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Zhao Y, Zou L, Dong MH, Liu XX, Liu YL, Zhu JW, Luo QQ, Gao H. Challenges for Obstetricians and the Countermeasures of COVID-19 Epidemic. MATERNAL-FETAL MEDICINE 2020; 2:68-71. [PMID: 34522893 PMCID: PMC8428489 DOI: 10.1097/fm9.0000000000000046] [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: 02/10/2020] [Indexed: 11/06/2022] Open
Abstract
Since the outbreak of the novel coronavirus in Wuhan, China, as obstetricians, we also face great challenges. We need to identify pregnant patients with 2019 coronavirus disease infection timely, and give them appropriate treatment in order to obtain a good maternal and infant prognosis. Here, we would like to share a case and provide some suggestions on how to screen, diagnose and treat pregnant women with 2019 coronavirus disease infection during the outbreak.
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Affiliation(s)
- Yin Zhao
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Li Zou
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | | | - Xiao-Xia Liu
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ya-Lan Liu
- Department of Pediatric, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jian-Wen Zhu
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Qing-Qing Luo
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Hui Gao
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Powis KM, Huo Y, Williams PL, Kacanek D, Jao J, Patel K, Seage GR, Van Dyke RB, Chadwick EG. Antiretroviral Prescribing Practices Among Pregnant Women Living With HIV in the United States, 2008-2017. JAMA Netw Open 2019; 2:e1917669. [PMID: 31851347 PMCID: PMC6991210 DOI: 10.1001/jamanetworkopen.2019.17669] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/27/2019] [Indexed: 12/25/2022] Open
Abstract
Importance Since 1994, the US Department of Health and Human Services has published treatment guidelines for pregnant women living with HIV. Understanding how well prescribing patterns correspond with treatment guidelines could inform health policy and influence future clinical practice. Objectives To compare antiretroviral prescribing practices over time among pregnant women living with HIV with Department of Health and Human Services treatment guidelines and identify factors associated with receiving recommended regimens. Design, Setting, and Participants A prospective cohort study of 1582 pregnant women living with HIV were enrolled in the Pediatric HIV/AIDS Cohort Study Surveillance Monitoring of ART (antiretroviral therapy) Toxicities study between January 1, 2008, and June 30, 2017. The study was conducted at 18 academic research hospitals in the United States. Exposures Antiretroviral medications (ARVs) prescribed during pregnancy. Main Outcomes and Measures Proportion of regimens prescribed to pregnant women living with HIV qualifying as preferred or alternative according to Department of Health and Human Services guidelines, stratified by timing of initiation. Results Of 1867 pregnancies (among 1582 pregnant women living with HIV with a mean [SD] age of 28.6 [6.1] years at conception), 1264 (67.7%) occurred among women self-identified as black, 480 (25.7%) self-identified as white, and 123 (6.6%) self-identified as other or unreported race/ethnicity. Antiretroviral medications were initiated prior to conception for 790 women (42.3%), resumed during pregnancy for 625 women (33.5%), and initiated during pregnancy for 452 women (24.2%). Only 925 pregnancies (49.5%) were associated with prescribed ARVs designated as preferred or alternative, while 492 (26.4%) involved ARVs with insufficient evidence for use during pregnancy and 136 (7.3%) involved ARVs that were not recommended during pregnancy. A higher proportion of treatment-naive pregnant women initiating ARVs were prescribed preferred or alternative ARVs compared with those resuming ARVs or those treated with ARVs before conception (316 of 452 [69.9%] vs 325 of 625 [52.0%] vs 284 of 790 [35.9%]; P < .001). A total of 91 of 452 women (20.1%) initiating ARVs during pregnancy were prescribed ARVs with insufficient evidence for use during pregnancy or not recommended during pregnancy. Among women resuming ARVs, those with a viral load greater than 1000 copies/mL early in pregnancy had higher odds of being prescribed guideline-recommended ARVs (adjusted odds ratio, 2.03 [95% CI, 1.33-3.10]) compared with those with a viral load of 400 copies/mL or less. Conclusions and Relevance This study suggests that US ARV prescribing practices for pregnant women living with HIV do not align well with national guidelines. This finding is particularly concerning when treatment is initiated during pregnancy. Further research is needed to understand disparities between prescribing practices and evidence-based guideline recommendations.
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Affiliation(s)
- Kathleen M. Powis
- Department of Internal Medicine, Massachusetts General Hospital, Boston
- Department of Pediatrics, Massachusetts General Hospital, Boston
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yanling Huo
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Paige L. Williams
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Deborah Kacanek
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jennifer Jao
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Infectious Diseases, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Kunjal Patel
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - George R. Seage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Russell B. Van Dyke
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana
| | - Ellen G. Chadwick
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Infectious Diseases, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
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Schalkwijk S, Ter Heine R, Colbers AC, Huitema ADR, Denti P, Dooley KE, Capparelli E, Best BM, Cressey TR, Greupink R, Russel FGM, Mirochnick M, Burger DM. A Mechanism-Based Population Pharmacokinetic Analysis Assessing the Feasibility of Efavirenz Dose Reduction to 400 mg in Pregnant Women. Clin Pharmacokinet 2018; 57:1421-1433. [PMID: 29520730 PMCID: PMC6182466 DOI: 10.1007/s40262-018-0642-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Reducing the dose of efavirenz can improve safety, reduce costs, and increase access for patients with HIV infection. According to the World Health Organization, a similar dosing strategy for all patient populations is desirable for universal roll-out; however, it remains unknown whether the 400 mg daily dose is adequate during pregnancy. METHODS We developed a mechanistic population pharmacokinetic model using pooled data from women included in seven studies (1968 samples, 774 collected during pregnancy). Total and free efavirenz exposure (AUC24 and C12) were predicted for 400 (reduced) and 600 mg (standard) doses in both pregnant and non-pregnant women. RESULTS Using a 400 mg dose, the median efavirenz total AUC24 and C12 during the third trimester of pregnancy were 91 and 87% of values among non-pregnant women, respectively. Furthermore, the median free efavirenz C12 and AUC24 were predicted to increase during pregnancy by 11 and 15%, respectively. CONCLUSIONS It was predicted that reduced-dose efavirenz provides adequate exposure during pregnancy. These findings warrant prospective confirmation.
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Affiliation(s)
- Stein Schalkwijk
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Angela C Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edmund Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences and School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences and School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Tim R Cressey
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Rick Greupink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frans G M Russel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
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Veroniki AA, Antony J, Straus SE, Ashoor HM, Finkelstein Y, Khan PA, Ghassemi M, Blondal E, Ivory JD, Hutton B, Gough K, Hemmelgarn BR, Lillie E, Vafaei A, Tricco AC. 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. PLoS One 2018; 13:e0198447. [PMID: 29912896 PMCID: PMC6005568 DOI: 10.1371/journal.pone.0198447] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 05/20/2018] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
| | - Jesmin Antony
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Sharon E. Straus
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Huda M. Ashoor
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Yaron Finkelstein
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Paul A. Khan
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Marco Ghassemi
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Erik Blondal
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - John D. Ivory
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Brian Hutton
- School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Center for Practice Changing Research, The Ottawa Hospital–General Campus, Ottawa, Ontario, Canada
| | - Kevin Gough
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brenda R. Hemmelgarn
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Erin Lillie
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Afshin Vafaei
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Andrea C. Tricco
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Chersich MF, Newbatt E, Ng’oma K, de Zoysa I. UNICEF's contribution to the adoption and implementation of option B+ for preventing mother-to-child transmission of HIV: a policy analysis. Global Health 2018; 14:55. [PMID: 29859098 PMCID: PMC5984744 DOI: 10.1186/s12992-018-0369-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/06/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Between 2011 and 2013, global and national guidelines for preventing mother-to-child transmission (PMTCT) of HIV shifted to recommend Option B+, the provision of lifelong antiretroviral treatment for all HIV-infected pregnant women. METHODS We aimed to analyse how Option B+ reached the policy agenda, and unpack the processes, actors and politics that explain its adoption, with a focus on examining UNICEF's contribution to these events. Analysis drew on published articles and other documentation, 30 key informants interviews with staff at UNICEF, partner organisations and government officials, and country case studies. Cameroon, India, South Africa and Zimbabwe were each visited for 5-8 days. Interview transcripts were analysed using Dedoose software, reviewed several times and then coded thematically. RESULTS A national policy initiative in Malawi in 2011, in which the country adopted Option B+, rather than existing WHO recommended regimens, irrevocably placed the policy on the global agenda. UNICEF and other organisations recognised the policy's potential impact and strategically crafted arguments to support it, framing these around operational considerations, cost-effectiveness and values. As 'policy entrepreneurs', these organisations vigorously promoted the policy through a variety of channels and means, overcoming concerted opposition. WHO, on the basis of scanty evidence, released a series of documents towards the policy's endorsement, paving the way for its widespread adoption. National-level policy transformation was rapid and definitive, distinct from previous incremental policy processes. Many organisations, including UNICEF, facilitated these changes in country, acting individually, or in concert. CONCLUSIONS The adoption of the Option B+ policy marked a departure from established processes for PMTCT policy formulation which had been led by WHO with the support of technical experts, and in which recommendations were developed following shifts in evidence. Rather, changes were spurred by a country-level initiative, and a set of strategically framed arguments that resonated with funders and country-level actors. This bottom-up approach, supported by normative agencies, was transformative. For UNICEF, alignment between the organisation's country focus and the policy's underpinning values, enabled it to work with partners and accelerate widespread policy change.
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Affiliation(s)
- M. F. Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - K. Ng’oma
- United Nations Children’s Fund, Pretoria, South Africa
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Venkatesh KK, Morrison L, Livingston EG, Stek A, Read JS, Shapiro DE, Tuomala RE. Changing Patterns and Factors Associated With Mode of Delivery Among Pregnant Women With Human Immunodeficiency Virus Infection in the United States. Obstet Gynecol 2018; 131:879-890. [PMID: 29630021 PMCID: PMC6075712 DOI: 10.1097/aog.0000000000002566] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe patterns and factors associated with mode of delivery among pregnant women with human immunodeficiency virus (HIV) infection in the United States in relation to evolving HIV-in-pregnancy guidelines. METHODS We conducted an analysis of two observational studies, Pediatric AIDS Clinical Trials Group and International Maternal Pediatric Adolescent AIDS Clinical Trials Network Protocol P1025, which enrolled pregnant women with HIV infection from 1998 to 2013 at more than 60 U.S. acquired immunodeficiency syndrome clinical research sites. Multivariable analyses of factors associated with an HIV-indicated cesarean delivery (ie, for prevention of mother-to-child transmission) compared with other indications were conducted and compared according to prespecified time periods of evolving HIV-in-pregnancy guidelines: 1998-1999, 2000-2008, and 2009-2013. RESULTS Among 6,444 pregnant women with HIV infection, 21% delivered in 1998-1999, 58% in 2000-2008, and 21% in 2009-2013; 3,025 (47%) delivered by cesarean. Cesarean delivery increased from 30% in 1998 to 48% in 2013. Of all cesarean deliveries, repeat cesarean deliveries increased from 16% in 1998 to 42% in 2013; HIV-indicated cesarean deliveries peaked at 48% in 2004 and then dropped to 12% by 2013. In multivariable analyses, an HIV diagnosis during pregnancy, initiation of antiretroviral therapy in the third trimester, a plasma viral load 500 copies/mL or greater, and delivery between 37 and 40 weeks of gestation increased the likelihood of an HIV-indicated cesarean delivery. In analyses by time period, an HIV diagnosis during pregnancy, initiation of antiretroviral therapy in the third trimester, and a plasma viral load of 500 copies/mL or greater were progressively more likely to be associated with an HIV-indicated cesarean delivery over time. CONCLUSION Almost 50% of pregnant women with HIV infection underwent cesarean delivery. Over time, the rate of repeat cesarean deliveries increased, whereas the rate of HIV-indicated cesarean deliveries decreased; cesarean deliveries were more likely to be performed in women at high risk of mother-to-child transmission. These findings reinforce the need for both early diagnosis and treatment of HIV infection in pregnancy and the option of vaginal delivery after cesarean among pregnant women with HIV infection.
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Affiliation(s)
- Kartik K Venkatesh
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina (Chapel Hill, NC)
| | - Leavitt Morrison
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (Boston, MA)
| | - Elizabeth G Livingston
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Duke University (Durham, NC)
| | - Alice Stek
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California (Los Angeles, CA)
| | - Jennifer S Read
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA
| | - David E Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (Boston, MA)
| | - Ruth E Tuomala
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Harvard Medical School (Boston, MA)
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Kahungu MM, Kiwanuka J, Kaharuza F, Wanyenze RK. Factors associated with HIV positive sero-status among exposed infants attending care at health facilities: a cross sectional study in rural Uganda. BMC Public Health 2018; 18:139. [PMID: 29338730 PMCID: PMC5771195 DOI: 10.1186/s12889-018-5024-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 01/02/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND East and South Africa contributes 59% of all pediatric HIV infections globally. In Uganda, HIV prevalence among HIV exposed infants was estimated at 5.3% in 2014. Understanding the remaining bottlenecks to elimination of mother-to-child transmission (eMTCT) is critical to accelerating efforts towards eMTCT. This study determined factors associated with HIV positive sero-status among exposed infants attending mother-baby care clinics in rural Kasese so as to inform enhancement of interventions to further reduce MTCT. METHODS This was a cross-sectional mixed methods study. Quantitative data was derived from routine service data from the mother's HIV care card and exposed infant clinical chart. Key informant interviews were conducted with health workers and in-depth interviews with HIV infected mothers. Quantitative data was analyzed using Stata version 12. Logistic regression was used to determine factors associated with HIV sero-status. Latent content analysis was used to analyse qualitative data. RESULTS Overall, 32 of the 493 exposed infants (6.5%) were HIV infected. Infants who did not receive ART prophylaxis at birth (AOR = 4.9, 95% CI: 1.901-13.051, p=0.001) and those delivered outside of a health facility (AOR = 5.1, 95% CI: 1.038 - 24.742, p = 0.045) were five times more likely to be HIV infected than those who received prophylaxis and those delivered in health facilities, respectively. Based on the qualitative findings, health system factors affecting eMTCT were long waiting time, understaffing, weak community follow up system, stock outs of Neverapine syrup and lack of HIV testing kits. CONCLUSION Increasing facility based deliveries and addressing underlying health system challenges related to staffing and availability of the required commodities may further accelerate eMTCT.
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Affiliation(s)
| | - Julius Kiwanuka
- Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - Frank Kaharuza
- Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - Rhoda K. Wanyenze
- Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
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Scott RK, Chakhtoura N, Burke MM, Cohen RA, Kreitchmann R. Delivery After 40 Weeks of Gestation in Pregnant Women With Well-Controlled Human Immunodeficiency Virus. Obstet Gynecol 2017; 130:502-510. [PMID: 28796679 PMCID: PMC5656396 DOI: 10.1097/aog.0000000000002186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether there is increased mother-to-child transmission of human immunodeficiency virus (HIV)-1 associated with deliveries at 40 weeks of estimated gestational age (EGA) or greater in pregnant women with HIV-1 viral loads of 1,000 copies/mL or less. METHODS We performed a secondary analysis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development International Site Development Initiative Perinatal and Longitudinal Study in Latin American Countries and International Maternal Pediatric Adolescent AIDS Clinical Trials P1025 cohorts. We included pregnant women with HIV-1 with recent viral loads of 1,000 copies/mL or less at the time of delivery and compared delivery outcomes at between 38 and less than 40 weeks EGA with delivery outcomes at 40 weeks EGA or greater, the exposure of interest. Our primary outcome of interest was mother-to-child transmission, and secondary outcomes included indicators of maternal and neonatal morbidity. We examined the association between EGA and mother-to-child transmission using Poisson distribution. Associations between EGA and secondary outcomes were examined through bivariate analyses using Pearson χ and Fisher exact test or the nonparametric Mann-Whitney U test. RESULTS Among the 2,250 eligible neonates, eight neonates were infected with HIV-1 (overall transmission rate 0.4%, 95% CI 0.2-8.1%, 40 weeks EGA or greater 0.5% [3/621, 95% CI 0.2-1.4%], less than 40 weeks EGA 0.3% [5/1,629, 95% CI 0.1-0.7%]); there was no significant difference in transmission by EGA (rate ratio 1.57, 95% CI 0.24-8.09, P=.77). There was no difference in maternal viral load between the two groups nor was there a difference in timing of transmission among neonates born with HIV-1. CONCLUSION In pregnant women with well-controlled HIV-1, the risk of mother-to-child transmission did not differ significantly by EGA at delivery, although we were not powered to demonstrate equivalence of proportions of mother-to-child transmission between EGA groups.
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Affiliation(s)
- Rachel K Scott
- MedStar Health Research Institute and MedStar Washington Hospital Center, Washington, DC; the Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; Women's and Infants' Services, MedStar Washington Hospital Center, Washington, DC; Westat, Rockville, Maryland; and the International Site Development Initiative Perinatal/Longitudinal Study in Latin American Countries Protocol, Irmandade da Santa Casa de Misericordia de Porto Alegre, Universidade Federal das Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
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Rimawi BH, Smith SL, Badell ML, Zahedi-Spung LD, Sheth AN, Haddad L, Chakraborty R. HIV and reproductive healthcare in pregnant and postpartum HIV-infected women: adapting successful strategies. Future Virol 2016; 11:577-581. [PMID: 28348636 PMCID: PMC5365084 DOI: 10.2217/fvl-2016-0065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Linkage and retention in care for many HIV-infected women in the postpartum period is suboptimal, which compromises long-term virologic suppression and the HIV Care Continuum. Efforts are needed to improve individual outcomes by addressing transitions in care. We summarize some successful strategies to engage and retain HIV-infected women in care during the postpartum period.
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Affiliation(s)
- Bassam H Rimawi
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Emory University School of Medicine, 550 Peachtree Street, 8th Floor, Atlanta, GA 30303, USA
| | - Somer L Smith
- Division of Infectious Diseases, Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive NE, 5th Floor, Atlanta, GA 30322, USA
| | - Martina L Badell
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Emory University School of Medicine, 550 Peachtree Street, 8th Floor, Atlanta, GA 30303, USA
| | - Leilah D Zahedi-Spung
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Emory University School of Medicine, 550 Peachtree Street, 8th Floor, Atlanta, GA 30303, USA
| | - Anandi N Sheth
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive SE, Atlanta, GA 30303, USA
| | - Lisa Haddad
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Emory University School of Medicine, 550 Peachtree Street, 8th Floor, Atlanta, GA 30303, USA
| | - Rana Chakraborty
- Division of Infectious Diseases, Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive NE, 5th Floor, Atlanta, GA 30322, USA
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10
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Gantt S, Leister E, Jacobson DL, Boucoiran I, Huang ML, Jerome KR, Jourdain G, Ngo-Giang-Huong N, Burchett S, Frenkel L. Risk of congenital cytomegalovirus infection among HIV-exposed uninfected infants is not decreased by maternal nelfinavir use during pregnancy. J Med Virol 2016; 88:1051-8. [PMID: 26519647 PMCID: PMC4818099 DOI: 10.1002/jmv.24420] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Congenital cytomegalovirus (cCMV) infection is common among infants born to HIV-infected women. Nelfinavir (NFV), an antiretroviral drug that is safe during pregnancy, inhibits CMV replication in vitro at concentrations that standard doses achieve in plasma. We hypothesized that infants born to women receiving NFV for prevention of mother-to-child transmission of HIV (PMTCT) would have a reduced prevalence of cCMV infection. METHODS The prevalence of cCMV infection was compared among HIV-uninfected infants whose HIV-infected mothers either received NFV for >4 weeks during pregnancy (NFV-exposed) or did not receive any NFV in pregnancy (NFV-unexposed). CMV PCR was performed on infant blood samples collected at <3 weeks from birth. RESULTS Of the 1,255 women included, 314 received NFV for >4 weeks during pregnancy and 941 did not receive any NFV during pregnancy. The overall prevalence of cCMV infection in the infants was 2.2%, which did not differ by maternal NFV use. Maternal CD4 T cell counts were inversely correlated with risk of cCMV infection, independent of the time NFV was initiated during gestation. Infants with cCMV infection were born 0.7 weeks earlier (P = 0.010) and weighed 170 g less (P = 0.009) than uninfected infants. CONCLUSION Among HIV-exposed uninfected infants, cCMV infection was associated with adverse perinatal outcomes. NFV use in pregnancy was not associated with protection against cCMV. Safe and effective strategies to prevent cCMV infection are needed.
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Affiliation(s)
- Soren Gantt
- University of British Columbia and Child & Family Research Institute
- Fred Hutchinson Cancer Research Center
| | - Erin Leister
- Center for Biostatistics in AIDS Research, The Harvard T. H. Chan School of Public Health
| | - Denise L. Jacobson
- Center for Biostatistics in AIDS Research, The Harvard T. H. Chan School of Public Health
| | | | - Meei-Li Huang
- Fred Hutchinson Cancer Research Center
- University of Washington
| | - Keith R. Jerome
- Fred Hutchinson Cancer Research Center
- University of Washington
| | - Gonzague Jourdain
- Institut de Recherche pour le Développement
- The Harvard T. H. Chan School of Public Health
| | - Nicole Ngo-Giang-Huong
- Institut de Recherche pour le Développement
- The Harvard T. H. Chan School of Public Health
| | | | - Lisa Frenkel
- University of Washington
- Seattle Children’s Research Institute
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11
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Thorne C, Tookey P. Strategies for Monitoring Outcomes in HIV-Exposed Uninfected Children in the United Kingdom. Front Immunol 2016; 7:185. [PMID: 27242792 PMCID: PMC4868959 DOI: 10.3389/fimmu.2016.00185] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 05/02/2016] [Indexed: 12/15/2022] Open
Abstract
Surveillance of pregnancies in women living with HIV is carried out on a national basis in the United Kingdom (UK) through the National Study of HIV in Pregnancy and Childhood. There are currently around 1100-1200 HIV-exposed uninfected (HEU) infants born every year in the UK, where vertical transmission of HIV now occurs in fewer than 5 in every 1000 pregnancies. By the end of 2014, there was a cumulative total of more than 15,000 HEU children with any combination antiretroviral therapy (cART) exposure and more than 5000 with cART exposure from conception in the UK. HEU infants are increasingly being exposed to newer antiretroviral drugs for which less is known regarding both short- and long-term safety. In this commentary, we describe the approaches that have been taken to explore health outcomes in HEU children born in the UK. This includes the Children exposed to AntiRetroviral Therapy (CHART) Study, which was a consented follow-up study carried out in 2002-2005 of HEU children born in 1996-2004. The CHART Study showed that 4% of HEU children enrolled had a major health or development problem in early childhood; this was within expected UK norms, but the study was limited by small numbers and short-term follow-up. However, the problems with recruitment and retention that were encountered within the CHART Study demonstrated that comprehensive, clinic-based follow-up was not a feasible approach for long-term assessment of HEU children in the UK. We describe an alternative approach developed to monitor some aspects of their long-term health, involving the "flagging" of HEU infants for death and cancer registration with the UK Office for National Statistics. Some of the ethical concerns regarding investigation of long-term outcomes of in utero and perinatal exposure to antiretrovirals, including those relating to consent and confidentiality, are also discussed.
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Affiliation(s)
- Claire Thorne
- Population, Policy and Practice Programme, UCL Institute of Child Health, University College London, London, UK
| | - Pat Tookey
- Population, Policy and Practice Programme, UCL Institute of Child Health, University College London, London, UK
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12
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Zash R, Souda S, Chen JY, Binda K, Dryden-Peterson S, Lockman S, Mmalane M, Makhema J, Essex M, Shapiro R. Reassuring Birth Outcomes With Tenofovir/Emtricitabine/Efavirenz Used for Prevention of Mother-to-Child Transmission of HIV in Botswana. J Acquir Immune Defic Syndr 2016; 71:428-36. [PMID: 26379069 PMCID: PMC4767604 DOI: 10.1097/qai.0000000000000847] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Before introduction of tenofovir/emtricitabine/efavirenz (TDF/FTC/EFV), 3-drug antiretroviral therapy (ART) was associated with increased adverse birth outcomes when used for prevention of mother-to-child HIV transmission (PMTCT) in Botswana. METHODS We extracted obstetric records from all women at the 2 largest maternities in Botswana from 2009-2011 when Botswana National Guidelines recommended zidovudine (ZDV) from 28 weeks gestational age (GA) for CD4 ≥350 and ART for CD4 <350, and again in 2013-2014 after implementation of TDF/FTC/EFV for prevention of mother-to-child HIV transmission regardless of CD4 or GA. We compared the use of TDF/FTC/EFV in pregnancy with other 3-drug ART regimens, and with initiation of ZDV, among women with similar CD4 cell counts. Outcomes included small for gestational age (SGA), preterm delivery (PTD) (<37 weeks GA), and stillbirths (SB). RESULTS Among 9445 HIV-infected women delivering during the study period, 170 were on TDF/FTC/EFV at conception and 1468 initiated TDF/FTC/EFV during pregnancy. Adverse birth outcomes were high overall (3% SB, 21% PTD, and 18% SGA) and among women receiving TDF/FTC/EFV (3% SB, 22% PTD, and 12% SGA). There was no difference in PTD or SB among women initiating TDF/FTC/EFV compared with ZDV or other 3-drug ART, but initiating TDF/FTC/EFV was associated with fewer SGA infants than other 3-drug ART (adjusted odds ratio: 0.4, 95% confidence interval: 0.2 to 0.7). CONCLUSIONS Adverse birth outcomes remain high among HIV-infected women. TDF/FTC/EFV was at least as safe as other ART and associated with fewer SGA infants when initiated during pregnancy. Larger studies are needed to evaluate birth outcomes and congenital abnormalities among women on TDF/FTC/EFV at conception.
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Affiliation(s)
- Rebecca Zash
- *Beth Israel Deaconess Medical Center, Boston, MA; †Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; ‡Harvard School of Public Health, Boston, MA; §Faculty of Health Sciences, University of Botswana, Gaborone, Botswana; ‖Massachusetts General Hospital, Boston, MA; and ¶Brigham and Women's Hospital, Boston, MA
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Pintye J, Langat A, Singa B, Kinuthia J, Odeny B, Katana A, Nganga L, John-Stewart G, McGrath CJ. Maternal Tenofovir Disoproxil Fumarate Use in Pregnancy and Growth Outcomes among HIV-Exposed Uninfected Infants in Kenya. Infect Dis Obstet Gynecol 2015; 2015:276851. [PMID: 26823647 PMCID: PMC4707364 DOI: 10.1155/2015/276851] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/02/2015] [Accepted: 12/03/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF) is commonly used in antiretroviral treatment (ART) and preexposure prophylaxis regimens. We evaluated the relationship of prenatal TDF use and growth outcomes among Kenyan HIV-exposed uninfected (HEU) infants. MATERIALS AND METHODS We included PCR-confirmed HEU infants enrolled in a cross-sectional survey of mother-infant pairs conducted between July and December 2013 in Kenya. Maternal ART regimen during pregnancy was determined by self-report and clinic records. Six-week and 9-month z-scores for weight-for-age (WAZ), weight-for-length (WLZ), length-for-age (LAZ), and head circumference-for-age (HCAZ) were compared among HEU infants with and without TDF exposure using t-tests and multivariate linear regression models. RESULTS Among 277 mothers who received ART during pregnancy, 63% initiated ART before pregnancy, of which 89 (32%) used TDF. No differences in birth weight (3.0 kg versus 3.1 kg, p = 0.21) or gestational age (38 weeks versus 38 weeks, p = 0.16) were detected between TDF-exposed and TDF-unexposed infants. At 6 weeks, unadjusted mean WAZ was lower among TDF-exposed infants (-0.8 versus -0.4, p = 0.03), with a trend towards association in adjusted analyses (p = 0.06). There were no associations between prenatal TDF use and WLZ, LAZ, and HCAZ in 6-week or 9-month infant cohorts. CONCLUSION Maternal TDF use did not adversely affect infant growth compared to other regimens.
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Affiliation(s)
- Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA 98104, USA
- Department of Nursing, University of Washington, Seattle, WA 98195, USA
| | - Agnes Langat
- United States Centers for Disease Control and Prevention (CDC), Nairobi 00202, Kenya
| | - Benson Singa
- Center for Microbiology Research and Center for Clinical Research, Kenya Medical Research Institute, Nairobi 00202, Kenya
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA 98104, USA
- Department of Obstetrics & Gynecology, Kenyatta National Hospital, Nairobi 00202, Kenya
| | - Beryne Odeny
- Department of Global Health, University of Washington, Seattle, WA 98104, USA
| | - Abraham Katana
- United States Centers for Disease Control and Prevention (CDC), Nairobi 00202, Kenya
| | - Lucy Nganga
- United States Centers for Disease Control and Prevention (CDC), Nairobi 00202, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA 98104, USA
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
- Department of Epidemiology, University of Washington, Seattle, WA 98195, USA
| | - Christine J. McGrath
- Department of Global Health, University of Washington, Seattle, WA 98104, USA
- University of Texas Medical Branch, Galveston, TX 77555, USA
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14
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Colbers A, Best B, Schalkwijk S, Wang J, Stek A, Hidalgo Tenorio C, Hawkins D, Taylor G, Kreitchmann R, Burchett S, Haberl A, Kabeya K, van Kasteren M, Smith E, Capparelli E, Burger D, Mirochnick M. Maraviroc Pharmacokinetics in HIV-1-Infected Pregnant Women. Clin Infect Dis 2015; 61:1582-9. [PMID: 26202768 PMCID: PMC4614410 DOI: 10.1093/cid/civ587] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 07/08/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To describe the pharmacokinetics of maraviroc in human immunodeficiency virus (HIV)-infected women during pregnancy and post partum. METHODS HIV-infected pregnant women receiving maraviroc as part of clinical care had intensive steady-state 12-hour pharmacokinetic profiles performed during the third trimester and ≥2 weeks after delivery. Cord blood samples and matching maternal blood samples were taken at delivery. The data were collected in 2 studies: P1026 (United States) and PANNA (Europe). Pharmacokinetic parameters were calculated. RESULTS Eighteen women were included in the analysis. Most women (12; 67%) received 150 mg of maraviroc twice daily with a protease inhibitor, 2 (11%) received 300 mg twice daily without a protease inhibitor, and 4 (22%) had an alternative regimen. The geometric mean ratios for third-trimester versus postpartum maraviroc were 0.72 (90% confidence interval, .60-.88) for the area under the curve over a dosing interval (AUCtau) and 0.70 (0.58-0.85) for the maximum maraviroc concentration. Only 1 patient showed a trough concentration (Ctrough) below the suggested target of 50 ng/mL, both during pregnancy and post partum. The median ratio of maraviroc cord blood to maternal blood was 0.33 (range, 0.03-0.56). The viral load close to delivery was <50 copies/mL in 13 women (76%). All children were HIV negative at testing. CONCLUSIONS Overall maraviroc exposure during pregnancy was decreased, with a reduction in AUCtau and maximum concentration of about 30%. Ctrough was reduced by 15% but exceeded the minimum Ctrough target concentration. Therefore, the standard adult dose seems sufficient in pregnancy. CLINICAL TRIALS REGISTRATION NCT00825929 and NCT000422890.
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Affiliation(s)
| | - Brookie Best
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences & School of Medicine, University of California San Diego
| | - Stein Schalkwijk
- Department of Pharmacy
- Department of Pharmacology and Toxicology, Radboud university medical center, Nijmegen
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard School of Public Health
| | - Alice Stek
- Maternal Child and Adolescent/Adult Center, University of Southern California School of Medicine, Los Angeles
| | - Carmen Hidalgo Tenorio
- Department of Infectious Diseases, Hospital Universitario Virgen de las Nieves Granada, Spain
| | | | - Graham Taylor
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Regis Kreitchmann
- HIV/AIDS Research Department, Irmandade da Santa Casa de Misericordia de Porto Alegre, Brazil
| | | | - Annette Haberl
- Department of Infectious Diseases, Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Kabamba Kabeya
- Department of Infectious Diseases, Saint-Pierre University Hospital, Brussels, Belgium
| | - Marjo van Kasteren
- Department of Internal Medicine, St Elisabeth Ziekenhuis, Tilburg, The Netherlands
| | - Elizabeth Smith
- Maternal, Adolescent, and Pediatric Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Edmund Capparelli
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences & School of Medicine, University of California San Diego
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15
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Abbawa F, Awoke W, Alemu Y. Fertility desire and associated factors among clients on highly active antiretroviral treatment at finoteselam hospital Northwest Ethiopia: a cross sectional study. Reprod Health 2015; 12:69. [PMID: 26260021 PMCID: PMC4531807 DOI: 10.1186/s12978-015-0063-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 08/06/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The accessibility of antiretroviral treatment changed the lives of persons living with HIV from hopelessness to hopefulness. Thus, many of them decided to have children. In Ethiopia, where there is high prevalence of HIV, level of fertility desire among persons living with HIV could have significant part in safe motherhood and child health. The aim of this study was to assess the level of fertility desire and identify factors associated with it among clients on highly active antiretroviral treatment at Finoteselam Hospital, Northwest Ethiopia. METHODS A cross-sectional study design supplemented by in-depth interview was conducted on 422 clients on Highly Active Antiretroviral Treatment from July 1 to August 12, 2013. Structured questionnaire was used to collect the data. Data were entered in to EPi Info version 3.5.1 and exported to SPSS software version 16 for further analysis. Descriptive and summary statistics were computed. Proportions were calculated to estimate fertility desire level. Binary logistic regression model was fitted to identify factors associated with fertility desire. RESULTS A total of 422 clients were included in the study of which 217 (51.4%) were males. The median age was 33 (IQR = 12) years. A total of 141(33.4%) of clients had desire for having children. Male clients desire children than their female counterparts [AOR = 3.19, 95 % CI: (1.56, 6.51)]. Clients who had no child had more desire for having children than those who had three or more children [AOR = 6.78, 95 % CI: (2.38, 19.27)] and those who had ≤2 years duration on ART had more desire than those with >2 years duration on ART [AOR = 3.64, 95 % CI: (1.74, 7.64)]. Clients who had discussion with ART service provider about sexuality, Fertility desire and family planning had more child desire [AOR = 3.12, 95 % CI: (1.54, 6.32)]. CONCLUSIONS One third of clients have desire to have a child/children in the future. Male clients and clients who have less than or equal to 2 years ART follow up, with no child and having discussion with ART service provider were associated with increased fertility desire. Guidelines formulated and counseling protocols developed shall consider this desire to achieve their reproductive goals in the healthiest and safest possible manner.
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Affiliation(s)
| | - Worku Awoke
- Department of Epidemiology, School of Public Health, College of Medicine and Health Sciences, BahirDar University, BahirDar, Ethiopia.
| | - Yayehirad Alemu
- Department of Public Health, College of Health Science, Mizan-Tepi University, MizanTeferi, Ethiopia.
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Ezeanolue EE, Pharr JR, Hunt A, Patel D, Jackson D. Why are Children Still Being Infected with HIV? Impact of an Integrated Public Health and Clinical Practice Intervention on Mother-to-Child HIV Transmission in Las Vegas, Nevada, 2007-2012. Ann Med Health Sci Res 2015; 5:253-9. [PMID: 26229713 PMCID: PMC4512117 DOI: 10.4103/2141-9248.160189] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: During a 9 months period, September 2005 through June 2006, Nevada documented six cases of pediatric HIV acquired through mother-to-child transmission. Subsequently, a community-based approach to the care of women and children living with or exposed to HIV was implemented. Subjects and Methods: A detailed review of mother-infant pairs where HIV transmission occurred was performed to identify missed opportunities for prevention of mother-to-child HIV transmission. An intervention program was developed and implemented using the six-step process. Data were collected prospectively over a 6 years period (2007–2012) and were evaluated for six core outcomes measures: (1) adequacy of prenatal care (2) HIV diagnoses of expectant mothers prior to delivery (3) appropriate use of antiretroviral (ARV) therapy before delivery (4) appropriate use of cesarean section for delivery (5) adequacy of zidovudine prophylaxis to newborn (6) HIV transmission rate. Results: Twenty-six infants were born to HIV-infected mothers from July 2005 to June 2006 with 6 documented infections. One hundred and five infants were born to HIV infected mothers from January 2007 to December 2012. Postimplementation, adequacy of prenatal care increased from 58% (15/26) to 85% (89/105); appropriate use of ARV therapy before delivery increased from 73% (19/26) to 86% (90/105); cesarean section as the method for delivery increased from 62% (16/26) to 74% (78/105); adequacy of zidovudine prophylaxis to newborn increased from 54% (14/26) to 87% (91/105). HIV transmission rate dropped from 23% (6/26) to 0%. Conclusion: Integrating public health and clinical services in the care of HIV-infected pregnant women and exposed infants leads to better coordination of care and improved quality of care.
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Affiliation(s)
- E E Ezeanolue
- Department of Pediatrics Las Vegas, University of Nevada School of Medicine, NV 89154, USA
| | - J R Pharr
- Department of Environmental and Occupational Health, University of Nevada Las Vegas, NV 89154, USA
| | - A Hunt
- Department of Pediatrics Las Vegas, University of Nevada School of Medicine, NV 89154, USA
| | - D Patel
- Department of Pediatrics Las Vegas, University of Nevada School of Medicine, NV 89154, USA
| | - D Jackson
- Department of Pediatrics Las Vegas, University of Nevada School of Medicine, NV 89154, USA
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17
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Kakkar F, Boucoiran I, Lamarre V, Ducruet T, Amre D, Soudeyns H, Lapointe N, Boucher M. Risk factors for pre-term birth in a Canadian cohort of HIV-positive women: role of ritonavir boosting? J Int AIDS Soc 2015; 18:19933. [PMID: 26051165 PMCID: PMC4458515 DOI: 10.7448/ias.18.1.19933] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 04/12/2015] [Accepted: 05/06/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The risk of pre-term birth (PTB) associated with the use of protease inhibitors (PIs) during pregnancy remains a subject of debate. Recent data suggest that ritonavir boosting of PIs may play a specific role in the initiation of PTB, through an effect on the maternal-fetal adrenal axis. The primary objective of this study is to compare the risk of PTB among women treated with boosted PI versus non-boosted PIs during pregnancy. METHODS Between 1988 and 2011, 705 HIV-positive women were enrolled into the Centre Maternel et Infantile sur le SIDA mother-infant cohort at Centre Hospitalier Universitaire Sainte-Justine in Montreal, Canada. Inclusion criteria for the study were: 1) attendance at a minimum of two antenatal obstetric visits and 2) singleton live birth, at 24 weeks gestational or older. The association between PTB (defined as delivery at <37 weeks gestational age), antiretroviral drug exposure and maternal risk factors was assessed retrospectively using logistic regression. RESULTS A total of 525 mother-infant pairs were included in the analysis. Among them, PI-based combination anti-retroviral therapy was used in 37.4%, boosted PI based in 24.4%, non-nucleoside reverse transcriptase inhibitor (NNRTI) or nucleoside reverse transcriptase inhibitor based in 28.1%, and no treatment was given in 10.0% of cases. Overall, 13.5% of women experienced PTB. Among women treated with antiretroviral therapy, the risk of PTB was significantly higher among women who received boosted versus non-boosted PI (OR 2.01, 95% CI 1.02-3.97). This remained significant after adjusting for maternal age, delivery CD4 count, hepatitis C co-infection, history of previous PTB, and parity (aOR 2.17, 95% CI 1.05-4.51). There was no increased risk of PTB with the use of unboosted PIs as compared to NNRTI- or NRTI-based regimens. CONCLUSION While previous studies on the association between PTB and PI use have generally considered all PIs the same, our results would indicate a possible role of ritonavir boosting as a risk factor for PTB. Further work is needed to understand the pathophysiologic mechanisms involved, and to identify the safest ARV regimens to be used in pregnancy.
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Affiliation(s)
- Fatima Kakkar
- Division of Infectious Diseases, CHU Sainte-Justine, Montréal, Canada
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
- Centre maternel et infantile sur le SIDA, CHU Sainte-Justine, Montreal, Canada;
| | - Isabelle Boucoiran
- Centre maternel et infantile sur le SIDA, CHU Sainte-Justine, Montreal, Canada
- Department of Obstetrics and Gynecology, Université de Montréal, CHU Sainte-Justine, Montreal, Canada
| | - Valerie Lamarre
- Division of Infectious Diseases, CHU Sainte-Justine, Montréal, Canada
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
- Centre maternel et infantile sur le SIDA, CHU Sainte-Justine, Montreal, Canada
| | - Thierry Ducruet
- Unité de recherche clinique appliquée, CHU Sainte-Justine, Montréal, Canada
| | - Devendra Amre
- Centre de recherche du CHU Sainte-Justine, Montréal, Canada
| | - Hugo Soudeyns
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
- Centre de recherche du CHU Sainte-Justine, Montréal, Canada
- Department of Microbiology, Infectious Diseases and Immunology, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Normand Lapointe
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
- Centre maternel et infantile sur le SIDA, CHU Sainte-Justine, Montreal, Canada
| | - Marc Boucher
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
- Centre maternel et infantile sur le SIDA, CHU Sainte-Justine, Montreal, Canada
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18
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Hardy E, Cu-Uvin S. Care of the HIV-infected pregnant woman in the developed world. Obstet Med 2015; 8:13-7. [PMID: 27512453 PMCID: PMC4934996 DOI: 10.1177/1753495x14531753] [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: 11/15/2022] Open
Abstract
The reduction of human immunodeficiency virus (HIV) transmission from mother to child is one of the success stories of modern medicine and public health. In the developed world, with universal HIV counseling and testing, antiretroviral prophylaxis, scheduled Caesarean delivery if indicated, and avoidance of breastfeeding, HIV transmission from mother to infant can be <2%. Despite this, transmissions continue to occur, often due to lack of knowledge of HIV status. Missed opportunities for prevention and prevention challenges include late prenatal care, lack of HIV testing in pregnancy, lack of preconception counseling, unintended pregnancy, and substance abuse. We review preconception counseling including options for serodiscordant couples, and antepartum, peripartum and postpartum care of the HIV-infected woman in the developed world, and advocate for a comprehensive, collaborative, multidisciplinary approach.
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Affiliation(s)
- Erica Hardy
- Infectious Disease and Obstetric Medicine, Women & Infants Hospital, Providence, RI, USA
- The Alpert Medical School of Brown University, Providence, RI, USA
| | - Susan Cu-Uvin
- The Alpert Medical School of Brown University, Providence, RI, USA
- Infectious Disease, The Miriam Hospital, Providence, RI, USA
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Haddad LB, Polis CB, Sheth AN, Brown J, Kourtis AP, King C, Chakraborty R, Ofotokun I. Contraceptive methods and risk of HIV acquisition or female-to-male transmission. Curr HIV/AIDS Rep 2014; 11:447-58. [PMID: 25297973 PMCID: PMC4310558 DOI: 10.1007/s11904-014-0236-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Effective family planning with modern contraception is an important intervention to prevent unintended pregnancies which also provides personal, familial, and societal benefits. Contraception is also the most cost-effective strategy to reduce the burden of mother-to-child HIV transmission for women living with HIV who wish to prevent pregnancy. There are concerns, however, that certain contraceptive methods, in particular the injectable contraceptive depot medroxyprogesterone acetate (DMPA), may increase a woman's risk of acquiring HIV or transmitting it to uninfected males. These concerns, if confirmed, could potentially have large public health implications. This paper briefly reviews the literature on use of contraception among women living with HIV or at high risk of HIV infection. The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommendations place no restrictions on the use of hormonal contraceptive methods by women with or at high risk of HIV infection, although a clarification recommends that, given uncertainty in the current literature, women at high risk of HIV who choose progestogen-only injectable contraceptives should be informed that it may or may not increase their risk of HIV acquisition and should also be informed about and have access to HIV preventive measures, including male or female condoms.
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Affiliation(s)
- Lisa B Haddad
- Department of Gynecology and Obstetrics, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA, 30303, USA,
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Mandelbrot L, Duro D, Belissa E, Peytavin G. Placental transfer of darunavir in an ex vivo human cotyledon perfusion model. Antimicrob Agents Chemother 2014; 58:5617-20. [PMID: 24982090 PMCID: PMC4135808 DOI: 10.1128/aac.03184-14] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 06/26/2014] [Indexed: 11/20/2022] Open
Abstract
Placental transfer of the HIV protease inhibitor darunavir was investigated in 5 term human cotyledons perfused with darunavir (1,000 ng/ml) in the maternal to fetal direction. The mean (± the standard deviation [SD]) fetal transfer rate (FTR) (fetal/maternal concentration at steady state from 30 to 90 min) was 15.0%±2.1%, and the mean (±SD) clearance index (darunavir FTR/antipyrine FTR) was 40.3%±5.8%. This shows that darunavir crosses the placenta at a relatively low rate, resulting in fetal exposure.
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Affiliation(s)
- Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Service de Gynécologie-Obstetrique, Département Hospitalier Universitaire Risque et Grossesse, Colombes, France Université Paris-Diderot, Paris, France
| | - Dominique Duro
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Service de Gynécologie-Obstetrique, Département Hospitalier Universitaire Risque et Grossesse, Colombes, France
| | - Emilie Belissa
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Clinical Pharmaco-Toxicology Department and IAME, INSERM, Paris, France
| | - Gilles Peytavin
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Clinical Pharmaco-Toxicology Department and IAME, INSERM, Paris, France
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21
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Tricco AC, Antony J, Angeliki VA, Ashoor H, Hutton B, Hemmelgarn BR, Moher D, Finkelstein Y, Gough K, Straus SE. Safety and effectiveness of antiretroviral therapies for HIV-infected women and their infants and children: protocol for a systematic review and network meta-analysis. Syst Rev 2014; 3:51. [PMID: 24887455 PMCID: PMC4039063 DOI: 10.1186/2046-4053-3-51] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 05/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antiretroviral therapy reduces mother-to-child transmission of human immunodeficiency virus (HIV) during pregnancy, delivery, and breastfeeding. However, these agents have been associated with preterm birth, anemia and low birth weight. We aim to evaluate the comparative safety and effectiveness of the use of antiretroviral drugs among HIV-infected women and the effects on their infants and children through a systematic review and network meta-analysis. METHODS/DESIGN Studies examining the effects of six antiretroviral drug classes (nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors, integrase inhibitors, fusion inhibitors, co-receptor inhibitors) administered to HIV-infected pregnant women will be included. We will include randomized clinical trials (RCTs), quasi-RCTs, non-RCTs, controlled before-after, interrupted time series, cohort, registry, and case-control studies. No limitations will be imposed on publication status (that is, unpublished studies are eligible for inclusion), duration of follow-up, study conduct period, and language of dissemination. Comprehensive literature searches will be conducted in major electronic databases, including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Gray literature will be identified through searching dissertation databases, trial protocol registries, and conference abstracts.Two team members will independently screen all citations, full-text articles, and abstract data; conflicts will be resolved through discussion. The risk of bias and methodological quality will be appraised using appropriate tools (for example, Cochrane Collaboration's tool for assessing risk of bias, Newcastle-Ottawa Scale, and McMaster Quality Assessment Scale of Harms). If feasible and appropriate, we will conduct random effects meta-analysis. Network meta-analysis will be considered for outcomes with the greatest number of treatment comparisons available that fulfill network meta-analysis assumptions (for example, consistency of evidence between direct and indirect data, and low statistical heterogeneity between included studies).The primary effectiveness outcome is mother-to-child transmission of HIV, and the primary safety outcome is major congenital malformation (overall and specific types) among newborns of HIV-infected women. Secondary safety outcomes include stillbirths, infant/child death, preterm delivery, overall and specific minor congenital malformations, and small for gestational age infants. DISCUSSION Our systematic review will be of utility to healthcare providers, policy-makers, and HIV-positive women regarding the use of antiretroviral drugs. TRIAL REGISTRATION PROSPERO registry number: CRD42014009071.
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Affiliation(s)
- Andrea C Tricco
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1 T8, Canada
| | - Jesmin Antony
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1 T8, Canada
| | - Veroniki A Angeliki
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1 T8, Canada
| | - Huda Ashoor
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1 T8, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Centre for Practice-Changing Research, Ottawa Hospital Research Institute and University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada
| | - Brenda R Hemmelgarn
- Departments of Medicine and Community Health Sciences, University of Calgary, 1403 29th St NW, Calgary, AB T2N 2T9, Canada
| | - David Moher
- Clinical Epidemiology Program, Centre for Practice-Changing Research, Ottawa Hospital Research Institute and University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada
| | - Yaron Finkelstein
- The Hospital for Sick Children and Department of Pediatrics, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Kevin Gough
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1 T8, Canada
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1 T8, Canada
- Department of Geriatric Medicine, University of Toronto, Toronto, ON, Canada
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22
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Smith KY, Tierney C, Mollan K, Venuto CS, Budhathoki C, Ma Q, Morse GD, Sax P, Katzenstein D, Godfrey C, Fischl M, Daar ES, Collier AC. Outcomes by sex following treatment initiation with atazanavir plus ritonavir or efavirenz with abacavir/lamivudine or tenofovir/emtricitabine. Clin Infect Dis 2014; 58:555-63. [PMID: 24253247 PMCID: PMC3905755 DOI: 10.1093/cid/cit747] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 11/04/2013] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We aimed to evaluate treatment responses to atazanavir plus ritonavir (ATV/r) or efavirenz (EFV) in initial antiretroviral regimens among women and men, and determine if treatment outcomes differ by sex. METHODS We performed a randomized trial of open-label ATV/r or EFV combined with abacavir/lamivudine (ABC/3TC) or tenofovir/emtricitabine (TDF/FTC) in 1857 human immunodeficiency virus type 1-infected, treatment-naive persons enrolled between September 2005 and November 2007 at 59 sites in the United States and Puerto Rico. Associations of sex with 3 primary study endpoints of time to virologic failure, safety, and tolerability events were analyzed using Cox proportional hazards models. Model-based population pharmacokinetic analysis was performed using nonlinear mixed effects modeling (NONMEM version VII). RESULTS Of 1857 participants, 322 were women. Women assigned to ATV/r had a higher risk of virologic failure with either nucleoside reverse transcriptase inhibitor backbone than women assigned to EFV, or men assigned to ATV/r. The effects of ATV/r and EFV upon safety and tolerability risk did not differ significantly by sex. With ABC/3TC, women had a significantly higher (32%) safety risk compared to men; with TDF/FTC, the safety risk was 20% larger for women compared to men, but not statistically significant. Women had slower ATV clearance and higher predose levels of ATV compared to men. Self-reported adherence did not differ significantly by sex. CONCLUSIONS This is the first randomized clinical trial to identify a significantly earlier time to virologic failure in women randomized to ATV/r compared to women randomized to EFV. This finding has important clinical implications given that boosted protease inhibitors are often favored over EFV in women of childbearing potential. CLINICAL TRIALS REGISTRATION NCT00118898.
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Affiliation(s)
- Kimberly Y. Smith
- Department of Medicine Division of Infectious Diseases, RushUniversity Medical Center, Chicago, Illinois
| | - Camlin Tierney
- Statistical Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts
| | - Katie Mollan
- Statistical Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts
- Center for AIDS Research, University of North Carolina at Chapel Hill
| | - Charles S. Venuto
- Center for Human Experimental Therapeutics, University of Rochester, New York
| | - Chakra Budhathoki
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Qing Ma
- Department of Pharmacy Practiceand
| | - Gene D. Morse
- School of Pharmacy and Pharmaceutical Sciences, University of Buffalo, State University of New York
| | - Paul Sax
- Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Katzenstein
- School of Medicine, Division of Infectious Diseases, Stanford University, California
| | | | - Margaret Fischl
- Department of Internal Medicine, University of Miami, Florida
| | - Eric S. Daar
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Ann C. Collier
- Department of Medicine, Division of Infectious Diseases, University of Washington Medical Center, Seattle
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Phiri K, Fischer MA, Mogun H, Williams PL, Palmsten K, Seage GR, Hernandez-Diaz S. Trends in antiretroviral drug use during pregnancy among HIV-infected women on medicaid: 2000-2007. AIDS Patient Care STDS 2014; 28:56-65. [PMID: 24517538 PMCID: PMC3926172 DOI: 10.1089/apc.2013.0165] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Optimal use of antiretroviral drugs by pregnant women living with human immunodeficiency virus (HIV) is crucial to treat maternal HIV infection and prevent perinatal transmission of the virus effectively. Our goal was to describe national trends of antiretroviral (ARV) use during pregnancy among HIV-infected women living in the U.S. and enrolled in Medicaid. We used the 2000-2007 Medicaid Analytic eXtract (MAX) files to identify our study cohort. ARV use was defined as the dispensing of at least one ARV drug prescription during pregnancy based on Medicaid pharmacy claims. The prevalence of HIV was calculated, and temporal trends of ARV use during pregnancy were compared to the U.S. perinatal treatment guidelines. Predictors of ARV use during pregnancy were assessed using logistic regression models. From 1,106,757 pregnancies (955,251 women), 3083 (2856 women, 0.28%) were identified as HIV positive. We found striking regional variations in the prevalence of HIV and ARV prescription dispensing among pregnant women. The states with the highest HIV prevalence were Washington DC (5.8%), Maryland (0.90%), and New York (0.89%); all other states had a prevalence below 0.5%. A substantial fraction of women did not have any ARV dispensing throughout pregnancy (637 of 3083 (21%) pregnancies), and women with limited health care utilization were the least likely to have ARV dispensings. This finding calls for further research to better characterize HIV-positive women who are enrolled in Medicaid prior to pregnancy and yet have no ARV prescriptions so that appropriate interventions can be implemented.
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Affiliation(s)
- Kelesitse Phiri
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Michael A. Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paige L. Williams
- Department of Biostatistics and Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts
| | - Kristin Palmsten
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - George R. Seage
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
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Usach I, Melis V, Peris JE. Non-nucleoside reverse transcriptase inhibitors: a review on pharmacokinetics, pharmacodynamics, safety and tolerability. J Int AIDS Soc 2013; 16:1-14. [PMID: 24008177 PMCID: PMC3764307 DOI: 10.7448/ias.16.1.18567] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 06/21/2013] [Accepted: 07/29/2013] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Human immunodeficiency virus (HIV) type-1 non-nucleoside and nucleoside reverse transcriptase inhibitors (NNRTIs) are key drugs of highly active antiretroviral therapy (HAART) in the clinical management of acquired immune deficiency syndrome (AIDS)/HIV infection. DISCUSSION First-generation NNRTIs, nevirapine (NVP), delavirdine (DLV) and efavirenz (EFV) are drugs with a low genetic barrier and poor resistance profile, which has led to the development of new generations of NNRTIs. Second-generation NNRTIs, etravirine (ETR) and rilpivirine (RPV) have been approved by the Food and Drug Administration and European Union, and the next generation of drugs is currently being clinically developed. This review describes recent clinical data, pharmacokinetics, metabolism, pharmacodynamics, safety and tolerability of commercialized NNRTIs, including the effects of sex, race and age differences on pharmacokinetics and safety. Moreover, it summarizes the characteristics of next-generation NNRTIs: lersivirine, GSK 2248761, RDEA806, BILR 355 BS, calanolide A, MK-4965, MK-1439 and MK-6186. CONCLUSIONS This review presents a wide description of NNRTIs, providing useful information for researchers interested in this field, both in clinical use and in research.
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Affiliation(s)
| | | | - José-Esteban Peris
- Department of Pharmacy and Pharmaceutical Technology, Burjassot, Valencia, Spain
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25
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Patterson KB, Dumond JB, Prince HA, Jenkins AJ, Scarsi KK, Wang R, Malone S, Hudgens MG, Kashuba ADM. Protein binding of lopinavir and ritonavir during 4 phases of pregnancy: implications for treatment guidelines. J Acquir Immune Defic Syndr 2013; 63:51-8. [PMID: 23221983 PMCID: PMC3625477 DOI: 10.1097/qai.0b013e31827fd47e] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To investigate the intraindividual pharmacokinetics (PKs) of total (protein bound plus unbound) and unbound lopinavir/ritonavir (LPV/RTV) and to assess whether the pediatric formulation (100 mg/25 mg) can overcome any pregnancy-associated changes. DESIGN Prospective longitudinal PK study. METHODS HIV-infected pregnant antiretroviral therapy-naive and experienced women receiving LPV/RTV 400 mg/100 mg tablets twice daily. Intensive PK evaluations were performed at 20-24 weeks (PK1), 30 weeks (PK2) followed by empiric dose increase using the pediatric formulation (100 mg/25 mg twice daily), 32 weeks (PK3), and 8 weeks postpartum (PK4). RESULTS Twelve women completed prespecified PK evaluations. Median (range) age was 28 (18-35) years and baseline BMI was 32 (19-41) kg/m. During pregnancy, total area under the time concentration (AUC0-12h) for LPV was significantly lower than postpartum (PK1, PK2, or PK3 vs. PK4, P = 0.005). Protein-unbound LPV AUC0-12h remained unchanged during pregnancy [PK1: 1.6 (1.3-1.9) vs. PK2: 1.6 (1.3-1.9) μg·h/mL, P = 0.4] despite a 25% dose increase [PK2 vs. PK3: 1.8 (1.3-2.1) μg·h/mL, P = 0.5]. Protein-unbound LPV predose concentrations (C12h) did not significantly change despite dose increase [PK2: 0.10 (0.08-0.15) vs. PK3: 0.12 (0.10-0.15) μg/mL, P = 0.09]. Albumin and LPV AUC0-12h fraction unbound were correlated (rs = 0.3, P = 0.03). CONCLUSIONS Total LPV exposure was significantly decreased throughout pregnancy despite the increased dose. However, the exposure of unbound LPV did not change significantly regardless of trimester or dose. Predose concentrations of unbound LPV were not affected by the additional dose and were 70-fold greater than the minimum efficacy concentration. These findings suggest dose adjustments may not be necessary in all HIV-infected pregnant women.
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Affiliation(s)
- Kristine B Patterson
- Department of Medicine, University of North Carolina, Chapel Hill, NC 27599-7215, USA.
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26
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Gertsch A, Michel O, Locatelli I, Bugnon O, Rickenbach M, Cavassini M, Schneider MP. Adherence to antiretroviral treatment decreases during postpartum compared to pregnancy: a longitudinal electronic monitoring study. AIDS Patient Care STDS 2013; 27:208-10. [PMID: 23506310 PMCID: PMC3624692 DOI: 10.1089/apc.2013.0005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Aurélie Gertsch
- Community Pharmacy, School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Switzerland
- Community Pharmacy, University of Lausanne, Switzerland
| | - Odile Michel
- Community Pharmacy, School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Switzerland
| | - Isabella Locatelli
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland
- Institute for Social and Preventive Medicine, University of Lausanne, Switzerland
| | - Olivier Bugnon
- Community Pharmacy, School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Switzerland
- Community Pharmacy, University of Lausanne, Switzerland
| | | | | | - Marie-Paule Schneider
- Community Pharmacy, School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Switzerland
- Community Pharmacy, University of Lausanne, Switzerland
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27
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King CC, Ellington SR, Kourtis AP. The role of co-infections in mother-to-child transmission of HIV. Curr HIV Res 2013; 11:10-23. [PMID: 23305198 PMCID: PMC4411038 DOI: 10.2174/1570162x11311010003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 12/11/2012] [Accepted: 12/14/2012] [Indexed: 01/27/2023]
Abstract
In HIV-infected women, co-infections that target the placenta, fetal membranes, genital tract, and breast tissue, as well as systemic maternal and infant infections, have been shown to increase the risk for mother-to-child transmission of HIV (MTCT). Active co-infection stimulates the release of cytokines and inflammatory agents that enhance HIV replication locally or systemically and increase tissue permeability, which weakens natural defenses to MTCT. Many maternal or infant co-infections can affect MTCT of HIV, and particular ones, such as genital tract infection with herpes simplex virus, or systemic infections such as hepatitis B, can have substantial epidemiologic impact on MTCT. Screening and treatment for co-infections that can make infants susceptible to MTCT in utero, peripartum, or postpartum can help reduce the incidence of HIV infection among infants and improve the health of mothers and infants worldwide.
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Affiliation(s)
- Caroline C King
- Division of Reproductive Health, NCCDPHP, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS-K34, Atlanta, GA 30341, USA.
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28
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Côté HCF, Soudeyns H, Thorne A, Alimenti A, Lamarre V, Maan EJ, Sattha B, Singer J, Lapointe N, Money DM, Forbes J, Wong J, Bitnun A, Samson L, Brophy J, Burdge D, Pick N, van Schalkwyk J, Montaner J, Harris M, Janssen P. Leukocyte telomere length in HIV-infected and HIV-exposed uninfected children: shorter telomeres with uncontrolled HIV viremia. PLoS One 2012; 7:e39266. [PMID: 22815702 PMCID: PMC3397986 DOI: 10.1371/journal.pone.0039266] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 05/22/2012] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Nucleoside reverse transcriptase inhibitors (NRTIs) used in HIV antiretroviral therapy can inhibit human telomerase reverse transcriptase. We therefore investigated whether in utero or childhood exposure to NRTIs affects leukocyte telomere length (LTL), a marker of cellular aging. METHODS In this cross-sectional CARMA cohort study, we investigated factors associated with LTL in HIV-1-infected (HIV(+)) children (n = 94), HIV-1-exposed uninfected (HEU) children who were exposed to antiretroviral therapy (ART) perinatally (n = 177), and HIV-unexposed uninfected (HIV(-)) control children (n = 104) aged 0-19 years. Univariate followed by multivariate linear regression models were used to examine relationships of explanatory variables with LTL for: a) all subjects, b) HIV(+)/HEU children only, and c) HIV(+) children only. RESULTS After adjusting for age and gender, there was no difference in LTL between the 3 groups, when considering children of all ages together. In multivariate models, older age and male gender were associated with shorter LTL. For the HIV(+) group alone, having a detectable HIV viral load was also strongly associated with shorter LTL (p = 0.007). CONCLUSIONS In this large study, group rates of LTL attrition were similar for HIV(+), HEU and HIV(-) children. No associations between children's LTL and their perinatal ART exposure or HIV status were seen in linear regression models. However, the association between having a detectable HIV viral load and shorter LTL suggests that uncontrolled HIV viremia rather than duration of ART exposure may be associated with acceleration of blood telomere attrition.
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Affiliation(s)
- Hélène C F Côté
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
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29
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Siberry GK, Williams PL, Mendez H, Seage GR, Jacobson DL, Hazra R, Rich KC, Griner R, Tassiopoulos K, Kacanek D, Mofenson LM, Miller T, DiMeglio LA, Watts DH. Safety of tenofovir use during pregnancy: early growth outcomes in HIV-exposed uninfected infants. AIDS 2012; 26:1151-9. [PMID: 22382151 PMCID: PMC3476702 DOI: 10.1097/qad.0b013e328352d135] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the association of tenofovir disoproxil fumarate (TDF) use during pregnancy with early growth parameters in HIV-exposed, uninfected (HEU) infants. DESIGN US-based prospective cohort study of HEU children to examine potential adverse effects of prenatal TDF exposure. METHODS We evaluated the association of maternal TDF use during pregnancy with small for gestational age (SGA); low birth weight (LBW, <2.5 kg); weight-for-age z-scores (WAZ), length-for-age z-scores (LAZ), and head circumference-for-age (HCAZ) z-scores at newborn visit; and LAZ, HCAZ, and WAZ at age 1 year. Logistic regression models for LBW and SGA were fit, adjusting for maternal and sociodemographic factors. Adjusted linear regression models were used to evaluate LAZ, WAZ, and HCAZ by TDF exposure. RESULTS Of 2029 enrolled children with maternal antiretroviral information, TDF was used by 449 (21%) HIV-infected mothers, increasing from 14% in 2003 to 43% in 2010. There was no difference between those exposed to combination regimens with vs. without TDF for SGA, LBW, and newborn LAZ and HCAZ. However, at age 1 year, infants exposed to combination regimens with TDF had significantly lower adjusted mean LAZ and HCAZ than those without TDF (LAZ: -0.17 vs. -0.03, P=0.04; HCAZ: 0.17 vs. 0.42, P=0.02). CONCLUSION TDF use during pregnancy was not associated with increased risk for LBW or SGA. The slightly lower mean LAZ and HCAZ observed at age 1 year in TDF-exposed infants are of uncertain significance but underscore the need for additional studies of growth outcomes after TDF use during pregnancy.
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Affiliation(s)
- George K Siberry
- Pediatric Adolescent Maternal AIDS Branch, Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA.
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30
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Gibb DM, Kizito H, Russell EC, Chidziva E, Zalwango E, Nalumenya R, Spyer M, Tumukunde D, Nathoo K, Munderi P, Kyomugisha H, Hakim J, Grosskurth H, Gilks CF, Walker AS, Musoke P. Pregnancy and infant outcomes among HIV-infected women taking long-term ART with and without tenofovir in the DART trial. PLoS Med 2012; 9:e1001217. [PMID: 22615543 PMCID: PMC3352861 DOI: 10.1371/journal.pmed.1001217] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2011] [Accepted: 04/05/2012] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Few data have described long-term outcomes for infants born to HIV-infected African women taking antiretroviral therapy (ART) in pregnancy. This is particularly true for World Health Organization (WHO)-recommended tenofovir-containing first-line regimens, which are increasingly used and known to cause renal and bone toxicities; concerns have been raised about potential toxicity in babies due to in utero tenofovir exposure. METHODS AND FINDINGS Pregnancy outcome and maternal/infant ART were collected in Ugandan/Zimbabwean HIV-infected women initiating ART during The Development of AntiRetroviral Therapy in Africa (DART) trial, which compared routine laboratory monitoring (CD4; toxicity) versus clinically driven monitoring. Women were followed 15 January 2003 to 28 September 2009. Infant feeding, clinical status, and biochemistry/haematology results were collected in a separate infant study. Effect of in utero ART exposure on infant growth was analysed using random effects models. 382 pregnancies occurred in 302/1,867 (16%) women (4.4/100 woman-years [95% CI 4.0-4.9]). 226/390 (58%) outcomes were live-births, 27 (7%) stillbirths (≥22 wk), and 137 (35%) terminations/miscarriages (<22 wk). Of 226 live-births, seven (3%) infants died <2 wk from perinatal causes and there were seven (3%) congenital abnormalities, with no effect of in utero tenofovir exposure (p>0.4). Of 219 surviving infants, 182 (83%) enrolled in the follow-up study; median (interquartile range [IQR]) age at last visit was 25 (12-38) months. From mothers' ART, 62/9/111 infants had no/20%-89%/≥90% in utero tenofovir exposure; most were also zidovudine/lamivudine exposed. All 172 infants tested were HIV-negative (ten untested). Only 73/182(40%) infants were breast-fed for median 94 (IQR 75-212) days. Overall, 14 infants died at median (IQR) age 9 (3-23) months, giving 5% 12-month mortality; six of 14 were HIV-uninfected; eight untested infants died of respiratory infection (three), sepsis (two), burns (one), measles (one), unknown (one). During follow-up, no bone fractures were reported to have occurred; 12/368 creatinines and seven out of 305 phosphates were grade one (16) or two (three) in 14 children with no effect of in utero tenofovir (p>0.1). There was no evidence that in utero tenofovir affected growth after 2 years (p = 0.38). Attained height- and weight for age were similar to general (HIV-uninfected) Ugandan populations. Study limitations included relatively small size and lack of randomisation to maternal ART regimens. CONCLUSIONS Overall 1-year 5% infant mortality was similar to the 2%-4% post-neonatal mortality observed in this region. No increase in congenital, renal, or growth abnormalities was observed with in utero tenofovir exposure. Although some infants died untested, absence of recorded HIV infection with combination ART in pregnancy is encouraging. Detailed safety of tenofovir for pre-exposure prophylaxis will need confirmation from longer term follow-up of larger numbers of exposed children. TRIAL REGISTRATION www.controlled-trials.com ISRCTN13968779
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Nkwo PO. Prevention of mother to child transmission of human immunodeficiency virus: the nigerian perspective. Ann Med Health Sci Res 2012; 2:56-65. [PMID: 23209993 PMCID: PMC3507117 DOI: 10.4103/2141-9248.96940] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Despite the proven effectiveness of the prevention of mother to child transmission (PMTCT) of human immunodeficiency virus (HIV) program, Nigeria currently has the highest burden of vertical transmission of HIV in the world due to poor coverage of the PMTCT program partly as a result of poor knowledge of PMTCT interventions amongst healthcare providers in the country. This paper aims at making information on PMTCT interventions more readily available to healthcare providers in developing countries. The internet was searched using Google and Google scholar. In addition, relevant electronic journals from the Universities library including PubMed and Scirus, Medline, Cochrane library, and World Health Organization (WHO)'s Hinari were used. There was paucity of published work on PMCT from Nigeria. Most of the information concerning PMCT in Nigeria was obtained from technical reports from the Federal Ministry of Health and WHO. It is expected that this article will help in improving healthcare providers' knowledge of PMTCT interventions and thus help in the urgently needed rapid scale-up of PMTCT services in Nigeria.
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Affiliation(s)
- PO Nkwo
- Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria
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Increasing use of rapid HIV testing in labor and delivery among women with no prenatal care: a local initiative. Matern Child Health J 2011; 15:822-6. [PMID: 20602157 DOI: 10.1007/s10995-010-0636-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pregnant women who do not receive prenatal care and may not be aware of their HIV status are at greatest risk of transmitting HIV to their newborn. A multi-component intervention was designed and implemented to increase the use of rapid HIV testing among pregnant women with no prenatal care at labor and delivery in two county hospitals in Houston/Harris County, Texas. The intervention involved establishing a local task force including representatives from each hospital, assessing each hospital's readiness to implement rapid testing, providing educational presentations and materials, and offering individualized follow-up. Outcomes data were obtained and included the number of patients presenting with no prenatal care who received rapid HIV testing on admission. Before the intervention, both hospitals had rapid test kits available but were not using them consistently. Following the intervention, we observed a significant increase in the use of rapid HIV testing at both institutions (P < 0.001). In the 3 months immediately following the intervention, use of rapid testing at Hospital 1 increased from 7.4 to 35.3% and at Hospital 2 from 27.4 to 41.5%. At 1 year, almost 100% of women with no prenatal care at both hospitals received rapid testing. Educating staff and clinicians and implementing system-wide changes may facilitate behavior change regarding prenatal HIV testing.
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Reilley B, Redd JT, Cheek J, Giberson S. A review of missed opportunities for prenatal HIV screening in a nationwide sample of health facilities in the Indian Health Service. J Community Health 2011; 36:631-4. [PMID: 21222022 DOI: 10.1007/s10900-010-9352-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
To better serve our patients, we sought to identify missed opportunities for prenatal HIV screening across Indian Health Service and potential ways to increase screening. Twenty-seven of 161 Federal or Tribal IHS health facilities were randomly selected. Each facility received a standardized set of commands to identify the charts of prenatal patients who were not screened for HIV according to the national Health Information Technology (HIT) platform. We reviewed 598 records at 27 sites of prenatal patients who were identified as not screened for HIV during their pregnancy. According to on-site chart review, nearly half (267/598, 45%) had been screened for HIV, and a slight majority (331/598, 55%) had not been screened. Among the 331 pregnant women not screened for HIV, about half had no HIV screening despite having had ≥2 prenatal care encounters and no screening exclusions (167/331, 50%). A majority of missed opportunities (118/167, 71%) had prenatal testing for other infectious diseases. Based on these results, the National HIV/AIDS program has encouraged increased bundling of HIV with infectious disease tests in prenatal laboratory panels. Improvements in documentation of HIV screening are expected with the IHS transition to electronic health records.
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Affiliation(s)
- Brigg Reilley
- Division of Epidemiology and Disease Prevention, Indian Health Service, 5300 Homestead Rd, Albuquerque, NM 87110, USA.
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Swindells S, Flexner C, Fletcher CV, Jacobson JM. The critical need for alternative antiretroviral formulations, and obstacles to their development. J Infect Dis 2011; 204:669-74. [PMID: 21788451 PMCID: PMC3156101 DOI: 10.1093/infdis/jir370] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 03/31/2011] [Indexed: 01/01/2023] Open
Affiliation(s)
- Susan Swindells
- Departments of Internal Medicine and Pharmacy Practice, University of Nebraska Medical Center, Omaha, NE, USA.
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Anderson PL, Kiser JJ, Gardner EM, Rower JE, Meditz A, Grant RM. Pharmacological considerations for tenofovir and emtricitabine to prevent HIV infection. J Antimicrob Chemother 2011; 66:240-50. [PMID: 21118913 PMCID: PMC3019086 DOI: 10.1093/jac/dkq447] [Citation(s) in RCA: 139] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The use of antiretroviral medications in HIV-negative individuals as pre-exposure prophylaxis (PrEP) is a promising approach to prevent HIV infection. Tenofovir disoproxil fumarate (TDF) and emtricitabine exhibit desirable properties for PrEP including: favourable pharmacokinetics that support infrequent dosing; few major drug-drug or drug-food interactions; an excellent clinical safety record; and pre-clinical evidence for efficacy. Several large, randomized, controlled clinical trials are evaluating the safety and efficacy of TDF and emtricitabine for this new indication. A thorough understanding of variability in drug response will help determine future investigations in the field and/or implementation into clinical care. Because tenofovir and emtricitabine are nucleos(t)ide analogues, the HIV prevention and toxicity effects depend on the triphosphate analogue formed intracellularly. This review identifies important cellular pharmacology considerations for tenofovir and emtricitabine, which include drug penetration into relevant tissues and cell types, race/ethnicity/pharmacogenetics, gender, cellular activation state and appropriate episodic or alternative dosing strategies based on pharmacokinetic principles. The current state of knowledge in these areas is summarized and the future utility of intracellular pharmacokinetics/pharmacodynamics for the PrEP field is discussed.
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Affiliation(s)
- Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado Denver, Aurora, CO, USA.
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Hsu HE, Rydzak CE, Cotich KL, Wang B, Sax PE, Losina E, Freedberg KA, Goldie SJ, Lu Z, Walensky RP. Quantifying the risks and benefits of efavirenz use in HIV-infected women of childbearing age in the USA. HIV Med 2011; 12:97-108. [PMID: 20561082 PMCID: PMC3010302 DOI: 10.1111/j.1468-1293.2010.00856.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of the study was to quantify the benefits (life expectancy gains) and risks (efavirenz-related teratogenicity) associated with using efavirenz in HIV-infected women of childbearing age in the USA. METHODS We used data from the Women's Interagency HIV Study in an HIV disease simulation model to estimate life expectancy in women who receive an efavirenz-based initial antiretroviral regimen compared with those who delay efavirenz use and receive a boosted protease inhibitor-based initial regimen. To estimate excess risk of teratogenic events with and without efavirenz exposure per 100,000 women, we incorporated literature-based rates of pregnancy, live births, and teratogenic events into a decision analytic model. We assumed a teratogenicity risk of 2.90 events/100 live births in women exposed to efavirenz during pregnancy and 2.68/100 live births in unexposed women. RESULTS Survival for HIV-infected women who received an efavirenz-based initial antiretroviral therapy (ART) regimen was 0.89 years greater than for women receiving non-efavirenz-based initial therapy (28.91 vs. 28.02 years). The rate of teratogenic events was 77.26/100,000 exposed women, compared with 72.46/100,000 unexposed women. Survival estimates were sensitive to variations in treatment efficacy and AIDS-related mortality. Estimates of excess teratogenic events were most sensitive to pregnancy rates and number of teratogenic events/100 live births in efavirenz-exposed women. CONCLUSIONS Use of non-efavirenz-based initial ART in HIV-infected women of childbearing age may reduce life expectancy gains from antiretroviral treatment, but may also prevent teratogenic events. Decision-making regarding efavirenz use presents a trade-off between these two risks; this study can inform discussions between patients and health care providers.
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Affiliation(s)
- H E Hsu
- Harvard Medical School, Boston, MA, USA
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Wesolowski LG, Delaney KP, Lampe MA, Nesheim SR. False-positive human immunodeficiency virus enzyme immunoassay results in pregnant women. PLoS One 2011; 6:e16538. [PMID: 21304592 PMCID: PMC3029371 DOI: 10.1371/journal.pone.0016538] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 12/21/2010] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Examine whether false-positive HIV enzyme immunoassay (EIA) test results occur more frequently among pregnant women than among women who are not pregnant and men (others). DESIGN To obtain a large number of pregnant women and others tested for HIV, we identified specimens tested at a national laboratory using Genetic Systems HIV-1/HIV-2 Plus O EIA from July 2007 to June 2008. METHODS Specimens with EIA repeatedly reactive and Western blot-negative or indeterminate results were considered EIA false-positive. We compared the false-positive rate among uninfected pregnant women and others, adjusting for HIV prevalence. Among all reactive EIAs, we evaluated the proportion of false-positives, positive predictive value (PPV), and Western blot bands among indeterminates, by pregnancy status. RESULTS HIV prevalence was 0.06% among 921,438 pregnant women and 1.34% among 1,103,961 others. The false-positive rate was lower for pregnant women than others (0.14% vs. 0.21%, odds ratio 0.65 [95% confidence interval 0.61, 0.70]). Pregnant women with reactive EIAs were more likely than others (p<0.01) to have Western blot-negative (52.9% vs. 9.8%) and indeterminate results (17.0% vs. 3.7%) and lower PPV (30% vs. 87%). The p24 band was detected more often among pregnant women (p<0.01). CONCLUSIONS False-positive HIV EIA results were rare and occurred less frequently among pregnant women than others. Pregnant women with reactive EIAs were more likely to have negative and indeterminate Western blot results due to lower HIV prevalence and higher p24 reactivity, respectively. Indeterminate results may complicate clinical management during pregnancy. Alternative methods are needed to rule out infection in persons with reactive EIAs from low prevalence populations.
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Affiliation(s)
- Laura G. Wesolowski
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Kevin P. Delaney
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Margaret A. Lampe
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Steven R. Nesheim
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Bailey H, Townsend C, Cortina-Borja M, Thorne C. Insufficient antiretroviral therapy in pregnancy: missed opportunities for prevention of mother-to-child transmission of HIV in Europe. Antivir Ther 2011; 16:895-903. [PMID: 21900722 PMCID: PMC3428867 DOI: 10.3851/imp1849] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although mother-to-child transmission (MTCT) rates are at an all-time low in Western Europe, potentially preventable transmissions continue to occur. Duration of antenatal combination antiretroviral therapy (ART) is strongly associated with MTCT risk. METHODS Data on pregnant HIV-infected women enrolled in the Western and Central European sites of the European Collaborative Study between January 2000 and July 2009 were analysed. The proportion of women receiving no antenatal ART or 1-13 days of treatment was investigated, and associated factors explored using logistic regression models. RESULTS Of 2,148 women, 142 (7%) received no antenatal ART, decreasing from 8% in 2000-2003 to 5% in 2004-2009 (χ(2)=8.73; P<0.01). A further 41 (2%) received 1-13 days of ART. One-third (64/171) of women with 'insufficient' (0 or 1-13 days) antenatal ART had a late HIV diagnosis (in the third trimester or intrapartum), but half (85/171) were diagnosed before conception. Pre-term delivery <34 weeks was associated with receipt of no and 1-13 days antenatal ART (adjusted odds ratios [ORs] 2.9 [P<0.01] and 4.5 [P<0.01], respectively). History of injecting drug use was associated with an increased risk of no ART (adjusted OR 2.9; P<0.01) and severe symptomatic HIV disease with a decreased risk (adjusted OR 0.2; P<0.01). MTCT rates were 1.1% (15/1,318) among women with ≥14 days antenatal ART and 7.4% (10/136) among those with insufficient ART. CONCLUSIONS Over the last 10 years, around one in 11 women in this study received insufficient antenatal ART, accounting for 40% of MTCTs. One-half of these women were diagnosed before conception, suggesting disengagement from care.
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Affiliation(s)
- Heather Bailey
- MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, University College London, UK
| | - Claire Townsend
- MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, University College London, UK
| | - Mario Cortina-Borja
- MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, University College London, UK
| | - Claire Thorne
- MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, University College London, UK
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Antunes AMM, Godinho AL, Martins IL, Oliveira MC, Gomes RA, Coelho AV, Beland FA, Marques MM. Protein adducts as prospective biomarkers of nevirapine toxicity. Chem Res Toxicol 2010; 23:1714-25. [PMID: 20809596 PMCID: PMC2981636 DOI: 10.1021/tx100186t] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Nevirapine (NVP) is a non-nucleoside reverse transcriptase inhibitor used against human immunodeficiency virus type-1 (HIV-1), mostly to prevent mother-to-child HIV-1 transmission in developing countries. Despite its clinical efficacy, NVP administration is associated with a variety of toxic responses that include hepatotoxicity and skin rash. Although the reasons for the adverse effects of NVP administration are still unclear, increasing evidence supports the involvement of metabolic activation to reactive electrophiles. In particular, Phase II activation of the NVP metabolite 12-hydroxy-NVP is thought to mediate NVP binding to bionucleophiles, which may be at the onset of toxicity. In the present study, we investigated the nature and specific locations of the covalent adducts produced in human serum albumin and human hemoglobin by reaction in vitro with the synthetic model electrophile 12-mesyloxy-NVP, used as a surrogate for the Phase II metabolite 12-sulfoxy-NVP. Multiple sites of modification were identified by two different mass spectrometry-based methodologies, liquid chromatography-electrospray ionization tandem mass spectrometry (LC-ESI-MS/MS) and matrix-assisted laser desorption ionization tandem mass spectrometry (MALDI-TOF-TOF-MS). These two distinct methodologies, which in some instances afforded complementary information, allowed the identification of multiple adducts involving cysteine, lysine, tryptophan, histidine, serine, and the N-terminal valine of hemoglobin. Tryptophan, which is not a common site of covalent protein modification, was the NVP-modified amino acid residue detected in the two proteins and consistently identified by both LC-ESI-MS/MS and MALDI-TOF-TOF-MS. The propensity of tryptophan to react with the NVP-derived electrophile is further emphasized by the fact that human serum albumin possesses a single tryptophan residue, which suggests a remarkable selectivity that may be useful for biomonitoring purposes. Likewise, the NVP adduct with the terminal valine of hemoglobin, detected by LC-ESI-MS/MS after N-alkyl Edman degradation, appears as an easily assessed marker of NVP binding to proteins. Our results demonstrate the merits and complementarity of the two MS-based methodologies for the characterization of protein binding by NVP and suggest a series of plausible biomarkers of NVP toxicity that should be useful in the monitoring of toxicity effects in patients administered NVP.
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Affiliation(s)
- Alexandra M. M. Antunes
- Centro de Química Estrutural, Instituto Superior Técnico, Universidade Técnica de Lisboa, 1049-001 Lisboa, Portugal
| | - Ana L.A. Godinho
- Centro de Química Estrutural, Instituto Superior Técnico, Universidade Técnica de Lisboa, 1049-001 Lisboa, Portugal
| | - Inês L. Martins
- Centro de Química Estrutural, Instituto Superior Técnico, Universidade Técnica de Lisboa, 1049-001 Lisboa, Portugal
| | - M. Conceição Oliveira
- Centro de Química Estrutural, Instituto Superior Técnico, Universidade Técnica de Lisboa, 1049-001 Lisboa, Portugal
| | - Ricardo A. Gomes
- Instituto de Tecnologia Química e Biológica, Universidade Nova de Lisboa, 2781-901 Oeiras, Portugal
| | - Ana V. Coelho
- Centro de Química Estrutural, Instituto Superior Técnico, Universidade Técnica de Lisboa, 1049-001 Lisboa, Portugal
| | - Frederick A. Beland
- Division of Biochemical Toxicology, National Center for Toxicological Research, Jefferson, AR 72079
| | - M. Matilde Marques
- Centro de Química Estrutural, Instituto Superior Técnico, Universidade Técnica de Lisboa, 1049-001 Lisboa, Portugal
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Divi RL, Einem TL, Leonard Fletcher SL, Shockley ME, Kuo MM, St Claire MC, Cook A, Nagashima K, Harbaugh SW, Harbaugh JW, Poirier MC. Progressive mitochondrial compromise in brains and livers of primates exposed in utero to nucleoside reverse transcriptase inhibitors (NRTIs). Toxicol Sci 2010; 118:191-201. [PMID: 20702595 PMCID: PMC2955212 DOI: 10.1093/toxsci/kfq235] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 07/26/2010] [Indexed: 11/13/2022] Open
Abstract
Mitochondrial compromise has been documented in infants born to women infected with the human immunodeficiency virus (HIV-1) who received nucleoside reverse transcriptase inhibitor (NRTI) therapy during pregnancy. To model these human exposures, we examined mitochondrial integrity at birth and 1 year in brain cortex and liver from offspring of retroviral-free Erythrocebus patas dams-administered human-equivalent NRTI doses for the last half (10 weeks) of gestation. Additional infants, followed for 1 year, were given the same drugs as their mothers for the first 6 weeks of life. Exposures included: no drug, Zidovudine (AZT), Lamivudine (3TC), AZT/3TC, AZT/Didanosine (ddI), and Stavudine (d4T)/3TC. In brain and liver, oxidative phosphorylation (OXPHOS) enzyme activities (complexes I, II, and IV) showed minimal differences between unexposed and NRTI-exposed offspring at both times. Brain and liver mitochondria from most NRTI-exposed patas, both at birth and 1 year of age, contained significant (p < 0.05) morphological damage observed by electron microscopy (EM), based on scoring of coded photomicrographs. Brain and liver mitochondrial DNA (mtDNA) levels in NRTI-exposed patas were depleted significantly in the 3TC and d4T/3TC groups at birth and were depleted significantly (p < 0.05) at 1 year in all NRTI-exposed groups. In 1-year-old infants exposed in utero to NRTIs, mtDNA depletion was 28.8-51.8% in brain and 37.4-56.5% in liver. These investigations suggest that some NRTI-exposed human infants may sustain similar mitochondrial compromise in brain and liver and should be followed long term for cognitive integrity and liver function.
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Affiliation(s)
- Rao L. Divi
- Carcinogen-DNA Interactions Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892-4255
| | - Tracey L. Einem
- Carcinogen-DNA Interactions Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892-4255
| | - Sarah L. Leonard Fletcher
- Carcinogen-DNA Interactions Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892-4255
| | - Marie E. Shockley
- Carcinogen-DNA Interactions Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892-4255
| | - Maryanne M. Kuo
- Carcinogen-DNA Interactions Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892-4255
| | - Marisa C. St Claire
- Division of Clinical Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Ft Detrick, Frederick, Maryland 21702
| | | | - Kunio Nagashima
- Electron Microscope Laboratory, National Cancer Institute—Frederick, Advance Technology Program, Science Applications International Corporation-Frederick, Frederick Maryland 21702
| | | | | | - Miriam C. Poirier
- Carcinogen-DNA Interactions Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892-4255
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Brogly SB, Abzug MJ, Watts DH, Cunningham CK, Williams PL, Oleske J, Conway D, Sperling RS, Spiegel H, Van Dyke RB. Birth defects among children born to human immunodeficiency virus-infected women: pediatric AIDS clinical trials protocols 219 and 219C. Pediatr Infect Dis J 2010; 29:721-7. [PMID: 20539252 PMCID: PMC2948952 DOI: 10.1097/inf.0b013e3181e74a2f] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Some studies have detected associations between in utero antiretroviral therapy (ARV) exposure and birth defects but evidence is inconclusive. METHODS A total of 2202 human immunodeficiency virus (HIV)-exposed children enrolled in the Pediatric AIDS Clinical Trials Group 219 and 219 C protocols before 1 year of age were included. Birth defects were classified using the Metropolitan Atlanta Congenital Defects Program coding. Logistic regression models were used to evaluate associations between first trimester in utero ARV exposure and birth defects. RESULTS A total of 117 live-born children had birth defects for a prevalence of 5.3% (95% confidence interval [CI]: 4.4, 6.3). Prevalence did not differ by HIV infection status or overall ARV exposure; rates were 4.8% (95% CI: 3.7, 6.1) and 5.8% (95% CI: 4.2, 7.8) in children without and with first trimester ARV exposure, respectively. The defect rate was higher among children with first trimester efavirenz exposure (5/32, 15.6%) versus children without first trimester efavirenz exposure (adjusted odds ratio [aOR] = 4.31 [95% CI: 1.56, 11.86]). Protective effects of first trimester zidovudine exposure on musculoskeletal defects were detected (aOR = 0.24 [95% CI: 0.08, 0.69]), while a higher risk of heart defects was found (aOR = 2.04 [95% CI: 1.03, 4.05]). CONCLUSIONS The prevalence of birth defects was higher in this cohort of HIV-exposed children than in other pediatric cohorts. There was no association with overall ARV exposure, but there were some associations with specific agents, including efavirenz. Additional studies are needed to rule out confounding and to evaluate newer ARV agents.
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Affiliation(s)
- Susan B Brogly
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, MA, USA.
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Livingston EG, Huo Y, Patel K, Brogly SB, Tuomala R, Scott GB, Bardeguez A, Stek A, Read JS. Mode of delivery and infant respiratory morbidity among infants born to HIV-1-infected women. Obstet Gynecol 2010; 116:335-343. [PMID: 20664394 PMCID: PMC2964131 DOI: 10.1097/aog.0b013e3181e8f38a] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To estimate risk of infant respiratory morbidity associated with cesarean delivery before labor and ruptured membranes among HIV-1-infected women. METHODS In a prospective cohort study of HIV-1-infected women and their infants, mode of delivery was determined by clinicians at the participating sites. For this analysis, "elective cesarean delivery" was defined as any cesarean delivery, regardless of gestational age, without labor and with duration of ruptured membranes of less than 5 minutes. Nonelective cesarean deliveries were those performed after the onset of labor, rupture of membranes, or both. Vaginal delivery included normal spontaneous and instrument deliveries. Associations between mode of delivery and infant respiratory morbidity were assessed using chi or Fisher's exact test. Adjusted odds of respiratory distress syndrome by delivery mode were assessed using multivariable logistic regression. RESULTS Among 1,194 mother-infant pairs, there were significant differences according to mode of delivery in median gestational age (weeks) at delivery (vaginal, n=566, median=38.8; nonelective cesarean, n=216, median=38.0; and elective cesarean, n=412, median 38.1; P<.001) and incidence of respiratory distress syndrome (vaginal, n=9, 1.6%, reference; nonelective cesarean, n=16, 7.4%; elective cesarean, n=18; 4.4%; (P<.001). In analyses adjusted for gestational age and birth weight, mode of delivery was not statistically significantly associated with infant respiratory distress syndrome (P=.10), although a trend toward an increased risk of respiratory distress syndrome among infants delivered by cesarean was suggested (nonelective cesarean adjusted odds ratio [OR] 2.32, 95% confidence interval [CI] 0.95-5.67; elective cesarean OR 2.56, 95% CI 1.01-6.48). CONCLUSION Respiratory distress syndrome rates associated with elective cesarean delivery among HIV-1-infected women are low, comparable with published rates among uninfected women. There is minimal neonatal respiratory morbidity risk in near-term infants born by elective cesarean delivery to HIV-1-infected women. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Elizabeth G Livingston
- From Duke University, Durham, North Carolina; Harvard School of Public Health, Center for Biostatistics in Acquired Immunodeficiency Syndrome (AIDS) Research, Boston, Massachusetts; Harvard University, Boston, Massachusetts; the University of Miami Miller School of Medicine, Miami, Florida; the University of Medicine and Dentistry of New Jersey, Newark, New Jersey; the University of Southern California, Los Angeles, California; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Ramautarsing R, Ananworanich J. Generic and low dose antiretroviral therapy in adults and children: implication for scaling up treatment in resource limited settings. AIDS Res Ther 2010; 7:18. [PMID: 20569473 PMCID: PMC2898660 DOI: 10.1186/1742-6405-7-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 06/23/2010] [Indexed: 11/10/2022] Open
Abstract
Although access to antiretroviral therapy (ART) for the treatment of HIV has increased during the last decade, many patients are still in need of treatment. With limited funds to provide ART to millions of patients worldwide, there is a need for alternative ways to scale up ART in resource limited settings. This review provides an overview of pharmacokinetic, safety and efficacy studies of generic and reduced dose ART. The production of generic ART has greatly influenced the decline in drug prices and the increased in ART access. Generic ART has good pharmacokinetic profile, safety and efficacy. Toxicity is however the main cause for ART discontinuation. Several dose reduction studies have shown adequate pharmacokinetic parameters and short term efficacy with reduced dose ART. Ethnicity may affect drug metabolism; several pharmacokinetic studies have confirmed higher plasma ART concentration in Asians. Randomized efficacy trial of reduced versus standard ART is warranted.
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Affiliation(s)
- Reshmie Ramautarsing
- The HIV Netherlands Australia Thailand Research Collaboration (HIVNAT), Bangkok, Thailand
- Centre for Poverty-related Communicable Diseases (CPCD), Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Jintanat Ananworanich
- The HIV Netherlands Australia Thailand Research Collaboration (HIVNAT), Bangkok, Thailand
- The Southeast Asia Research Collaboration with Hawaii (SEARCH), Bangkok, Thailand
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Shapiro RL, Hughes MD, Ogwu A, Kitch D, Lockman S, Moffat C, Makhema J, Moyo S, Thior I, McIntosh K, van Widenfelt E, Leidner J, Powis K, Asmelash A, Tumbare E, Zwerski S, Sharma U, Handelsman E, Mburu K, Jayeoba O, Moko E, Souda S, Lubega E, Akhtar M, Wester C, Tuomola R, Snowden W, Martinez-Tristani M, Mazhani L, Essex M. Antiretroviral regimens in pregnancy and breast-feeding in Botswana. N Engl J Med 2010; 362:2282-94. [PMID: 20554983 PMCID: PMC2999916 DOI: 10.1056/nejmoa0907736] [Citation(s) in RCA: 372] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The most effective highly active antiretroviral therapy (HAART) to prevent mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1) in pregnancy and its efficacy during breast-feeding are unknown. METHODS We randomly assigned 560 HIV-1-infected pregnant women (CD4+ count, > or = 200 cells per cubic millimeter) to receive coformulated abacavir, zidovudine, and lamivudine (the nucleoside reverse-transcriptase inhibitor [NRTI] group) or lopinavir-ritonavir plus zidovudine-lamivudine (the protease-inhibitor group) from 26 to 34 weeks' gestation through planned weaning by 6 months post partum. A total of 170 women with CD4+ counts of less than 200 cells per cubic millimeter received nevirapine plus zidovudine-lamivudine (the observational group). Infants received single-dose nevirapine and 4 weeks of zidovudine. RESULTS The rate of virologic suppression to less than 400 copies per milliliter was high and did not differ significantly among the three groups at delivery (96% in the NRTI group, 93% in the protease-inhibitor group, and 94% in the observational group) or throughout the breast-feeding period (92% in the NRTI group, 93% in the protease-inhibitor group, and 95% in the observational group). By 6 months of age, 8 of 709 live-born infants (1.1%) were infected (95% confidence interval [CI], 0.5 to 2.2): 6 were infected in utero (4 in the NRTI group, 1 in the protease-inhibitor group, and 1 in the observational group), and 2 were infected during the breast-feeding period (in the NRTI group). Treatment-limiting adverse events occurred in 2% of women in the NRTI group, 2% of women in the protease-inhibitor group, and 11% of women in the observational group. CONCLUSIONS All regimens of HAART from pregnancy through 6 months post partum resulted in high rates of virologic suppression, with an overall rate of mother-to-child transmission of 1.1%. (ClinicalTrials.gov number, NCT00270296.)
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Affiliation(s)
- R L Shapiro
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, 110 Francis St., Suite GB, Boston, MA 02215, USA.
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Giaquinto C, Penazzato M, Rosso R, Bernardi S, Rampon O, Nasta P, Ammassari A, Antinori A, Badolato R, Castelli Gattinara G, d'Arminio Monforte A, De Martino M, De Rossi A, Di Gregorio P, Esposito S, Fatuzzo F, Fiore S, Franco A, Gabiano C, Galli L, Genovese O, Giacomet V, Giannattasio A, Gotta C, Guarino A, Martino A, Mazzotta F, Principi N, Regazzi MB, Rossi P, Russo R, Saitta M, Salvini F, Trotta S, Viganò A, Zuccotti G, Carosi G. Italian consensus statement on paediatric HIV infection. Infection 2010; 38:301-19. [PMID: 20514509 DOI: 10.1007/s15010-010-0020-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 03/17/2010] [Indexed: 02/01/2023]
Abstract
The objective of this document is to identify and reinforce current recommendations concerning the management of HIV infection in infants and children in the context of good resource availability. All recommendations were graded according to the strength and quality of the evidence and were voted on by the 57 participants attending the first Italian Consensus on Paediatric HIV, held in Siracusa in 2008. Paediatricians and HIV/AIDS care specialists were requested to agree on different statements summarizing key issues in the management of paediatric HIV. The comprehensive approach on preventing mother-to-child transmission (PMTCT) has clearly reduced the number of children acquiring the infection in Italy. Although further reduction of MTCT should be attempted, efforts to personalize intervention to specific cases are now required in order to optimise the treatment and care of HIV-infected children. The prompt initiation of treatment and careful selection of first-line regimen, taking into consideration potency and tolerance, remain central. In addition, opportunistic infection prevention, adherence to treatment, and long-term psychosocial consequences are becoming increasingly relevant in the era of effective antiretroviral combination therapies (ART). The increasing proportion of infected children achieving adulthood highlights the need for multidisciplinary strategies to facilitate transition to adult care and maintain strategies specific to perinatally acquired HIV infection.
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Affiliation(s)
- C Giaquinto
- Dipartimento di Pediatria, Università degli Studi di Padova, Padova, Italy
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Grant RM. Antiretroviral agents used by HIV-uninfected persons for prevention: pre- and postexposure prophylaxis. Clin Infect Dis 2010; 50 Suppl 3:S96-101. [PMID: 20397962 PMCID: PMC3663282 DOI: 10.1086/651479] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Prophylactic use of antimicrobial agents and microbicides has been proven for many infections, including surgical, gastrointestinal, upper respiratory, and meningococcal infections. Antiretroviral therapy for pregnant women prevents mother-to-child transmission of human immunodeficiency virus (HIV), which has become rare in settings where access to therapy is widespread. Postexposure prophylaxis after needlestick injury or significant sexual exposure is recommended on the basis of animal studies and case-control observational studies, although use of these interventions is limited to those who recognize exposure, have access, and have the power to use the interventions. Clinical trials are evaluating whether regular or preexposure use of antiretroviral therapy provides additional protection for persons at high risk of infection who are also offered standard prevention care, including HIV testing, counseling, condoms, and management of sexually transmitted infections. Trials are evaluating topical or oral use. Concerns have arisen with regard to optimal dosing strategies, costs, access, drug resistance, risk behavior, and the role of communities. Future implementation, if warranted, will be guided by the results of clinical trials in progress and engagement of communities exposed to HIV.
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Affiliation(s)
- Robert M Grant
- Gladstone Institute of Virology and Immunology and University of California, San Francisco, USA.
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Hoffman RM, Black V, Technau K, van der Merwe KJ, Currier J, Coovadia A, Chersich M. Effects of highly active antiretroviral therapy duration and regimen on risk for mother-to-child transmission of HIV in Johannesburg, South Africa. J Acquir Immune Defic Syndr 2010; 54:35-41. [PMID: 20216425 PMCID: PMC2880466 DOI: 10.1097/qai.0b013e3181cf9979] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Limited information exists about effects of different highly active antiretroviral therapy (HAART) regimens and duration of regimens on mother-to-child transmission (MTCT) of HIV among women in Africa who start treatment for advanced immunosuppression. METHODS Between January 2004 to August 2008, 1142 women were followed at antenatal antiretroviral clinics in Johannesburg. Predictors of MTCT (positive infant HIV DNA polymerase chain reaction at 4-6 weeks) were assessed with multivariate logistic regression. RESULTS Mean age was 30.2 years (SD = 5.0) and median baseline CD4 count was 161 cells per cubic millimeter (SD = 84.3). HAART duration at time of delivery was a mean 10.7 weeks (SD = 7.4) for the 85% of women who initiated treatment during pregnancy and 93.4 weeks (SD = 37.7) for those who became pregnant on HAART. Overall MTCT rate was 4.9% (43 of 874), with no differences detected between HAART regimens. MTCT rates were lower in women who became pregnant on HAART than those initiating HAART during pregnancy (0.7% versus 5.7%; P = 0.01). In the latter group, each additional week of treatment reduced odds of transmission by 8% (95% confidence interval: 0.87 to 0.99, P = 0.02). CONCLUSIONS Late initiation of HAART is associated with increased risk of MTCT. Strategies are needed to facilitate earlier identification of HIV-infected women.
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Affiliation(s)
- Risa M Hoffman
- David Geffen School of Medicine at UCLA, Division of Infectious Diseases and Center for Clinical AIDS Research and Education, Los Angeles, CA, USA.
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Katz IT, Shapiro R, Li D, Govindarajulu U, Thompson B, Watts DH, Hughes MD, Tuomala R. Risk factors for detectable HIV-1 RNA at delivery among women receiving highly active antiretroviral therapy in the women and infants transmission study. J Acquir Immune Defic Syndr 2010; 54:27-34. [PMID: 20065861 PMCID: PMC2860013 DOI: 10.1097/qai.0b013e3181caea89] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Detectable HIV-1 RNA at delivery is the strongest predictor of mother-to-child transmission. The risk factors for detectable HIV, including type of regimen, are unknown. We evaluated factors, including highly active antiretroviral (HAART) regimen, associated with detectable HIV-1 RNA at delivery in the Women and Infants Transmission Study (WITS). METHODS Data from 630 HIV-1-infected women who enrolled from 1998 to 2005 and received HAART during pregnancy were analyzed. Multivariable analyses examined associations between regimens, demographic factors, and detectable HIV-1 RNA (>400 copies/milliliter) at delivery. RESULTS Overall, 32% of the women in the cohort had detectable HIV-1 RNA at delivery. Among the subset of 364 HAART-experienced women, a lower CD4 cell count at enrollment [adjusted odds ratio (AOR) = 1.20 per 100 cells/microL, confidence interval (CI) 1.04 to 1.37] and higher HIV-1 RNA at enrollment (AOR = 1.52 per log10 copies/milliliter, CI 1.32 to 1.75) were significantly associated with detectable HIV-1 RNA levels at delivery. For the 266 HAART-naive women, both lower CD4 cell count at enrollment (AOR = 1.24 per 100 cells/microL, CI 1.05 to 1.48) and higher HIV-1 RNA at enrollment (AOR = 1.35 per log10 copies/milliliter, CI 1.12 to 1.63) were associated with detectable HIV-1 RNA at delivery. In addition, age at delivery (AOR = 0.92 per 10 years older, CI 0.86 to 0.99) and maternal illicit drug use (AOR = 3.15, CI 1.34 to 7.41) were significantly associated with detectable HIV-1 RNA at delivery among HAART-naive women. Type of HAART regimen was not significant in either group. CONCLUSIONS Lack of viral suppression at delivery was common in the WITS cohort, but differences by antiretroviral regimen were not identified. Despite a transmission rate below 1% in the last 5 years of the WITS cohort, improved measures to maximize HIV-1 RNA suppression at term among high-risk women are warranted.
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Melekhin VV, Shepherd BE, Jenkins CA, Stinnette SE, Rebeiro PF, Bebawy SS, Rasbach DA, Hulgan T, Sterling TR. Postpartum discontinuation of antiretroviral therapy and risk of maternal AIDS-defining events, non-AIDS-defining events, and mortality among a cohort of HIV-1-infected women in the United States. AIDS Patient Care STDS 2010; 24:279-86. [PMID: 20438375 PMCID: PMC2875979 DOI: 10.1089/apc.2009.0283] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This retrospective cohort study of HIV-infected women receiving highly active antiretroviral therapy (HAART) while pregnant assessed the effect of postpartum HAART discontinuation on maternal AIDS-defining events (ADEs), non-AIDS-defining events (non-ADEs), and death 1997-2008 in Nashville, Tennessee. Cox proportional hazards models compared rates of ADE or all-cause death and non-ADE or all-cause death, and competing risks analyses compared rates of ADE or ADE-related death and non-ADE or non-ADE-related death across the groups. There were two groups: women who stopped HAART postpartum (discontinuation, n = 54) and women who continued HAART postpartum (continuation, n = 69). Fifty percent were African American, 40% had prior non-HAART antiretroviral therapy (ART) use, and 38% had a history of illicit drug use. Median age was 27.5 years, baseline CD4(%) was 532 (34%) and CD4 nadir was 332 cells/mm(3), baseline and peak HIV-1 RNA were 2.6 and 4.32 log(10) copies per milliliter, respectively. Women in the continuation group were older, had lower baseline CD4, CD4%, and CD4 nadir, and had higher peak HIV-1 RNA. In multivariable proportional hazards models, the hazard ratios [95% confidence interval (CI)] of ADE or all-cause death and non-ADE or all-cause death were lower in the continuation group, but not statistically significantly: 0.50 (0.12, 2.12; p = 0.35) and 0.69 (0.24, 1.95; p = 0.48), respectively. The results were similar in competing risks analyses. Despite having characteristics associated with worse prognosis, women who continued HAART postpartum had lower hazard ratio point estimates for ADEs or death and non-ADEs or death than women who discontinued HAART. Larger studies with longer follow-up are indicated to assess this association.
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Affiliation(s)
- Vlada V Melekhin
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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McCabe CJ, Goldie SJ, Fisman DN. The cost-effectiveness of directly observed highly-active antiretroviral therapy in the third trimester in HIV-infected pregnant women. PLoS One 2010; 5:e10154. [PMID: 20405011 PMCID: PMC2854147 DOI: 10.1371/journal.pone.0010154] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Accepted: 03/04/2010] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In HIV-infected pregnant women, viral suppression prevents mother-to-child HIV transmission. Directly observed highly-active antiretroviral therapy (HAART) enhances virological suppression, and could prevent transmission. Our objective was to project the effectiveness and cost-effectiveness of directly observed administration of antiretroviral drugs in pregnancy. METHODS AND FINDINGS A mathematical model was created to simulate cohorts of one million asymptomatic HIV-infected pregnant women on HAART, with women randomly assigned self-administered or directly observed antiretroviral therapy (DOT), or no HAART, in a series of Monte Carlo simulations. Our primary outcome was the quality-adjusted life expectancy in years (QALY) of infants born to HIV-infected women, with the rates of Caesarean section and HIV-transmission after DOT use as intermediate outcomes. Both self-administered HAART and DOT were associated with decreased costs and increased life-expectancy relative to no HAART. The use of DOT was associated with a relative risk of HIV transmission of 0.39 relative to conventional HAART; was highly cost-effective in the cohort as a whole (cost-utility ratio $14,233 per QALY); and was cost-saving in women whose viral loads on self-administered HAART would have exceeded 1000 copies/ml. Results were stable in wide-ranging sensitivity analyses, with directly observed therapy cost-saving or highly cost-effective in almost all cases. CONCLUSIONS Based on the best available data, programs that optimize adherence to HAART through direct observation in pregnancy have the potential to diminish mother-to-child HIV transmission in a highly cost-effective manner. Targeted use of DOT in pregnant women with high viral loads, who could otherwise receive self-administered HAART would be a cost-saving intervention. These projections should be tested with randomized clinical trials.
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Affiliation(s)
- Caitlin J. McCabe
- Child Health Evaluative Sciences, Research Institute of the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sue J. Goldie
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - David N. Fisman
- Child Health Evaluative Sciences, Research Institute of the Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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