Safety and effectiveness of antiretroviral therapies for HIV-infected women and their infants and children: protocol for a systematic review and network meta-analysis

Does antiretroviral therapy cause congenital malformations? A systematic review and meta-analysis

OBJECTIVES

This meta-analysis investigated the risk of congenital anomalies among infants of human immunodeficiency virus-infected pregnant women who were exposed to antiretroviral therapy (ART).

METHODS

Cohort studies, case-control studies, randomized controlled trials, and controlled clinical trials were reviewed by searching MEDLINE/PubMed, Embase, Web of Science, Scopus, AIDSLINE, CINAHL, Cochrane Library, and Google/Google Scholar. Methodological quality was assessed using the GRADE evaluation. A DerSimonian and Laird random-effects model was used. Subgroup analyses and meta-regression were used to investigate heterogeneity.

RESULTS

The electronic searches yielded 765 items. After quality assessment and grading, 30 studies were suitable for metaanalysis. In total, 1,461 congenital anomalies were found among 53,186 births. Children born to women receiving combined antiretroviral therapy (cART) had an approximately 10% higher risk of developing congenital anomalies (relative risk [RR], 1.09; 95% confidence interval [CI], 1.04 to 1.14). A subgroup analysis found no significant difference in the risk of congenital anomalies between cART and efavirenz users. However, zidovudine and protease inhibitor (RR, 1.09; 95% CI, 1.00 to 1.19) users were found to have a 10% increased risk of congenital anomalies, and integrase inhibitor users had a 60% increase in risk (RR, 1.61; 95% CI, 1.60 to 2.43). The subgroup results should be interpreted cautiously because of the moderate heterogeneity (I² =58%).

CONCLUSIONS

The use of protease inhibitors, integrase inhibitors, zidovudine, and newer drugs should be carefully considered in pregnant women. Further studies are needed to address environmental, nutrition, and adherence factors related to ART. Establishing a congenital anomalies surveillance system is recommended.

Comparative safety and effectiveness of perinatal antiretroviral therapies for HIV-infected women and their children: Systematic review and network meta-analysis including different study designs

BACKGROUND

Nearly all newly infected children acquire Human Immunodeficiency virus (HIV) via mother-to-child transmission (MTCT) during pregnancy, labour or breastfeeding from untreated HIV-positive mothers. Antiretroviral therapy (ART) is the standard care for pregnant women with HIV. However, evidence of ART effectiveness and harms in infants and children of HIV-positive pregnant women exposed to ART has been largely inconclusive. The aim of our systematic review and network meta-analysis (NMA) was to evaluate the comparative safety and effectiveness of ART drugs in children exposed to maternal HIV and ART (or no ART/placebo) across different study designs.

METHODS

We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (inception until December 7, 2015). Primary outcomes were any congenital malformations (CMs; safety), including overall major and minor CMs, and mother-to-child transmission (MTCT; effectiveness). Random-effects Bayesian pairwise meta-analyses and NMAs were conducted. After screening 6,468 citations and 1,373 full-text articles, 90 studies of various study designs and 90,563 patients were included.

RESULTS

The NMA on CMs (20 studies, 7,503 children, 16 drugs) found that none of the ART drugs examined here were associated with a significant increase in CMs. However, zidovudine administered with lamivudine and indinavir was associated with increased risk of preterm births, zidovudine administered with nevirapine was associated with increased risk of stillbirths, and lamivudine administered with stavudine and efavirenz was associated with increased risk of low birth weight. A NMA on MTCT (11 studies, 10,786 patients, 6 drugs) found that zidovudine administered once (odds ratio [OR] = 0.39, 95% credible interval [CrI]: 0.19-0.83) or twice (OR = 0.43, 95% CrI: 0.21-0.68) was associated with significantly reduced risk of MTCT.

CONCLUSIONS

Our findings suggest that ART drugs are not associated with an increased risk of CMs, yet some may increase adverse birth events. Some ART drugs (e.g., zidovudine) effectively reduce MTCT.

Magnitude of HIV and syphilis seroprevalence among pregnant women in Gondar, Northwest Ethiopia: a cross-sectional study

Background

Human immunodeficiency virus (HIV) and syphilis are major public health problems in sub-Saharan Africa, causing numerous adverse pregnancy outcomes. The aim of study was to assess the magnitude of HIV and syphilis seroprevalence among pregnant women at University of Gondar Teaching Hospital.

Method

The study was conducted between March and May, 2012. Sociodemographic data were collected through face-to-face interview. HIV1/2 was tested following current national HIV1/2 testing algorithm. Syphilis infection was also tested using the rapid plasm reagin test for screening and Treponema pallidum hemagglutination as a confirmatory test. Both bivariate and multivariate analysis were used to identify factors associated with HIV and syphilis seroprevalence from selected sociodemographic variables.

Results

Of 300 women, 31 (10.33%), eleven (3.7%), and three (1%) were seroreactive for HIV, syphilis, and HIV–syphilis coinfection, respectively. High seroprevalence of HIV was found in women ages 25–30 years (13.4%), and women whose husbands attended primary school (19.7%). Syphilis was high in women occupationally housewives (15.2%) and whose husbands were illiterate (11.5%). HIV was associated with husband illiteracy (AOR [adjusted odds ratio] of 4.13, 95% CI [confidence interval] [1.01, 16.95]) and primary educational level of husbands (AOR [95% CI] =3.83 [1.50, 9.90]), whereas syphilis was associated with illiteracy of husband (AOR [95% CI] =7.25 [1.74, 30.30]).

Conclusion

Seroprevalence of HIV and syphilis was high. Low husband educational status was a risk factor for HIV and syphilis. Therefore, substantial efforts have to be made to reinforce prevention strategies and to screen as early as possible to prevent mother-to-child and further horizontal transmission.

Methods and characteristics of published network meta-analyses using individual patient data: protocol for a scoping review

INTRODUCTION

Individual patient data (IPD) meta-analysis (MA) offers advantages over aggregate MA of using standardised criteria for patient characteristics across trials, and allowing reliable investigation of subgroup effects of interventions. Network meta-analysis (NMA) allows for the comparison of multiple treatments in a comprehensive analysis and the determination of the best treatment among several competing treatments, including those that have never been compared in a head-to-head study. Including IPD in NMA may enable the prevention of misleading inferences due to several biases, such as aggregation bias. Application of IPD-NMA methods in healthcare have begun to appear in medical journals. Our objective is to conduct a scoping review of existing IPD-NMA methods, and summarise their properties. We also aim to describe the characteristics of empirical IPD-NMAs, and examine how their results are reported.

METHODS AND ANALYSIS

We will search relevant electronic databases from inception until October 2014 (eg, MEDLINE), grey literature, and Google. The scoping review will consider published and unpublished papers that report completion of an IPD-NMA, describe a method, or report the methodological quality of IPD-NMA. We will include IPD-NMA of any quantitative study (eg, experimental, quasiexperimental, observational studies). Two reviewers will independently screen titles, abstracts and full-text articles, and will complete data abstraction. The anticipated outcome will be a collection of all the IPD-NMAs completed to date, and a description of their methods and reporting of results. We will create summary tables providing the characteristics of the included studies, and the various methods. Quantitative data (eg, number of patients) will be summarised by medians and IQRs, and categorical data (eg, type of effect size) by frequencies and percentages.

ETHICS AND DISSEMINATION

Ethical approval is not required as our study will not include confidential participant data and interventions. We will disseminate our results through an open access, peer-reviewed publication.