiency virus during pregnancy.
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Affiliation(s)
- Sarah C Rogan
- Maternal and Fetal Medicine Division, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA
| | - Richard H Beigi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Magee-Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213, USA.
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21
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Abdi F, Alimoradi Z, Alidost F. Pregnancy outcomes and effects of antiretroviral drugs in HIV-positive pregnant women: a systematic review. Future Virol 2019. [DOI: 10.2217/fvl-2018-0213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: Despite the clear morbidity, mortality and vertical transmission rates in women infected with HIV, there is still controversy surrounding the relationship between maternal infection and adverse neonatal outcomes. Antiretroviral therapy during pregnancy is considered the main and most effective method for reducing the vertical transmission of infection. However, there is no consensus over potential associations between antiretroviral therapy and adverse pregnancy outcomes. This systematic review focuses on the effects of antiretroviral drugs on pregnancy outcomes in HIV-positive women. Methods: After searching MEDLINE, the Cochrane Database of Systematic Reviews, the ISI Web of Sciences and EMBASE, 570 potentially eligible papers were identified. Only 32 papers were selected based on the inclusion criteria. Results: The most prevalent adverse pregnancy outcomes were low birth weight, preterm birth and stillbirth. Conclusion: Considering the higher prevalence of adverse pregnancy outcomes in HIV-infected women, HIV screening methods should be administered in all pregnant women. Appropriate treatment modalities should also be selected to minimize adverse pregnancy outcomes.
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Affiliation(s)
- Fatemeh Abdi
- Student Research Committee, Nursing & Midwifery Faculty, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zainab Alimoradi
- Department of Midwifery, Nursing & Midwifery Faculty, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Farzane Alidost
- Department of Reproductive Health, Nursing & Midwifery Faculty, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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22
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Price JT, Vwalika B, Freeman BL, Cole SR, Mulenga HB, Winston J, Mbewe FM, Chomba E, Mofenson LM, Rouse DJ, Goldenberg RL, Stringer JSA. Intramuscular 17-hydroxyprogesterone caproate to prevent preterm birth among HIV-infected women in Zambia: study protocol of the IPOP randomized trial. BMC Pregnancy Childbirth 2019; 19:81. [PMID: 30813934 PMCID: PMC6391830 DOI: 10.1186/s12884-019-2224-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Each year, an estimated 15 million babies are born preterm, a global burden borne disproportionately by families in lower-income countries. Maternal HIV infection increases a woman's risk of delivering prematurely, and antiretroviral therapy (ART) may compound this risk. While prenatal progesterone prophylaxis prevents preterm birth among some high-risk women, it is unknown whether HIV-infected women could benefit from this therapy. We are studying the efficacy of progesterone supplementation to reduce the risk of preterm birth among pregnant women with HIV in Lusaka, Zambia. METHODS The Improving Pregnancy Outcomes with Progesterone (IPOP) study is a Phase III double-masked, placebo-controlled, randomized trial of intramuscular 17-alpha hydroxprogesterone caproate (17P) to prevent preterm birth in HIV-infected women. A total of 800 women will be recruited prior to 24 weeks of gestation and randomly allocated to 17P or placebo administered by weekly intramuscular injection. The primary outcome will be a composite of live birth prior to 37 completed gestational weeks or stillbirth at any gestational age. Secondary outcomes will include very preterm birth (< 34 weeks), extreme preterm birth (< 28 weeks), small for gestational age (<10th centile), low birth weight (< 2500 g), and neonatal outcomes. In secondary analysis, we will assess whether specific HIV-related covariates, including the timing of maternal ART initiation relative to conception, is associated with progesterone's prophylactic efficacy, if any. DISCUSSION We hypothesize that weekly prenatal 17P will reduce the risk of HIV-related preterm birth. An inexpensive intervention to prevent preterm birth among pregnant women with HIV could have substantial global public health impact. TRIAL REGISTRATION NCT03297216 ; September 29, 2017.
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Affiliation(s)
- Joan T Price
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 3009 Old Clinic Building, Campus Box 7577, Chapel Hill, NC, 27599-7577, USA. .,Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia.
| | - Bellington Vwalika
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 3009 Old Clinic Building, Campus Box 7577, Chapel Hill, NC, 27599-7577, USA.,Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Bethany L Freeman
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 3009 Old Clinic Building, Campus Box 7577, Chapel Hill, NC, 27599-7577, USA
| | - Stephen R Cole
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Jennifer Winston
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 3009 Old Clinic Building, Campus Box 7577, Chapel Hill, NC, 27599-7577, USA
| | | | - Elwyn Chomba
- Department of Paediatrics, University Teaching Hospital, Lusaka, Zambia
| | | | - Dwight J Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, RI, USA
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Jeffrey S A Stringer
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 3009 Old Clinic Building, Campus Box 7577, Chapel Hill, NC, 27599-7577, USA
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Abstract
OBJECTIVES The aim of this study was to investigate whether specific nucleoside reverse transcriptase inhibitor (NRTI) backbones are associated with risk of adverse pregnancy outcomes among pregnant women starting antiretroviral therapy (ART). DESIGN Seven observational studies across eight European countries of pregnancies in HIV-positive women. METHODS Individual-level data were pooled on singleton pregnancies conceived off-ART in which a single combination ART regimen was initiated at least 2 weeks before delivery, and ending in a live birth in 2008-2014. Preterm delivery (PTD) was defined as less than 37 gestational weeks and small-for-gestational-age (SGA) as less than 10th percentile according to INTERGROWTH standards. Poisson regression models were fitted to investigate associations between NRTI backbones and PTD/SGA. RESULTS Out of 7193 pregnancies, 45% (3207) were in UK/Ireland, 44% (3134) in Ukraine. 10% (722/7193) of deliveries were preterm and 11.1% (785/7089) of newborns SGA. The most common NRTI backbones were zidovudine (ZDV)-lamivudine (3TC) (71%), tenofovir (TDF)-XTC (16%) and abacavir (ABC)-3TC (10%) with TDF-containing backbone use increasing over time. Overall, 77% of regimens contained ritonavir-boosted lopinavir (LPV/r). There was no association between NRTI backbone and PTD in main adjusted analyses [adjusted prevalence ratios (aPRs) 0.97 (95% confidence interval, 95% CI 0.73-1.28] for ABC-3TC and aPR 1.06 (95% CI 0.83-1.35) for TDF-XTC, both vs. ZDV-3TC) or in 4720 pregnancies on LPV/r [aPR 1.03 (95% CI 0.74-1.43) for ABC-3TC and aPR 1.16 [0.85-1.57] for TDF-XTC, both vs. ZDV-3TC]. Infants exposed to ABC-3TC or TDF-XTC in utero were less likely to be SGA than those exposed to ZDV-3TC [aPR 0.72 (95% CI 0.53-0.97) and aPR 0.70 (95% CI 0.53-0.93), respectively]. CONCLUSION Results support the safety of TDF-XTC backbones initiated in pregnancy with respect to gestation length and birthweight.
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24
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HIV treatment in pregnancy. Lancet HIV 2018; 5:e457-e467. [PMID: 29958853 DOI: 10.1016/s2352-3018(18)30059-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 01/15/2023]
Abstract
Almost 25 years since antiretroviral therapy (ART) was first shown to prevent mother-to-child transmission of HIV, 76% of pregnant women living with HIV (over 1 million women) receive ART annually. This number is the result of successes in universal ART scale-up in low-income and middle-income countries. Despite unprecedented ART-related benefits to maternal and child health, challenges remain related to ART adherence, retention in care, and unequal access to ART. Implementation research is ongoing to understand and to address obstacles that lead to loss to follow-up. The biological mechanisms that underlie observed associations between antenatal ART and adverse outcomes in pregnancy and birth are not completely understood, with further research needed as well as strengthening of the systems to assess safety of antiretroviral drugs for the mother and HIV-exposed child. In the treat-all era, as duration of treatment and options for ART expand, pregnant women will remain a priority population for treatment optimisation to promote their health and that of their ART-exposed children.
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25
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Wang L, Zhao H, Cai W, Tao J, Zhao Q, Sun L, Fan Q, Kourtis AP, Shepard C, Zhang F. Risk factors associated with preterm delivery and low delivery weight among HIV-exposed neonates in China. Int J Gynaecol Obstet 2018; 142:300-307. [PMID: 29772068 DOI: 10.1002/ijgo.12532] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/26/2018] [Accepted: 05/15/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine the relationship between combination antiretroviral therapy (cART) and preterm delivery (PTD) or low delivery weight among pregnant Chinese women with HIV. METHODS The present retrospective cross-sectional medical chart review enrolled pregnant women with HIV who delivered at five tertiary hospitals in China between January 1, 2009, and December 31, 2014. Generalized linear mixed modeling was used to explore PTD (<37 weeks of pregnancy) and low delivery weight (<2500 g) risk factors. RESULTS Among 731 mother-neonate pairs, 93 (12.7%) mothers had PTD and 133 (18.2%) neonates had low delivery weight. Use of cART pre-conception or its initiation in the first trimester was associated with PTD (adjusted odds ratio [aOR] 2.82; P=0.002) and low delivery weight (aOR 1.92; P=0.026). First-trimester cART initiation was associated with PTD for lopinavir/ritonavir (aOR 2.59; P=0.006) and nevirapine (aOR, 2.64; P=0.003) regimens compared with later; the same was not true for efavirenz-based cART (P=0.197). Low maternal body mass index (≤23.5) before delivery was independently associated with an increased likelihood of low delivery weight (aOR 1.60; P=0.038) but not PTD. CONCLUSION Early use of cART was associated with increased likelihood of PTD and low delivery weight. Efavirenz-based cART appeared to be favorable for women with HIV regardless of the timing of cART initiation. Good nutritional status is essential to prevent low delivery weight.
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Affiliation(s)
- Liming Wang
- Beijing Ditan Hospital, Capital Medical University, Beijing, China.,Clinical Center for HIV/AIDS, Capital Medical University, Beijing, China.,Division of Global HIV/TB-China Office, US Centers for Disease Control and Prevention, Beijing, China
| | - Hongxin Zhao
- Beijing Ditan Hospital, Capital Medical University, Beijing, China.,Clinical Center for HIV/AIDS, Capital Medical University, Beijing, China
| | - Weiping Cai
- Guangzhou No. 8 People's Hospital, Guangdong, China
| | - Jie Tao
- Liuzhou Maternal and Child Health Hospital, Guangxi, China
| | | | - Lijun Sun
- Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Qingbo Fan
- Peking Union Medical College Hospital, Beijing, China
| | - Athena P Kourtis
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Colin Shepard
- Division of Global HIV/TB-China Office, US Centers for Disease Control and Prevention, Beijing, China
| | - Fujie Zhang
- Beijing Ditan Hospital, Capital Medical University, Beijing, China.,Clinical Center for HIV/AIDS, Capital Medical University, Beijing, China
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26
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Dara JS, Hanna DB, Anastos K, Wright R, Herold BC. Low Birth Weight in Human Immunodeficiency Virus-Exposed Uninfected Infants in Bronx, New York. J Pediatric Infect Dis Soc 2018; 7:e24-e29. [PMID: 29301007 PMCID: PMC5954301 DOI: 10.1093/jpids/pix111] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/30/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Prevention of mother-to-child transmission of human immunodeficiency virus (HIV) with antiretroviral therapy (ART) has been highly successful. However, HIV-exposed uninfected (HIV-EU) infants might be at increased risk for low birth weight and/or preterm birth. We compared the birth weights and gestational ages of HIV-EU infants to those of HIV-unexposed control infants in Bronx, New York, an epicenter of the HIV epidemic in the United States. METHODS This study was performed with a retrospective cohort of HIV-EU infants born at Montefiore Medical Center between 2008 and 2012 and HIV-unexposed control infants. Each HIV-EU infant was matched according to year of birth with 5 HIV-unexposed controls from the New York City Department of Health and Mental Hygiene birth certificate database. We used regression models to assess the association between HIV exposure and birth weight while controlling for potential confounders. A secondary analysis was performed to determine the association of maternal protease inhibitor-based ART use and birth weight among HIV-EU infants. RESULTS We included 155 HIV-EU infants born between 2008 and 2012 (51% female, 61% black, 32% Hispanic) and 775 HIV-unexposed infants. The mean (± standard deviation) unadjusted birth weights were 2971 ± 616 g (HIV-EU infants) and 3163 ± 644 g (HIV-unexposed infants) (P < .01). Multivariable regression revealed significantly lower birth weight for the HIV-EU infants (difference, -101.5 g [95% confidence interval, -181.4 to -21.6]). We found no difference in mean birth weight or gestational age with maternal protease inhibitor-based ART use when compared to the use of other regimens. CONCLUSIONS We found significantly lower birth weight among HIV-EU infants. Long-term prospective studies are necessary to determine the implications of this finding on infant growth and development.
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Affiliation(s)
- Jasmeen S Dara
- Department of Pediatrics, Montefiore Medical Center, Bronx, New York,Correspondence: J. S. Dara, MD, University of California, San Francisco, Benioff Children’s Hospital, Department of Pediatrics, Division of Pediatric Allergy and Immunology, Mission Hall, 4th Floor, 550 16th St, Box 0434, San Francisco, CA ()
| | - David B Hanna
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Kathryn Anastos
- Department of Medicine, Montefiore Medical Center, Bronx, New York,Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Rodney Wright
- Department of Obstetrics and Gynecology, Montefiore Medical Center, Bronx, New York
| | - Betsy C Herold
- Department of Pediatrics, Montefiore Medical Center, Bronx, New York
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27
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Abstract
Medical conditions such as epilepsy or infection with human immunodeficiency virus (HIV) are known to be associated with a spectrum of adverse health outcomes if not appropriately managed by efficacious treatment and care. Medications for such conditions can be potent, and their use might sometimes have unintended health consequences. Prominent examples have emerged in HIV perinatal research in which use of antiretroviral treatment during pregnancy to treat maternal HIV infection and prevent transmission of the virus to the fetus have been shown to be associated with adverse birth outcomes. Likewise, use of antiepileptic drugs during pregnancy to treat maternal epilepsy has been shown to increase the risk of birth defects. Pharmacoepidemiology studies routinely aim to quantify the extent to which, in such settings, an observed association between an underlying medical condition and certain health outcomes can be attributed to the natural progression of the disease, and the extent to which it might be mediated by medication used to slow disease progression. We describe a simple yet principled methodology to quantify medication-mediated effects to address these types of queries. While methods for causal mediation analysis abound, there also has been much criticism of these methods as relying on untestable and sometimes unrealistic assumptions. In contrast, here we show that when the disease-free control group is also medication-free, mediated effects of the type described above are nonparametrically identified under standard no-unobserved confounding conditions, thus establishing that such effects are in a sense immune to recent criticism leveled at causal mediation methodology.
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28
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Abstract
BACKGROUND Questions remain regarding preterm delivery (PTD) risk in HIV-infected women on antiretroviral therapy (ART), including the role of ritonavir (RTV)-boosted protease inhibitors, timing of ART initiation and immune status. METHODS We examined data from the UK/Ireland National Study of HIV in Pregnancy and Childhood on women with HIV delivering a singleton live infant in 2007-2015, including those pregnancies receiving RTV-boosted protease inhibitor-based (n = 4184) or nonnucleoside reverse transcriptase inhibitors-based regimens (n = 1889). We conducted logistic regression analysis adjusted for risk factors associated with PTD and stratified by ART at conception and CD4 cell count to minimize bias by indication for treatment and to assess whether PTD risk differs by ART class and specific drug combinations. RESULTS Among women conceiving on ART, lopinavir/RTV was associated with increased PTD risk in those with CD4 cell count 350 cells/μl or less [odds ratio 1.99 (1.02, 3.85)] and with CD4 cell count more than 350 cells/μl [odds ratio 1.61 (1.07, 2.43)] vs. women on nonnucleoside reverse transcriptase inhibitors-based (mainly efavirenz and nevirapine) regimens in the same CD4 subgroup. Associations between other protease inhibitor-based regimens (mainly atazanavir and darunavir) and PTD risk were complex. Overall, PTD risk was higher in women who conceived on ART, had low CD4 cell count and were older. No trend of association of PTD with tenofovir or any specific drug combinations was observed. CONCLUSION Our data support a link between the initiation of RTV-boosted/lopinavir-based ART preconception and PTD in subsequent pregnancies, with implications for treatment guidelines. Continued monitoring of PTD risk is needed as increasing numbers of pregnancies are conceived on new drugs.
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Wong JMH, Kanga N, Dogra N, Ngoma MS, Serghides L, Silverman M. Perceived acceptability of progesterone to prevent preterm births and low birth weight among HIV-infected and HIV-uninfected Zambian pregnant women. Int J Womens Health 2017; 9:827-833. [PMID: 29180906 PMCID: PMC5695261 DOI: 10.2147/ijwh.s136191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Intramuscular and vaginal progesterone are recommended for prevention of preterm labor (PTL) in women with risk factors. Studies are emerging to indicate that HIV-infected women on combination antiretroviral therapy (cART) are at risk of PTL and low birth weight (LBW), and may benefit from supplemental progesterone. This study aims to determine the perceived acceptability of various modes of progesterone supplementation to prevent PTL and LBW in HIV-infected and HIV-uninfected women. Methods HIV-infected and HIV-uninfected women were recruited in Lusaka, Zambia. The participants completed a questionnaire to assess their willingness to take oral, vaginal, or intramuscular progesterone supplementation for preventing PTL and LBW, preferred modes of supplementation, and concern for PTL and LBW. Results The study questionnaire was completed by 147 participants. Of the participants, 98.6% would consider using a medication to help prevent PTL and LBW, of whom 97.9% would consider using an oral form of progesterone. In addition, 83.3% and 84.0% of women would consider intramuscular and vaginal (gel or tablet) administration of progesterone respectively. Between intramuscular and vaginal modes of progesterone, 60.5% of participants (n=147) preferred intramuscular progesterone, while 39.5% preferred vaginal progesterone. There was no difference in preference between HIV-infected (n=70) and HIV-uninfected (n=77) women. Conclusions/implications Pregnant Zambian women demonstrated a high degree of acceptance for all modes of progesterone supplementation for the prevention of PTL and LBW. Women preferred intramuscular over vaginal supplementation. Progesterone supplementation can be considered a feasible intervention for preventing PTL and LBW in both HIV-infected and HIV-uninfected pregnant Zambian women.
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Affiliation(s)
| | - Neha Kanga
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nupur Dogra
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Lena Serghides
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Michael Silverman
- Department of Infectious Diseases, Western University, London, ON, Canada
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Antiretroviral combination use during pregnancy and the risk of major congenital malformations. AIDS 2017; 31:2267-2277. [PMID: 28806195 DOI: 10.1097/qad.0000000000001610] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To quantify the risk of major congenital malformations (MCMs) associated with gestational combination antiretroviral use. DESIGN Population-based prospective cohort study. METHODS Using the Quebec Pregnancy Cohort from 1998 to 2015, we included women who were covered by the Quebec Drug Plan and had a singleton livebirth. All antiretroviral use alone or in combination were considered. MCMs overall and organ-specific malformations in the first year of life were identified. RESULTS In total, 214 240 pregnancies met inclusion criteria; 0.09% (n = 198) occurred while on antiretroviral combinations during the first trimester; 169 HIV-positive women without antiretroviral treatment were included. Compared with the general population in this cohort, the prevalence of MCMs was significantly higher in unexposed HIV-positive women (14.8 vs. 8.6%, P = 0.004) but not in antiretroviral-exposed HIV-positive women (10.3%, P = 0.41). Adjusting for potential confounders, including maternal HIV status, antiretroviral use during the first trimester was not associated with the risk of MCMs (adjusted odds ratio 0.59, 95% confidence interval 0.33-1.06). However, antiretroviral combination use during the first trimester was associated with an increased risk of defects of the small intestine (adjusted odds ratio 10.32, 95% confidence interval 2.85-37.38, P = 0.0004). CONCLUSION Antiretroviral therapy during the first trimester was not associated with the risk of overall MCMs but may be associated with an increased risk of defects of the small intestine. However, HIV-positive pregnant women who are not treated with antiretrovirals during pregnancy seem to have a higher risk of malformations; this is not seen among those who are treated, which could indicate that the underlying condition puts women at risk and not the treatment.
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Jao J, Freimanis L, Mussi-Pinhata MM, Cohen RA, Monteiro JP, Cruz ML, Branch A, Sperling RS, Siberry GK. Severe Vitamin D Deficiency in Human Immunodeficiency Virus-Infected Pregnant Women is Associated with Preterm Birth. Am J Perinatol 2017; 34:486-492. [PMID: 27716863 PMCID: PMC5367960 DOI: 10.1055/s-0036-1593536] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background Low maternal vitamin D has been associated with preterm birth (PTB). Human immunodeficiency virus (HIV)-infected pregnant women are at risk for PTB, but data on maternal vitamin D and PTB in this population are scarce. Methods In a cohort of Latin American HIV-infected pregnant women from the National Institute of Child Health and Human Development International Site Development Initiative protocol, we examined the association between maternal vitamin D status and PTB. Vitamin D status was defined as the following 25-hydroxyvitamin D levels: severe deficiency (< 10 ng/mL), deficiency (10-20 ng/mL), insufficiency (21-29 ng/mL), and sufficiency (≥30 ng/mL). PTB was defined as delivery at < 37 weeks' gestational age (GA). Logistic regression was used to assess the association between maternal vitamin D status and PTB. Results Of 715 HIV-infected pregnant women, 13 (1.8%) were severely vitamin D deficient, 224 (31.3%) were deficient, and 233 were (32.6%) insufficient. Overall, 23.2% (166/715) of pregnancies resulted in PTB (median GA of PTBs = 36 weeks [interquartile range: 34-36]). In multivariate analysis, severe vitamin D deficiency was associated with PTB (odds ratio = 4.7, 95% confidence interval: 1.3-16.8]). Conclusion Severe maternal vitamin D deficiency is associated with PTB in HIV-infected Latin American pregnant women. Further studies are warranted to determine if vitamin D supplementation in HIV-infected women may impact PTB.
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Affiliation(s)
- Jennifer Jao
- Icahn School of Medicine at Mount Sinai, New York, NY, USA, Department of Medicine, Department of Obstetrics, Gynecology and Reproductive Science
| | | | | | | | | | - Maria Leticia Cruz
- Hospital Federal dos Servidores do Estado, Brazil, Serviço de Doenças Infecciosas e Parasitárias
| | - Andrea Branch
- Icahn School of Medicine at Mount Sinai, New York, NY, USA, Department of Medicine
| | - Rhoda S. Sperling
- Icahn School of Medicine at Mount Sinai, New York, NY, USA, Department of Obstetrics, Gynecology, and Reproductive Science
| | - George K. Siberry
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Maternal and Pediatric Infectious Disease Branch, Bethesda, MD, USA
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Mandelbrot L, Sibiude J. A link between antiretrovirals and perinatal outcomes? Lancet HIV 2016; 4:e3-e5. [PMID: 27863997 DOI: 10.1016/s2352-3018(16)30188-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/16/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Service de Gynécologie-Obstétrique, Hôpitaux Universitaires Paris-Nord Val de Seine, 178 rue des Renouillers, 92700 Colombes, France; Université Paris-Diderot, Université Sorbonne Paris-Cité, Paris, France; Département Hospitalier Universitaire Risques et Grossesse, Paris, France; INSERM U1018, Kremlin-Bicêtre, France.
| | - Jeanne Sibiude
- Département Hospitalier Universitaire Risques et Grossesse, Paris, France; INSERM U1018, Kremlin-Bicêtre, France; Assistance Publique-Hôpitaux de Paris, Maternité Port Royal, Hôpital Cochin, Paris, France
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Maternal HIV infection alters the immune balance in the mother and fetus; implications for pregnancy outcome and infant health. Curr Opin HIV AIDS 2016; 11:138-45. [PMID: 26679415 DOI: 10.1097/coh.0000000000000239] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW With the rapid roll-out of combination antiretroviral therapy to prevent mother-to-child transmission of HIV, there is an annual increase in the number of uninfected infants born to HIV-infected women. Although the introduction of combination antiretroviral therapy has vastly improved pregnancy outcome and the health of infants born to HIV-infected women, concerns remain regarding the impact the maternal HIV infection on the pregnancy outcome and the health of HIV-exposed uninfected infants. RECENT FINDINGS Maternal HIV infection is associated with negative pregnancy outcomes such as low birth weight. In addition, an increased susceptibility to infections is reported in HIV-exposed uninfected infants compared with infants born to uninfected women. Studies have shown that HIV-exposure affects the maternal/fetal unit, with increase of proinflammatory cytokine produced by placental cells, as well as altered infant immune responses. These changes could provide the underlying conditions for negative pregnancy outcomes and facilitate mother-to-child transmission of HIV in the infant. Further studies are required to understand the underlying mechanisms and investigate whether these altered infant immune responses persist and have clinical consequences beyond childhood. SUMMARY HIV infection in pregnant women is associated with altered immune responses in HIV-infected women and their offspring with clinical consequences for pregnancy outcome and the HIV-exposed uninfected infant. Further studies are required to address the origin and long-term consequences of prenatal HIV-exposure and subsequent immune activation for infant health.
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Disclosing in utero HIV/ARV exposure to the HIV-exposed uninfected adolescent: is it necessary? J Int AIDS Soc 2016; 19:21099. [PMID: 27741954 PMCID: PMC5065689 DOI: 10.7448/ias.19.1.21099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 09/06/2016] [Accepted: 09/14/2016] [Indexed: 01/04/2023] Open
Abstract
Introduction The tremendous success of antiretroviral therapy has resulted in a diminishing population of perinatally HIV-infected children on the one hand and a mounting number of HIV-exposed uninfected (HEU) children on the other. As the oldest of these HEU children are reaching adolescence, questions have emerged surrounding the implications of HEU status disclosure to these adolescents. This article outlines the arguments for and against disclosure of a child's HEU status. Discussion Disclosure of a child's HEU status, by definition, requires disclosure of maternal HIV status. It is necessary to weigh the benefits and harms which could occur with disclosure in each of the following domains: psychosocial impact, long-term physical health of the HEU individual and the public health impact. Does disclosure improve or worsen the psychological health of the HEU individual and extended family unit? Do present data on the long-term safety of in utero HIV/ARV exposure reveal potential health risks which merit disclosure to the HEU adolescent? What research and public health programmes or systems need to be in place to afford monitoring of HEU individuals and which, if any, of these require disclosure? Conclusions At present, it is not clear that there is sufficient evidence on whether long-term adverse effects are associated with in utero HIV/ARV exposures, making it difficult to mandate universal disclosure. However, as more countries adopt electronic medical record systems, the HEU status of an individual should be an important piece of the health record which follows the infant not only through childhood and adolescence but also adulthood. Clinicians and researchers should continue to approach the dialogue around mother–child disclosure with sensitivity and a cogent consideration of the evolving risks and benefits as new information becomes available while also working to maintain documentation of an individual's perinatal HIV/ARV exposures as a vital part of his/her medical records. As more long-term adult safety data on in utero HIV/ARV exposures become available these decisions may become clearer, but at this time, they remain complex and multi-faceted.
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Ewing AC, Datwani HM, Flowers LM, Ellington SR, Jamieson DJ, Kourtis AP. Trends in hospitalizations of pregnant HIV-infected women in the United States: 2004 through 2011. Am J Obstet Gynecol 2016; 215:499.e1-8. [PMID: 27263995 DOI: 10.1016/j.ajog.2016.05.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 05/26/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND With the development and widespread use of combination antiretroviral therapy, HIV-infected women live longer, healthier lives. Previous research has shown that, since the adoption of combination antiretroviral therapy in the United States, rates of morbidity and adverse obstetric outcomes remained higher for HIV-infected pregnant women compared with HIV-uninfected pregnant women. Monitoring trends in the outcomes these women experience is essential, as recommendations for this special population continue to evolve with the progress of HIV treatment and prevention options. OBJECTIVE We conducted an analysis comparing rates of hospitalizations and associated outcomes among HIV-infected and HIV-uninfected pregnant women in the United States from 2004 through 2011. STUDY DESIGN We used cross-sectional hospital discharge data for girls and women age 15-49 from the 2004, 2007, and 2011 Nationwide Inpatient Sample, a nationally representative sample of US hospital discharges. Demographic characteristics, morbidity outcomes, and time trends were compared using χ(2) tests and multivariate logistic regression. Analyses were weighted to produce national estimates. RESULTS In 2011, there were 4751 estimated pregnancy hospitalizations and 3855 delivery hospitalizations for HIV-infected pregnant women; neither increased since 2004. Compared with those of HIV-uninfected women, pregnancy hospitalizations of HIV-infected women were more likely to be longer, be in the South and Northeast, be covered by public insurance, and incur higher charges (all P < .005). Hospitalizations among pregnant women with HIV infection had higher rates for many adverse outcomes. Compared to 2004, hospitalizations of HIV-infected pregnant women in 2011 had higher odds of gestational diabetes (adjusted odds ratio, 1.81; 95% confidence interval, 1.16-2.84), preeclampsia/hypertensive disorders of pregnancy (adjusted odds ratio, 1.58; 95% confidence interval, 1.12-2.24), viral/mycotic/parasitic infections (adjusted odds ratio, 1.90; 95% confidence interval, 1.69-2.14), and bacterial infections (adjusted odds ratio, 2.54; 95% confidence interval, 1.53-4.20). Bacterial infections did not increase among hospitalizations of HIV-uninfected pregnant women. CONCLUSION The numbers of hospitalizations during pregnancy and delivery have not increased for HIV-infected women since 2004, a departure from previously estimated trends. Pregnancy hospitalizations of HIV-infected women remain more medically complex than those of HIV-uninfected women. An increasing trend in infections among the delivery hospitalizations of HIV-infected pregnant women warrant further attention.
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Price JT, Wheeler SB, Stranix-Chibanda L, Hosek SG, Watts DH, Siberry GK, Spiegel HML, Stringer JS, Chi BH. Cost-Effectiveness of Pre-exposure HIV Prophylaxis During Pregnancy and Breastfeeding in Sub-Saharan Africa. J Acquir Immune Defic Syndr 2016; 72 Suppl 2:S145-53. [PMID: 27355502 PMCID: PMC5043081 DOI: 10.1097/qai.0000000000001063] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Antiretroviral pre-exposure prophylaxis (PrEP) for the prevention of HIV acquisition is cost-effective when delivered to those at substantial risk. Despite a high incidence of HIV infection among pregnant and breastfeeding women in sub-Saharan Africa (SSA), a theoretical increased risk of preterm birth on PrEP could outweigh the HIV prevention benefit. METHODS We developed a decision analytic model to evaluate a strategy of daily oral PrEP during pregnancy and breastfeeding in SSA. We approached the analysis from a health care system perspective across a lifetime time horizon. Model inputs were derived from existing literature and local sources. The incremental cost-effectiveness ratio (ICER) of PrEP versus no PrEP was calculated in 2015 U.S. dollars per disability-adjusted life year (DALY) averted. We evaluated the effect of uncertainty in baseline estimates through one-way and probabilistic sensitivity analyses. RESULTS PrEP administered to pregnant and breastfeeding women in SSA was cost-effective. In a base case of 10,000 women, the administration of PrEP averted 381 HIV infections but resulted in 779 more preterm births. PrEP was more costly per person ($450 versus $117), but resulted in fewer disability-adjusted life years (DALYs) (3.15 versus 3.49). The incremental cost-effectiveness ratio of $965/DALY averted was below the recommended regional threshold for cost-effectiveness of $6462/DALY. Probabilistic sensitivity analyses demonstrated robustness of the model. CONCLUSIONS Providing PrEP to pregnant and breastfeeding women in SSA is likely cost-effective, although more data are needed about adherence and safety. For populations at high risk of HIV acquisition, PrEP may be considered as part of a broader combination HIV prevention strategy.
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Affiliation(s)
- Joan T. Price
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lynda Stranix-Chibanda
- Department of Pediatrics and Child Health, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Sybil G. Hosek
- Department of Psychiatry, John Stroger Hospital of Cook County, Chicago, IL
| | - D. Heather Watts
- Office of the Global AIDS Coordinator and Health Diplomacy, U.S. Department of State, Washington, DC
| | - George K. Siberry
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD; and
| | - Hans M. L. Spiegel
- Kelly Government Services, Contractor to Prevention Sciences Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Jeffrey S. Stringer
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Benjamin H. Chi
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, NC
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Altfeld M, Bunders MJ. Impact of HIV-1 infection on the feto-maternal crosstalk and consequences for pregnancy outcome and infant health. Semin Immunopathol 2016; 38:727-738. [PMID: 27392971 DOI: 10.1007/s00281-016-0578-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/16/2016] [Indexed: 12/21/2022]
Abstract
Adaptation of the maternal immune system to establish maternal/fetal equilibrium is required for a successful pregnancy. Viral infections, including HIV-1 infection, can alter this maternal/fetal equilibrium, with significant consequences for pregnancy outcome, including miscarriages, impaired fetal growth, and premature delivery. Furthermore, maternal HIV-1 infection has been shown to have a long-term impact on the developing fetal immune system also when the infant is not infected with the virus. In this review, we discuss the consequences of maternal HIV-1 infection and antiretroviral therapy on pregnancy outcome and the health of the uninfected HIV-1-exposed infant.
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Affiliation(s)
- Marcus Altfeld
- Department of Virus Immunology, Heinrich-Pette Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany
| | - Madeleine J Bunders
- Department of Virus Immunology, Heinrich-Pette Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany. .,Department of Experimental Immunology, University of Amsterdam (UvA), Academic Medical Center (AMC), Amsterdam, The Netherlands. .,Emma Childrens Hospital,UvA, AMC, Amsterdam, The Netherlands.
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Gagnon LH, MacGillivray J, Urquia ML, Caprara D, Murphy KE, Yudin MH. Antiretroviral therapy during pregnancy and risk of preterm birth. Eur J Obstet Gynecol Reprod Biol 2016; 201:51-5. [PMID: 27060543 DOI: 10.1016/j.ejogrb.2016.03.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 03/23/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Antiretroviral therapy use in pregnancy, and specifically regimens containing protease inhibitors (PIs), has been associated with adverse infant outcomes including preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA) infants. However, there are conflicting results in the literature with respect to the degree of risk. These results may be related to demographic factors and confounding of maternal HIV infection and degree of immune suppression. OBJECTIVE The primary objective of our study was to assess the risk of PTB in HIV-positive pregnant women on ART compared to HIV-negative pregnant women. Secondary objectives included: comparing the risks of LBW and SGA infants in HIV-positive women on ART to HIV-negative pregnant women; comparing the risks of PTB, LBW and SGA in HIV-positive women on PI-based regimens compared to HIV-negative women. METHODS A retrospective matched cohort study of 384 women was conducted between 2007 and 2012 comparing outcomes of HIV-positive women on ART to HIV-negative women. Univariate and multivariable logistic regression models were used, adjusting for potential confounding factors, to compare the two groups on adverse infant outcomes. RESULTS Unadjusted odds ratios revealed a >2-fold increase in rates: PTB OR 2.6 [95% CI 1.3-5.1]; LBW OR 2.9 [95% CI 1.4-6.3]; SGA OR 2.5 [95% CI 1.3-4.7]. Once odds ratios were adjusted to account for race (p<0.01), our results were no longer statistically significant as this study was underpowered to detect smaller differences: PTB aOR 1.4 [95% CI 0.5-3.6]; LBW OR 1.9 [95% CI 0.6-5.5]; SGA OR 1.8 [95% CI 0.8-4.6]. CONCLUSION Our preliminary results show an increase in PTB, LBW and SGA but due to lack of power, our adjusted results are not statistically significant. A larger prospective follow-up study is needed to further explore these findings in this population.
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Affiliation(s)
| | - Jay MacGillivray
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Canada
| | - Marcelo L Urquia
- Dalla Lana School of Public Health, University of Toronto, Keenan Research Institute, St. Michael's Hospital, Canada
| | - Daniela Caprara
- Department of Obstetrics and Gynecology, University of Toronto, Canada
| | - Kellie E Murphy
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Canada
| | - Mark H Yudin
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Canada
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Vreeman RC, Scanlon ML, McHenry MS, Nyandiko WM. The physical and psychological effects of HIV infection and its treatment on perinatally HIV-infected children. J Int AIDS Soc 2015; 18:20258. [PMID: 26639114 PMCID: PMC4670835 DOI: 10.7448/ias.18.7.20258] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/25/2015] [Accepted: 09/02/2015] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION As highly active antiretroviral therapy (HAART) transforms human immunodeficiency virus (HIV) into a manageable chronic disease, new challenges are emerging in treating children born with HIV, including a number of risks to their physical and psychological health due to HIV infection and its lifelong treatment. METHODS We conducted a literature review to evaluate the evidence on the physical and psychological effects of perinatal HIV (PHIV+) infection and its treatment in the era of HAART, including major chronic comorbidities. RESULTS AND DISCUSSION Perinatally infected children face concerning levels of treatment failure and drug resistance, which may hamper their long-term treatment and result in more significant comorbidities. Physical complications from PHIV+ infection and treatment potentially affect all major organ systems. Although treatment with antiretroviral (ARV) therapy has reduced incidence of severe neurocognitive diseases like HIV encephalopathy, perinatally infected children may experience less severe neurocognitive complications related to HIV disease and ARV neurotoxicity. Major metabolic complications include dyslipidaemia and insulin resistance, complications that are associated with both HIV infection and several ARV agents and may significantly affect cardiovascular disease risk with age. Bone abnormalities, particularly amongst children treated with tenofovir, are a concern for perinatally infected children who may be at higher risk for bone fractures and osteoporosis. In many studies, rates of anaemia are significantly higher for HIV-infected children. Renal failure is a significant complication and cause of death amongst perinatally infected children, while new data on sexual and reproductive health suggest that sexually transmitted infections and birth complications may be additional concerns for perinatally infected children in adolescence. Finally, perinatally infected children may face psychological challenges, including higher rates of mental health and behavioural disorders. Existing studies have significant methodological limitations, including small sample sizes, inappropriate control groups and heterogeneous definitions, to name a few. CONCLUSIONS Success in treating perinatally HIV-infected children and better understanding of the physical and psychological implications of lifelong HIV infection require that we address a new set of challenges for children. A better understanding of these challenges will guide care providers, researchers and policymakers towards more effective HIV care management for perinatally infected children and their transition to adulthood.
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Affiliation(s)
- Rachel C Vreeman
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya;
| | - Michael L Scanlon
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Megan S McHenry
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Winstone M Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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Xiao PL, Zhou YB, Chen Y, Yang MX, Song XX, Shi Y, Jiang QW. Association between maternal HIV infection and low birth weight and prematurity: a meta-analysis of cohort studies. BMC Pregnancy Childbirth 2015; 15:246. [PMID: 26450602 PMCID: PMC4599647 DOI: 10.1186/s12884-015-0684-z] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 10/04/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To assess the association between maternal human immunodeficiency virus (HIV) infection and low birth weight (LBW)/prematurity (PTD), we conducted a meta-analysis of cohort studies of HIV infected and uninfected women. METHODS Several English and Chinese databases were searched (updated to May 2015) to find the studies reporting infant outcomes associated with exposure to maternal HIV infection during pregnancy. Relevant articles were manually selected based on several inclusion and exclusion criteria. RESULTS Fifty-two cohort studies including 15,538 (for LBW) and 200,896 (for PTD) HIV infected women met the inclusion criteria. There was significant heterogeneity among studies for maternal HIV infection associated with LBW/PTD (I(2) = 71.7%, P < 0.05, and I(2) = 51.8%, P < 0.05 for LBW and PTD, respectively). The meta-analysis demonstrated that the maternal HIV infection was significantly associated with both LBW (pooled odds ratio (OR): 1.73, 95% confidence interval (CI): 1.64, 1.82, P < 0.001) and PTD (pooled OR: 1.56, 95% CI: 1.49, 1.63, P < 0.001). No significant difference in the relationship between maternal HIV infection and adverse pregnancy outcomes was detected among the groups of different study periods. HIV infected women were at slightly higher risk of LBW in developing countries compared with women in developed countries (OR: 2.12 (95% CI: 1.81, 2.48) vs. 1.75 (95% CI: 1.44, 2.12)). Antiretroviral drugs usage did not significantly change the associations of maternal HIV exposure with LBW and PTD. CONCLUSIONS HIV infected women were at higher risk of having a low birth weight infant or a preterm delivery infant compared with uninfected women. Such associations did not change significantly over time or were not significantly affected by the usage of antiretroviral drugs.
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Affiliation(s)
- Peng-Lei Xiao
- Fudan University School of Public Health, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
- Key Laboratory of Public Health Safety, Fudan University, Ministry of Education, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
- Fudan University Center for Tropical Disease Research, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
| | - Yi-Biao Zhou
- Fudan University School of Public Health, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
- Key Laboratory of Public Health Safety, Fudan University, Ministry of Education, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
- Fudan University Center for Tropical Disease Research, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
| | - Yue Chen
- School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8 M5, Canada.
| | - Mei-Xia Yang
- Xuhui Center for Disease Prevention and Control, 50 Yongchuan Road, Xuhui District, Shanghai, 200032, China.
| | - Xiu-Xia Song
- Fudan University School of Public Health, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
- Key Laboratory of Public Health Safety, Fudan University, Ministry of Education, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
- Fudan University Center for Tropical Disease Research, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
| | - Yan Shi
- Fudan University School of Public Health, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
- Key Laboratory of Public Health Safety, Fudan University, Ministry of Education, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
- Fudan University Center for Tropical Disease Research, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
| | - Qing-Wu Jiang
- Fudan University School of Public Health, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
- Key Laboratory of Public Health Safety, Fudan University, Ministry of Education, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
- Fudan University Center for Tropical Disease Research, Building 8, 130 Dong'an Road, Xuhui District, Shanghai, 200032, China.
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Mandelbrot L. Antiretroviral therapy and perinatal outcomes. Lancet HIV 2015; 2:e356-e357. [PMID: 26423541 DOI: 10.1016/s2352-3018(15)00131-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 07/01/2015] [Indexed: 06/05/2023]
Affiliation(s)
- Laurent Mandelbrot
- Department of Gynaecology and Obstetrics, Hôpital Louis Mourier, Hôpitaux Universitaires Paris Nord, Colombes 92700, and Université Paris-Diderot, Paris, France.
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Mandelbrot L, Tubiana R, Le Chenadec J, Dollfus C, Faye A, Pannier E, Matheron S, Khuong MA, Garrait V, Reliquet V, Devidas A, Berrebi A, Allisy C, Elleau C, Arvieux C, Rouzioux C, Warszawski J, Blanche S. No perinatal HIV-1 transmission from women with effective antiretroviral therapy starting before conception. Clin Infect Dis 2015. [PMID: 26197844 DOI: 10.1093/cid/civ578] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The efficacy of preventing perinatal transmission (PT) of human immunodeficiency virus type 1 (HIV-1) depends on both viral load (VL) and treatment duration. The objective of this study was to determine whether initiating highly active antiretroviral therapy (ART) before conception has the potential to eliminate PT. METHODS A total of 8075 HIV-infected mother/infant pairs included from 2000 to 2011 in the national prospective multicenter French Perinatal Cohort (ANRS-EPF) received ART, delivered live-born children with determined HIV infection status, and did not breastfeed. PT was analyzed according to maternal VL at delivery and timing of ART initiation. RESULTS The overall rate of PT was 0.7% (56 of 8075). No transmission occurred among 2651 infants born to women who were receiving ART before conception, continued ART throughout the pregnancy, and delivered with a plasma VL <50 copies/mL (upper 95% confidence interval [CI], 0.1%). VL and timing of ART initiation were independently associated with PT in logistic regression. Regardless of VL, the PT rate increased from 0.2% (6 of 3505) for women starting ART before conception to 0.4% (3 of 709), 0.9% (24 of 2810), and 2.2% (23 of 1051) for those starting during the first, second, or third trimester (P < .001). Regardless of when ART was initiated, the PT rate was higher for women with VLs of 50-400 copies/mL near delivery than for those with <50 copies/mL (adjusted odds ratio, 4.0; 95% CI, 1.9-8.2). CONCLUSIONS Perinatal HIV-1 transmission is virtually zero in mothers who start ART before conception and maintain suppression of plasma VL.
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Affiliation(s)
- Laurent Mandelbrot
- Obstetrics-Gynecology Department, Hôpital Louis Mourier, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique-Hôpitaux de Paris, Colombes CESP, INSERM U1018 Université Paris Diderot Risks in Pregnancy University Department
| | - Roland Tubiana
- Infectious Diseases Department, Hôpital Pitié Salpétrière and Université Pierre et Marie Curie INSERM- UMR_S 943 Pierre Louis Institute of Epidemiology and Public Health
| | | | | | - Albert Faye
- Université Paris Diderot Infectious Diseases Department, Bichat-Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine
| | - Emmanuelle Pannier
- Risks in Pregnancy University Department, Obstetrics-Gynecology Department, Hôpital Cochin Port Royal
| | - Sophie Matheron
- Université Paris Diderot Pediatrics Department, Hôpital Robert Debré
| | | | - Valerie Garrait
- Internal Medicine Department, Hôpital Intercommunal de Créteil
| | - Veronique Reliquet
- Infectious Diseases Department, Centre Hospitalier Universitaire de Nantes
| | - Alain Devidas
- Infectious Diseases Department, Hôpital Sud Francilien, Evry
| | - Alain Berrebi
- Obstetrics-Gynecology Department, Centre Hospitalier Universitaire de Toulouse, Maternité Paule de Viguier
| | | | | | - Cedric Arvieux
- Infectious Diseases Department, Centre Hospitalier Universitaire de Rennes, France
| | | | - Josiane Warszawski
- CESP, INSERM U1018 Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris Université Paris Sud, Le Kremlin-Bicêtre
| | - Stéphane Blanche
- EA Pharmacologie, INSERM, Université Paris Descartes, Sorbonne Paris-Cité Pediatric Immunology Department, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris
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Bagkeris E, Malyuta R, Volokha A, Cortina-Borja M, Bailey H, Townsend CL, Thorne C. Pregnancy outcomes in HIV-positive women in Ukraine, 2000-12 (European Collaborative Study in EuroCoord): an observational cohort study. Lancet HIV 2015; 2:e385-92. [PMID: 26423552 DOI: 10.1016/s2352-3018(15)00079-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 04/22/2015] [Accepted: 04/23/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Women living with HIV are potentially at increased risk of adverse pregnancy outcomes, due to a range of factors, including immunosuppression, use of combination antiretroviral therapy (ART), and injecting drug use. Rates of mother-to-child transmission of HIV in Ukraine have declined to around 2-4%, but little is known about other pregnancy outcomes in this setting. We used data from an observational prospective cohort study to assess pregnancy outcomes among HIV-positive women in Ukraine. METHODS The European Collaborative Study (ECS) in EuroCoord is a continuing cohort study, established in Ukraine in 2000. Eligible women are those with a diagnosis of HIV infection before or during pregnancy (including intrapartum) who deliver liveborn babies at seven sites. Maternal sociodemographic, HIV-related, and delivery (mother and infant) data were collected with study-specific questionnaires. We used Poisson regression models to identify factors associated with preterm delivery (before 37 weeks' gestation) and small weight for gestational age (less than the tenth percentile of weight for gestational age), based on complete cases. FINDINGS Between January, 2000, and July, 2012, data were collected on 8884 HIV-positive mother and liveborn infant pairs. Median maternal age was 26·5 years (IQR 23·1-30·3). 832 (11%) women had WHO stage 3 or 4 HIV and 1474 (17%) had a history of injecting drug use. 7348 (83%) had received antenatal ART. Among 7435 for whom ART type was available, 4396 (50%) had received zidovudine monotherapy and 2949 (33%) combination ART. Preterm delivery was seen in 780 (9%, 95% CI 8-9) of 8860 births overall and in 77 (9%, 7-11) of 889 babies with small size for gestational age. Factors associated with preterm delivery were history of injecting drug use (adjusted risk ratio 1·64, 95% CI 1·38-1·95), no ART (2·94, 2·43-3·57 vs zidovudine monotherapy), antenatal combination ART (1·40, 1·14-1·73 vs zidovudine monotherapy), WHO stage 4 HIV (2·42, 1·71-3·41 vs WHO stage 1), and being in the most socially deprived group (1·38, 1·11-1·71). Small size for gestational age was associated with history of injecting drug use (adjusted RR 1·39, 95% CI 1·16-1·65), most socially deprived (1·32, 1·09-1·61), no ART (1·60, 1·32-1·94 vs zidovudine monotherapy), and antenatal combination ART (1·33, 1·12-1·60 vs zidovudine monotherapy). INTERPRETATION Some risk factors for adverse pregnancy outcomes were directly associated with HIV and treatment and others were shared with the general antenatal population. Monitoring of pregnancy outcomes in Ukraine will be important as use of antenatal combination ART increases. FUNDING European Union Seventh Framework Programme, Wellcome Trust.
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Affiliation(s)
- Emmanouil Bagkeris
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Ruslan Malyuta
- Perinatal Prevention of AIDS Initiative, Odessa, Ukraine
| | - Alla Volokha
- Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine
| | - Mario Cortina-Borja
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Heather Bailey
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Claire L Townsend
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Claire Thorne
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK.
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Peters H, Byrne L, De Ruiter A, Francis K, Harding K, Taylor GP, Tookey PA, Townsend CL. Duration of ruptured membranes and mother-to-child HIV transmission: a prospective population-based surveillance study. BJOG 2015; 123:975-81. [PMID: 26011825 DOI: 10.1111/1471-0528.13442] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the association between duration of rupture of membranes (ROM) and mother-to-child HIV transmission (MTCT) rates in the era of combination antiretroviral therapy (cART). DESIGN The National Study of HIV in Pregnancy and Childhood (NSHPC) undertakes comprehensive population-based surveillance of HIV in pregnant women and children. SETTING UK and Ireland. POPULATION A cohort of 2398 singleton pregnancies delivered vaginally, or by emergency caesarean section, in women on cART in pregnancy during the period 2007-2012 with information on duration of ROM; HIV infection status was available for 1898 infants. METHODS Descriptive analysis of NSHPC data. MAIN OUTCOME MEASURES Rates of MTCT. RESULTS In 2116 pregnancies delivered at term, the median duration of ROM was 3 hours 30 minutes (interquartile range, IQR 1-8 hours). The overall MTCT rate for women delivering at term with duration of ROM ≥4 hours was 0.64% compared with 0.34% for ROM <4 hours, with no significant difference between the groups (OR 1.90, 95% CI 0.45-7.97). In women delivering at term with a viral load of <50 copies/ml, there was no evidence of a difference in MTCT rates with duration of ROM ≥4 hours, compared with <4 hours (0.14% for ≥4 hours versus 0.12% for <4 hour; OR 1.14, 95% CI 0.07-18.27). Among infants born preterm with infection status available, there were no transmissions in 163 deliveries where the maternal viral load was <50 copies/ml. CONCLUSIONS No association was found between duration of ROM and MTCT in women taking cART. TWEETABLE ABSTRACT Rupture of membranes of more than 4 hours is not associated with MTCT of HIV in women on effective ART delivering at term.
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Affiliation(s)
- H Peters
- Population, Policy and Practice Programme, UCL Institute of Child Health, University College London, London, UK
| | - L Byrne
- Population, Policy and Practice Programme, UCL Institute of Child Health, University College London, London, UK
| | - A De Ruiter
- Guys & St Thomas' NHS Foundation Trust, London, UK
| | - K Francis
- Population, Policy and Practice Programme, UCL Institute of Child Health, University College London, London, UK
| | - K Harding
- Guys & St Thomas' NHS Foundation Trust, London, UK
| | - G P Taylor
- Imperial College Healthcare NHS Trust, London, UK
| | - P A Tookey
- Population, Policy and Practice Programme, UCL Institute of Child Health, University College London, London, UK
| | - C L Townsend
- Population, Policy and Practice Programme, UCL Institute of Child Health, University College London, London, UK
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Darak S, Mills M, Kulkarni V, Kulkarni S, Hutter I, Janssen F. Trajectories of Childbearing among HIV Infected Indian Women: A Sequence Analysis Approach. PLoS One 2015; 10:e0124537. [PMID: 25906185 PMCID: PMC4408012 DOI: 10.1371/journal.pone.0124537] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 03/16/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND HIV infection closely relates to and deeply affects the reproductive career of those infected. However, little is known about the reproductive career trajectories, specifically the interaction of the timing of HIV diagnosis with the timing and sequencing of reproductive events among HIV infected women. This is the first study to describe and typify this interaction. METHODS Retrospective calendar data of ever married HIV infected women aged 15-45 attending a HIV clinic in Pune, Maharashtra, Western India (N=622) on reproductive events such as marriage, cohabitation with the partner, use of contraception, pregnancy, childbirth and HIV diagnosis were analyzed using sequence analysis and multinomial logistic regression. RESULTS Optimal matching revealed three distinct trajectories: 1) HIV diagnosis concurrent with childbearing (40.7%), 2) HIV diagnosis after childbearing (32.1%), and 3) HIV diagnosis after husband's death (27.2%). Multinomial logistic regression (trajectory 1 = baseline) showed that women who got married before the age of 21 years and who had no or primary level education had a significantly higher risk of knowing their HIV status either after childbearing or close to their husband's death. The risk of HIV diagnosis after husband's death was also higher among rural women and those who were diagnosed before 2005. CONCLUSIONS Three distinct patterns of interaction of timing of HIV diagnosis with timing and sequencing of events in the reproductive career were observed that have clear implications for (i) understanding of the individual life planning process in the context of HIV, (ii) formulation of assumptions for estimating HIV infected women in need of PMTCT services, and (iii) provision of care services.
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Affiliation(s)
- Shrinivas Darak
- Population Research Centre, Faculty of Spatial Sciences, University of Groningen, Groningen, The Netherlands
- PRAYAS Health Group, Pune, Maharashtra, India
| | - Melinda Mills
- Department of Sociology, Nuffield College, University of Oxford, Oxford, England
| | | | | | - Inge Hutter
- Population Research Centre, Faculty of Spatial Sciences, University of Groningen, Groningen, The Netherlands
| | - Fanny Janssen
- Population Research Centre, Faculty of Spatial Sciences, University of Groningen, Groningen, The Netherlands
- Netherlands Interdisciplinary Demographic Institute, The Hague, The Netherlands
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Montgomery-Taylor S, Hemelaar J. Management and outcomes of pregnancies among women with HIV in Oxford, UK, in 2008-2012. Int J Gynaecol Obstet 2015; 130:59-63. [PMID: 25912413 DOI: 10.1016/j.ijgo.2015.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/20/2015] [Accepted: 03/26/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the management and outcomes of pregnancies among women with HIV infection. METHODS A retrospective cohort study was undertaken of pregnant women with HIV who delivered at one center in the UK in 2008-2012. Case notes were reviewed and detailed information extracted regarding obstetric and virological management. RESULTS Overall, 61 pregnancies were included; 43% (26/60) were unplanned and 39% (22/57) booked late. HIV infection was diagnosed during pregnancy for 32% (19/60); 71% (12/17) were diagnosed after the first trimester. At booking, 47% of women (28/60) were not on treatment, all but one of whom commenced treatment, either for maternal reasons (CD4 count <350 cells per mm(3); 48% [13/27]) or prevention of mother-to-child-transmission (52% [14/27]). Viral load was high (>50 copies per mL) at delivery for 13% of women (8/61). Delivery was by cesarean for 74% [45/61]. One neonate was diagnosed with HIV infection. There were 6 (10%) preterm births, 9 (15%) cases of low birth weight, 11 (18%) small-for-gestational-age neonates, and 1 (2%) stillbirth. CONCLUSION Better pregnancy planning, earlier booking and HIV diagnosis, and optimal antiretroviral treatment should increase the proportion of women with a low viral load (<50 copies per mL) at delivery, lead to more vaginal deliveries, and further reduce mother-to-child transmission of HIV.
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Affiliation(s)
| | - Joris Hemelaar
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, UK; Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK.
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Papp E, Mohammadi H, Loutfy MR, Yudin MH, Murphy KE, Walmsley SL, Shah R, MacGillivray J, Silverman M, Serghides L. HIV protease inhibitor use during pregnancy is associated with decreased progesterone levels, suggesting a potential mechanism contributing to fetal growth restriction. J Infect Dis 2015; 211:10-8. [PMID: 25030058 PMCID: PMC4264589 DOI: 10.1093/infdis/jiu393] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 05/09/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Protease inhibitor (PI)-based combination antiretroviral therapy (cART) is administered during pregnancy to prevent perinatal human immunodeficiency virus (HIV) transmission. However, PI use has been associated with adverse birth outcomes, including preterm delivery and small-for-gestational-age (SGA) births. The mechanisms underlying these outcomes are unknown. We hypothesized that PIs contribute to these adverse events by altering progesterone levels. METHODS PI effects on trophoblast progesterone production were assessed in vitro. A mouse pregnancy model was used to assess the impact of PI-based cART on pregnancy outcomes and progesterone levels in vivo. Progesterone levels were assessed in plasma specimens from 27 HIV-infected and 17 HIV-uninfected pregnant women. RESULTS PIs (ritonavir, lopinavir, and atazanavir) but not nucleoside reverse transcriptase inhibitors (NRTIs) or nonnucleoside reverse transcriptase inhibitors reduced trophoblast progesterone production in vitro. In pregnant mice, PI-based cART but not dual-NRTI therapy was associated with significantly lower progesterone levels that directly correlated with fetal weight. Progesterone supplementation resulted in a significant improvement in fetal weight. We observed lower progesterone levels and smaller infants in HIV-infected women receiving PI-based cART, compared with the control group. In HIV-infected women, progesterone levels correlated significantly with birth weight percentile. CONCLUSIONS Our data suggest that PI use in pregnancy may lead to lower progesterone levels that could contribute to adverse birth outcomes.
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Affiliation(s)
- Eszter Papp
- Toronto General Research Institute, University Health Network
| | | | - Mona R. Loutfy
- Women's College Research Institute, Women's College Hospital
- University of Toronto
| | | | | | - Sharon L. Walmsley
- Toronto General Research Institute, University Health Network
- University of Toronto
| | | | | | - Michael Silverman
- University of Toronto
- Lakeridge Health, Rouge Valley Hospital, Ajax, Canada
| | - Lena Serghides
- Toronto General Research Institute, University Health Network
- Women's College Research Institute, Women's College Hospital
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Liuzzi G, Pinnetti C, Floridia M, Tamburrini E, Masuelli G, Dalzero S, Sansone M, Giacomet V, Degli Antoni AM, Guaraldi G, Meloni A, Maccabruni A, Alberico S, Portelli V, Ravizza M. Pregnancy Outcomes in HIV-Infected Women of Advanced Maternal Age. HIV CLINICAL TRIALS 2014; 14:110-9. [DOI: 10.1310/hct1403-110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Pregnancy outcomes among ART-naive and ART-experienced HIV-positive women: data from the ICONA foundation study group, years 1997-2013. J Acquir Immune Defic Syndr 2014; 67:258-67. [PMID: 25314248 DOI: 10.1097/qai.0000000000000297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We analyzed antiretroviral therapy (ART) regimens and pregnancy outcomes in naive and ART-experienced HIV-positive women from Italian Cohort Naive Antiretrovirals cohort and investigated frequency and predictors of detectable viral load (VL) at delivery. METHODS All pregnancies resulting in live births were included. Based on ART at the beginning of pregnancy, pregnancies were allocated either to the ART-naive or ART-experienced group. Analyses were stratified according to calendar periods. Multivariate logistic regression was used to describe predictors of detectable VL at delivery. RESULTS One hundred fifty-eight of 2862 women experienced 169 pregnancies (88 in naives and 81 in 70 ART-experienced women). ART regimens varied according to calendar periods; mono-dual combination regimens progressively decreased over time (P value for trend <0.0001). Protease inhibitor-including regimens were the most frequently used regimens at delivery (71.6% vs 63.0% in naives and in ART experienced, P = 0.2). VL was detectable in 35.6% of women at delivery; this was less likely with increasing calendar periods (adjusted odds ratio per 1-year longer: 0.8, 95% confidence interval: 0.7 to 0.9, P = 0.007) and more likely in women with HIV RNA >50 copies per milliliter at pregnancy ascertainment (adjusted odds ratio: 7.1, 95% confidence interval: 1.9 to 33.3, P = 0.006). Nevertheless, no cases of vertical transmission were diagnosed. Preterm birth rate of 17.3% (11.9% vs 22.6% naive and ART experienced, P = 0.1) was reported; this was not associated with ART duration or protease inhibitor-including regimens; 27.2% of infants had <2500 g birth weight. CONCLUSIONS Antiretroviral regimens prescribed during pregnancy changed over time according to guidelines. Although undetectable VL was not always achieved, no vertical transmission occurred; preterm delivery and low birth weight occurred in some cases and still remain key issues.
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