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Duffy CR, Herlihy JM, Zulu E, Mwananyanda L, Forman L, Heeren T, Gill CJ, Harper M, Chilengi R, Chavuma R, Payne-Lohman B, Thea DM. Preterm birth among women with HIV: impact of preconception cART initiation. AIDS 2024; 38:1749-1757. [PMID: 39017638 PMCID: PMC11356690 DOI: 10.1097/qad.0000000000003979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 06/04/2024] [Accepted: 06/10/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVE To examine the risk of preterm birth (PTB) and small for gestational age (SGA) among women with HIV compared to women without HIV. Secondary objectives were to explore the role of maternal immune activation (IA) and effect of cART timing on these outcomes. DESIGN Prospective observational cohort. SETTING Urban government-run clinic at Chawama Hospital in Lusaka, Zambia. PARTICIPANTS A total of 1481 women with and without HIV with singleton pregnancies enrolled before 26 weeks' gestation by ultrasound dating. METHODS From August 2019 to November 2022, pregnant women were enrolled in a 1 : 1 ratio of HIV infection. Maternal baseline clinical factors were collected, as well as CD4 + , viral load and CD8 + T-cell IA in women with HIV. Birth outcomes were also collected. The association of HIV-exposure and cART timing on outcomes was assessed by multivariable logistic regression. The independent role of IA was determined by mediation analysis. MAIN OUTCOME MEASURES PTB (<37 weeks) and SGA. RESULTS There were 38 fetal deaths and 1230 singleton live births. Maternal HIV infection was associated with PTB [adjusted odds ratio (AOR) 1.60, 95% confidence interval (CI) 1.11-2.32] and to a lesser extent SGA (AOR 1.29, 95% CI 0.98-1.70). Maternal cART timing impacted these associations, with highest risk in women who started cART after conception (PTB AOR 1.77, 95% CI 1.09-2.87, SGA AOR 1.52, 95% CI 1.04-2.22). Maternal IA was not associated with PTB independent of HIV infection. CONCLUSIONS HIV is associated with PTB. Risk of PTB and SGA was highest in women with HIV who started cART in pregnancy, a modifiable risk factor.
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Affiliation(s)
- Cassandra R. Duffy
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Julie M. Herlihy
- Boston University, Chobanian & Avedisian School of Medicine, Department of Pediatrics, Boston Medical Center, Boston, MA, USA
- Department of Global Health, Boston University School of Public Health
| | | | | | - Leah Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health
| | - Tim Heeren
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | | | - Megan Harper
- Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Barbara Payne-Lohman
- Institute for Immunology and Informatics, University of Rhode Island, South Kingstown, RI, USA
| | - Donald M. Thea
- Department of Global Health, Boston University School of Public Health
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Ajibola G, Mdluli C, Bennett K, Sakoi M, Batlang O, Makhema J, Lockman S, Shapiro R, Myer L, Powis K. No increased in utero and peripartum HIV acquisition risk in HIV-exposed preterm infants. South Afr J HIV Med 2023; 24:1509. [PMID: 37928500 PMCID: PMC10623649 DOI: 10.4102/sajhivmed.v24i1.1509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/13/2023] [Indexed: 11/07/2023] Open
Abstract
Background Limited data exist on the differential risk of HIV acquisition between infants born preterm versus those born at term to women living with HIV (WLHIV). With a reported increase in preterm delivery among pregnant WLHIV, understanding the risk of vertical transmission of HIV in preterm infants can inform strategies to optimise the timing of diagnostic testing, antiretroviral prophylaxis, and infant feeding. Objectives To describe the prevalence and timing of HIV acquisition, in utero versus perinatal, among infants with perinatal HIV exposure born prior to 37 weeks completed gestation age compared to those born at term in the Botswana-based Mpepu study and explore predictors of infant HIV acquisition. Method Using data extracted from the Mpepu study, we describe the prevalence, timing and risk factors for HIV acquisition in infants born preterm versus those born at term. Fisher exact testing was used to test for differences in prevalence and timing of HIV and a multivariable logistic regression model was used to assess risk factors for infant HIV acquisition. Results 2866 infants born to WLHIV were included in this secondary analysis. 532 (19%) were born preterm. There was no observed difference in the prevalence of HIV acquisition among infants born preterm versus at term overall (0.8% vs 0.6%, P = 0.54), at birth (0.2% vs 0.3%, P = 1.00) or between 14 and 34 days post-delivery (0.6% vs 0.3%, P = 0.41). The absence of maternal antiretroviral use during pregnancy significantly predicted infant HIV acquisition, with the risk of HIV acquisition reduced by 96% among infants whose mothers were taking antiretroviral treatment (ART) during pregnancy (adjusted odds ratio: 0.003, confidence interval: 0.01-0.02, P < 0.001). Conclusion There was no observed increase of in utero and peripartum HIV acquisition among infants born preterm following foetal exposure to HIV compared to those born at term.
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Affiliation(s)
| | | | - Kara Bennett
- Bennett Statistical Consulting Inc, New York, United States of America
| | - Maureen Sakoi
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
| | - Oganne Batlang
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
| | - Joseph Makhema
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
| | - Shahin Lockman
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
- Department of Infectious Diseases, Brigham and Womens Hospital, Boston, United States of America
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Roger Shapiro
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Landon Myer
- Department of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kathleen Powis
- Botswana Harvard AIDS Research Institute, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, United States of America
- Department of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, United States of America
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Fairlie L, Lavies D, Kalk E, Mhlongo O, Patel F, Technau KG, Mahtab S, Moodley D, Subedar H, Mullick S, Sawry S, Mehta U. Safety surveillance for PrEP in pregnant and breastfeeding women. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1221101. [PMID: 37854936 PMCID: PMC10581206 DOI: 10.3389/frph.2023.1221101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/14/2023] [Indexed: 10/20/2023] Open
Abstract
The risk of HIV acquisition is higher during pregnancy and postpartum than other times. Newly acquired maternal HIV infection associated with high primary viraemia, substantially increases the risk of vertical HIV transmission. Pre-exposure prophylaxis (PrEP) reduces the risk of HIV acquisition. Currently available products include oral tenofovir/emtricitabine (TDF/FTC) and tenofovir alafenamide (TAF)/FTC), long-acting cabotegravir (CAB-LA) and the dapivirine ring (DVR). All except oral TDF/FTC have limited safety data available for use in pregnant and breastfeeding women. The safety of new PrEP agents for pregnant women and the fetus, infant and child, either exposed in utero or during breastfeeding is an ongoing concern for health care workers and pregnant and breastfeeding women, particularly as the safety risk appetite for antiretroviral (ARV) agents used as PrEP is lower in pregnant and breastfeeding women who are HIV-uninfected, compared to women living with HIV taking ARVs as treatment. With the widespread rollout of TDF/FTC among pregnant women in South Africa and other low-middle income countries (LMIC) and the potential introduction of new PrEP agents for pregnant women, there is a need for safety surveillance systems to identify potential signals of risk to either the mother or fetus, measure the burden of such a risk, and where appropriate, provide specific reassurance to PrEP users. Safety data needs to be collected across the continuum of the product life cycle from pre-licensure into the post-marketing period, building a safety profile through both passive and active surveillance systems, recognising the strengths and limitations of each, and the potential for bias and confounding. Pharmacovigilance systems that aim to assess the risk of adverse birth outcomes in pregnant women exposed to PrEP and other agents need to consider the special requirements of pregnancy epidemiology to ensure that the data derived from surveillance are sufficiently robust to inform treatment policies. Here we review the known safety profiles of currently available PrEP candidates in women of child-bearing potential, pregnancy and breastfeeding and discuss pragmatic approaches for such surveillance in HIV-endemic LMICs.
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Affiliation(s)
- Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Diane Lavies
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Faeezah Patel
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karl-Günter Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Sana Mahtab
- Wits Vaccines & Infectious Diseases Analytics (VIDA) Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Dhayendre Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | | | - Saiqa Mullick
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shobna Sawry
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Chagomerana MB, Harrington BJ, DiPrete BL, Wallie S, Maliwichi M, Wesevich A, Phulusa JN, Kumwenda W, Jumbe A, Hosseinipour MC. Three-year outcomes for women newly initiated on lifelong antiretroviral therapy during pregnancy - Malawi option B. AIDS Res Ther 2023; 20:37. [PMID: 37308909 PMCID: PMC10258937 DOI: 10.1186/s12981-023-00523-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 05/02/2023] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Antiretroviral therapy (ART) is very effective in preventing vertical transmission of HIV but some women on ART experience different virologic, immunologic, and safety profiles. While most pregnant women are closely monitored for short-term effects of ART during pregnancy, few women receive similar attention beyond pregnancy. We aimed to assess retention in care and clinical and laboratory-confirmed outcomes over 3 years after starting ART under Malawi's Option B + program. METHODS We conducted a prospective cohort study of pregnant women newly diagnosed with HIV who started tenofovir disoproxil fumarate/emtricitabine/efavirenz (TDF/3TC/EFV) for the first time at Bwaila Hospital in Lilongwe, Malawi between May 2015 and June 2016. Participants were followed for 3 years. We summarized demographic characteristics, pregnancy outcomes, and clinical and laboratory adverse events findings using proportions. Log-binomial regression models were used to estimate the overall risk ratios (RR) and the corresponding 95% confidence interval (CI) for the association between index pregnancy (i.e. index pregnancy vs. subsequent pregnancy) and preterm birth, and index pregnancy and low birthweight. RESULTS Of the 299 pregnant women who were enrolled in the study, 255 (85.3%) were retained in care. There were 340 total pregnancies with known outcomes during the 36-month study period, 280 index pregnancies, and 60 subsequent pregnancies. The risks of delivering preterm (9.5% for index pregnancy and13.5% for subsequent pregnancy: RR = 0.70; 95% CI: 0.32-1.54), or low birth weight infant (9.8% for index pregnancy and 4.2% for subsequent pregnancy: RR = 2.36; 95% CI: 0.58-9.66) were similar between index and subsequent pregnancies. Perinatally acquired HIV was diagnosed in 6 (2.3%) infants from index pregnancies and none from subsequent pregnancies. A total of 50 (16.7%) women had at least one new clinical adverse event and 109 (36.5%) women had at least one incident abnormal laboratory finding. Twenty-two (7.3%) women switched to second line ART: of these 64.7% (8/17) had suppressed viral load and 54.9% (6/17) had undetectable viral load at 36 months. CONCLUSION Most of the women who started TDF/3TC/EFV were retained in care and few infants were diagnosed with perinatally acquired HIV. Despite switching, women who switched to second line therapy continued to have higher viral loads suggesting that additional factors beyond TDF/3TC/EFV failure may have contributed to the switch. Ongoing support during the postpartum period is necessary to ensure retention in care and prevention of vertical transmission.
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Affiliation(s)
- Maganizo B Chagomerana
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Bryna J Harrington
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Johns Hopkins Dept. of Gynecology & Obstetrics, Baltimore, MD, USA
| | - Bethany L DiPrete
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Austin Wesevich
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA
| | | | - Wiza Kumwenda
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Allan Jumbe
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Mina C Hosseinipour
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Tan Y, Wu S, Yan Y, Zou S, Feng L, Guo W, Wu M, Luo M, Liang K. Adverse pregnancy outcomes associated with antiretroviral therapy initiated before pregnancy and during pregnancy: a retrospective study in Hubei province, China. Front Med (Lausanne) 2023; 10:1158962. [PMID: 37275371 PMCID: PMC10232830 DOI: 10.3389/fmed.2023.1158962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 05/03/2023] [Indexed: 06/07/2023] Open
Abstract
Background Antiretroviral therapy (ART) initiation before pregnancy was reported to have an increased risk of adverse pregnancy outcomes (APOs) than ART initiation during pregnancy. However, the risks of APOs associated with different ART regimens initiated before or during pregnancy remain unknown. Methods Pregnant women living with HIV (PWLHIV) from Hubei Province, China, were retrospectively enrolled between January 1, 2004, and December 31, 2021. The trends of ART initiation time and application of different ART regimens were evaluated over time, separately. Using no ART exposure before and during pregnancy as control, the risks of APOs associated with protease inhibitor (PI) based regimens and non-nucleoside reverse transcriptase inhibitors (NNRTIs) based regimens initiated before pregnancy were analyzed; and the risks of APOs associated with PI-based regimens, NNRTIs based regimens and zidovudine (AZT) monotherapy initiated during pregnancy were analyzed. APOs, including low birthweight (LBW), stillbirth, preterm birth (PTB) and early miscarriage, were reviewed. Results Among 781 PWLHIV including 1,010 pregnancies, 522 pregnancies (51.7%) were exposed to ART before or during pregnancy. Of them, the proportion of ART initiation before pregnancy per year increased from around 20% in the early period to more than 60% after 2019. Efavirenz (EFV)-nucleoside reverse transcriptase inhibitors (NRTIs) (32.2%), LPV/r-NRTIs (31.2%), and nevirapine (NVP)-NRTIs (27.4%) were the most commonly used regimens, and the proportion of LPV/r-NRTIs used per year has increased to around 50.0% in recent years. LPV/r-NRTIs was associated with higher risks of LBW whether initiated before pregnancy [adjusted OR (aOR) = 2.59, 95%CI 1.04-6.45, p = 0.041] or during pregnancy (aOR = 2.19, 95%CI 1.03-4.67, p = 0.041), compared with no exposure to ART before and during pregnancy. However, no matter initiated before or during pregnancy, LPV/r-NRTIs had no significantly increased risks of stillbirth, PTB and early miscarriage, and EFV /NVP-NRTIs and AZT monotherapy had no significantly increased risks of LBW, stillbirth, PTB and early miscarriage when compared with no exposure to ART before and during pregnancy. Conclusion Our data suggests that LPV/r-NRTIs has been widely used among PWLHIV in recent years. However, the potential risk of LBW should be continuously monitored among PWLHIV whether LPV/r-NRTIs is initiated before or during pregnancy.
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Affiliation(s)
- Yuting Tan
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
- Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan, China
| | - Songjie Wu
- Department of Nosocomial Infection Management, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yajun Yan
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Shi Zou
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ling Feng
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wei Guo
- Department of Pathology, Zhongnan Hospital of Wuhan University, Wuhan, China
- Department of Pathology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Mengmeng Wu
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
- Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan, China
| | - Mingqi Luo
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ke Liang
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
- Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan, China
- Department of Nosocomial Infection Management, Zhongnan Hospital of Wuhan University, Wuhan, China
- Hubei Engineering Center for Infectious Disease Prevention, Control and Treatment, Wuhan, China
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Portwood C, Sexton H, Kumarendran M, Brandon Z, Johnson B, Kirtley S, Hemelaar J. Perinatal outcomes associated with combination antiretroviral therapy compared with monotherapy. AIDS 2023; 37:489-501. [PMID: 36695359 DOI: 10.1097/qad.0000000000003432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Increasing numbers of women living with HIV (WLHIV) worldwide receive combination antiretroviral therapy (cART) during pregnancy. We aimed to assess the risk of adverse perinatal outcomes in pregnant WLHIV receiving cART compared with pregnant WLHIV receiving zidovudine monotherapy. DESIGN Systematic review and meta-analysis. METHODS We searched four electronic literature databases (PubMed, CINAHL, Global Health, EMBASE) for studies published between 1 January 1980 and 20 April 2020 using a comprehensive search strategy. Studies reporting data on WLHIV receiving cART compared with WLHIV receiving monotherapy for 11 adverse perinatal outcomes were sought: preterm birth (PTB), very PTB, spontaneous PTB, low birthweight (LBW), very LBW, preterm and term LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Random-effects meta-analyses were conducted to calculate relative risk (RR) and 95% confidence intervals (95% CI). RESULTS We included 30 studies reporting on 317 101 pregnant women in 27 countries. WLHIV receiving cART were at increased risk of PTB (RR 1.32, 95% CI 1.18-1.46), LBW (1.35, 1.19-1.53), SGA (1.32, 1.13-1.53), VSGA (1.64, 1.34-2.02), and stillbirth (2.41, 1.83-3.17) compared to WLHIV receiving monotherapy. The significance of these results was maintained in subgroup analyses for studies conducted in low and middle-income countries and average quality studies. Additionally, WLHIV receiving nonnucleoside reverse transcriptase inhibitor-based cART were associated with increased risk of PTB, LBW, and stillbirth, while WLHIV receiving protease inhibitor-based cART were associated with increased risk of PTB, compared with WLHIV receiving monotherapy. CONCLUSION Pregnant WLHIV receiving cART are associated with increased risk of adverse perinatal outcomes, compared with WLHIV receiving monotherapy.
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Affiliation(s)
- Clara Portwood
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Harriet Sexton
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Bradley Johnson
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health
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Sexton H, Kumarendran M, Brandon Z, Shi C, Kirtley S, Hemelaar J. Adverse perinatal outcomes associated with timing of initiation of antiretroviral therapy: Systematic review and meta-analysis. HIV Med 2023; 24:111-129. [PMID: 35665582 DOI: 10.1111/hiv.13326] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 05/05/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The World Health Organization (WHO) recommends immediate initiation of lifelong antiretroviral therapy (ART) for all people living with HIV, including pregnant women. As a result, an increasing number of women living with HIV conceive while taking ART, the vast majority of whom reside in low- and middle-income countries (LMICs). We aimed to assess the association between timing of ART initiation and perinatal outcomes. METHODS We conducted a systematic literature review by searching PubMed, CINAHL (EBSCOhost), Global Health (Ovid), EMBASE (Ovid), and the Cochrane Central Register of Controlled Trials and four clinical trial databases (WHO International Clinical Trials Registry Platform, the Pan African Clinical Trials Registry, the ClinicalTrials.gov database, and the ISRCTN Registry) from 1 January 1980 to 28 April 2018. We identified studies reporting specific perinatal outcomes among pregnant women living with HIV according to timing of ART initiation and extracted data. Perinatal outcomes assessed were preterm birth (<37 weeks), very preterm birth (<32 weeks), low birthweight (<2500 g), very low birthweight (<1500 g), small for gestational age (<10th centile), very small for gestational age (<3rd centile) and neonatal death (<29 days). Random-effects meta-analyses examined perinatal outcomes associated with preconception and antenatal ART initiation as well as according to trimesters of antenatal initiation. We performed quality assessments and subgroup and sensitivity analyses, and assessed the effect of adjustment for confounders. This systematic review and meta-analyses is registered with PROSPERO, number CRD42021248987. RESULTS Of 51 874 unique citations, 25 studies (eight prospective and 17 retrospective cohort studies) were eligible for analysis, including 40 920 women living with HIV. Preconception ART initiation was associated with a significantly increased risk of preterm birth (relative risk 1.16; 95% confidence interval [CI] 1.03-1.31) compared with antenatal ART initiation. Preconception ART initiation was not significantly associated with very preterm birth, low birthweight, very low birthweight, small for gestational age, very small for gestational age, or neonatal death. First trimester exposure (i.e. preconception or first trimester initiation) was not significantly associated with any increased risk of adverse perinatal outcomes. No significant association between timing of ART initiation and adverse perinatal outcomes was found in the studies of higher quality and those conducted in LMICs. CONCLUSION Preconception ART initiation is associated with preterm birth but no other adverse perinatal outcomes. In LMICs, where most pregnant women living with HIV reside, the timing of ART initiation was not associated with any adverse perinatal outcomes.
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Affiliation(s)
- Harriet Sexton
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christine Shi
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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8
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Concepcion T, Velloza J, Kemp CG, Bhat A, Bennett IM, Rao D, Polyak CS, Ake JA, Esber A, Dear N, Maswai J, Owuoth J, Sing'oei V, Bahemana E, Iroezindu M, Kibuuka H, Collins PY. Perinatal Depressive Symptoms and Viral Non-suppression Among a Prospective Cohort of Pregnant Women Living with HIV in Nigeria, Kenya, Uganda, and Tanzania. AIDS Behav 2023; 27:783-795. [PMID: 36210392 PMCID: PMC9944362 DOI: 10.1007/s10461-022-03810-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 12/14/2022]
Abstract
Depression is common during pregnancy and is associated with reduced adherence to HIV-related care, though little is known about perinatal trajectories of depression and viral suppression among women living with HIV (WLHV) in sub-Saharan Africa. We sought to assess any association between perinatal depressive symptoms and viral non-suppression among WLWH. Depressive symptomatology and viral load data were collected every 6 months from WLWH enrolled in the African Cohort Study (AFRICOS; January 2013-February 2020). Generalized estimating equations modeled associations between depressive symptoms [Center for Epidemiological Studies Depression (CES-D) ≥ 16] and viral non-suppression. Of 1722 WLWH, 248 (14.4%) had at least one pregnancy (291 total) and for 61 pregnancies (21.0%), women reported depressive symptoms (13.4% pre-conception, 7.6% pregnancy, 5.5% one-year postpartum). Depressive symptomatology was associated with increased odds of viral non-suppression (aOR 2.2; 95% CI 1.2-4.0, p = 0.011). Identification and treatment of depression among women with HIV may improve HIV outcomes for mothers.
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Affiliation(s)
- Tessa Concepcion
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jennifer Velloza
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Christopher G Kemp
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA
| | - Amritha Bhat
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Ian M Bennett
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Deepa Rao
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Christina S Polyak
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Julie A Ake
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Allahna Esber
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Nicole Dear
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Jonah Maswai
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- US Army Medical Research Directorate-Africa, Kericho, Kenya
| | - John Owuoth
- U.S. Army Medical Research Directorate-Africa, Kisumu, Kenya
- HJF Medical Research International, Kisumu, Kenya
| | - Valentine Sing'oei
- U.S. Army Medical Research Directorate-Africa, Kisumu, Kenya
- HJF Medical Research International, Kisumu, Kenya
| | - Emmanuel Bahemana
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- HJF Medical Research International, Mbeya, Tanzania
| | - Michael Iroezindu
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- HJF Medical Research International, Abuja, Nigeria
| | - Hannah Kibuuka
- Makerere University Walter Reed Project, Kampala, Uganda
| | - Pamela Y Collins
- Department of Global Health, University of Washington, Seattle, WA, USA.
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.
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9
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Edmonds A, Brazier E, Musick BS, Yotebieng M, Humphrey J, Abuogi LL, Adedimeji A, Keiser O, Msukwa M, Carlucci JG, Maia M, Pinto JA, Leroy V, Davies MA, Wools-Kaloustian KK. Clinical and programmatic outcomes of HIV-exposed infants enrolled in care at geographically diverse clinics, 1997-2021: A cohort study. PLoS Med 2022; 19:e1004089. [PMID: 36107857 PMCID: PMC9477260 DOI: 10.1371/journal.pmed.1004089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/11/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Although 1·3 million women with HIV give birth annually, care and outcomes for HIV-exposed infants remain incompletely understood. We analyzed programmatic and health indicators in a large, multidecade global dataset of linked mother-infant records from clinics and programs associated with the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. METHODS AND FINDINGS HIV-exposed infants were eligible for this retrospective cohort analysis if enrolled at <18 months at 198 clinics in 10 countries across 5 IeDEA regions: East Africa (EA), Central Africa (CA), West Africa (WA), Southern Africa (SA), and the Caribbean, Central, and South America network (CCASAnet). We estimated cumulative incidences of DNA PCR testing, loss to follow-up (LTFU), HIV diagnosis, and death through 24 months of age using proportional subdistribution hazard models accounting for competing risks. Competing risks were transfer, care withdrawal, and confirmation of negative HIV status, along with LTFU and death, when not the outcome of interest. In CA and EA, we quantified associations between maternal/infant characteristics and each outcome. A total of 82,067 infants (47,300 EA, 10,699 CA, 6,503 WA, 15,770 SA, 1,795 CCASAnet) born from 1997 to 2021 were included. Maternal antiretroviral therapy (ART) use during pregnancy ranged from 65·6% (CCASAnet) to 89·5% (EA), with improvements in all regions over time. Twenty-four-month cumulative incidences varied widely across regions, ranging from 12·3% (95% confidence limit [CL], 11·2%,13·5%) in WA to 94·8% (95% CL, 94·6%,95·1%) in EA for DNA PCR testing; 56·2% (95% CL, 55·2%,57·1%) in EA to 98·5% (95% CL, 98·3%,98·7%) in WA for LTFU; 1·9% (95% CL, 1·6%,2·3%) in WA to 10·3% (95% CL, 9·7%,10·9%) in EA for HIV diagnosis; and 0·5% (95% CL, 0·2%,1·0%) in CCASAnet to 4·7% (95% CL, 4·4%,5·0%) in EA for death. Although infant retention did not improve, HIV diagnosis and death decreased over time, and in EA, the cumulative incidence of HIV diagnosis decreased substantially, declining to 2·9% (95% CL, 1·5%,5·4%) in 2020. Maternal ART was associated with decreased infant mortality (subdistribution hazard ratio [sdHR], 0·65; 95% CL, 0·47,0·91 in EA, and sdHR, 0·51; 95% CL, 0·36,0·74 in CA) and HIV diagnosis (sdHR, 0·40; 95% CL, 0·31,0·50 in EA, and sdHR, 0·41; 95% CL, 0·31,0·54 in CA). Study limitations include potential misclassification of outcomes in real-world service delivery data and possible nonrepresentativeness of IeDEA sites and the population of HIV-exposed infants they serve. CONCLUSIONS While there was marked regional and temporal heterogeneity in clinical and programmatic outcomes, infant LTFU was high across all regions and time periods. Further efforts are needed to keep HIV-exposed infants in care to receive essential services to reduce HIV infection and mortality.
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Affiliation(s)
- Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
| | - Beverly S. Musick
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Marcel Yotebieng
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - John Humphrey
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Lisa L. Abuogi
- Department of Pediatrics, University of Colorado, Denver, Aurora, Colorado, United States of America
| | - Adebola Adedimeji
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Malango Msukwa
- Center for International Health, Education, and Biosecurity, University of Maryland, Lilongwe, Malawi
| | - James G. Carlucci
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Marcelle Maia
- Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Jorge A. Pinto
- Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Valériane Leroy
- Inserm, Université de Toulouse, CERPOP, Université Paul Sabatier, Toulouse, France
| | | | - Kara K. Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
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Dapar MP, Joseph BN, Okunlola RC, Mutihir J, Chingle MP, Banwat ME. Pregnancy and Birth Outcomes Among Women on Antiretroviral Therapy: A Long-term Retrospective Analysis of Data from a Major Tertiary Hospital in North Central Nigeria. Int J MCH AIDS 2021; 10:183-190. [PMID: 34754614 PMCID: PMC8564061 DOI: 10.21106/ijma.511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Antiretroviral therapy (ART) has transformed human immune deficiency virus (HIV) infection from a death sentence to a chronic syndrome, allowing infected individuals to lead near-normal lives, including achieving pregnancy and bearing children. Notwithstanding, concerns remain about the effects of ART in pregnancy. Previous studies suggested contradictory associations between ART and pregnancy. This study determined birth outcomes in pregnant women who accessed ART between 2004 and 2017 at a major tertiary hospital in North Central Nigeria. METHODS This was a retrospective study of 5,080 participants. Ethical clearance was obtained from the Institutional Review Board of the Harvard T. H. Chan School of Public Health Boston. A pro forma for data abstraction was designed and used to collect data. Abstracted data were sorted and managed using SPSS® version 22. The Chi-square test was used to calculate the proportions of pregnancy outcomes. One-way analysis of variance was used to test the effect of antiretroviral drug regimens on mean birth weight and gestational age at delivery. All levels of significance were set at p 0.05. RESULTS Pregnancy outcomes were recorded as live birth (99.8%), stillbirth (0.2%), preterm delivery (6.6%), and low birth weight (23%). There was a statistically significant association between ART in pregnancy and low birth weight {χ2 [(5, n = 3439) = 11.99, p = 0.04]}. The highest mean birth weights were recorded in participants who received drug combinations with protease inhibitors or efavirenz, in contrast to participants who received Nevirapine, stavudine and Emtricitabine/Tenofovirbased regimens. However, there was no significant difference in the gestational age of babies at birth for the six ART regimens in the study. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS Findings support the benefits of ART in pregnancy, which is in line with the testing and treatment policies of the 90-90-90 targets for ending HIV by the year 2030.
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Affiliation(s)
- Maxwell P. Dapar
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, University of Jos, Nigeria
| | - Benjamin N. Joseph
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, University of Jos, Nigeria
| | - Rotkangmwa C. Okunlola
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, University of Jos, Nigeria
| | - Josiah Mutihir
- Department of Obstetrics and Gynecology, College of Health Sciences, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - Moses P. Chingle
- Department of Community Medicine, College of Health Sciences, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - Mathilda E. Banwat
- Department of Community Medicine, College of Health Sciences, University of Jos and Jos University Teaching Hospital, Jos Nigeria
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Maternal HIV infection is associated with distinct systemic cytokine profiles throughout pregnancy in South African women. Sci Rep 2021; 11:10079. [PMID: 33980919 PMCID: PMC8115111 DOI: 10.1038/s41598-021-89551-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 04/27/2021] [Indexed: 01/02/2023] Open
Abstract
Maternal HIV infection is associated with adverse pregnancy outcomes, but the mechanisms remain unknown. The course of pregnancy is regulated by immunological processes and HIV infection and antiretroviral therapy (ART) impact key immune mechanisms, which may disrupt the immune programme of pregnancy. We evaluated a broad range of systemic cytokines at each trimester of pregnancy in 56 women living with HIV (WLHIV) and 68 HIV-negative women, who were enrolled in a prospective pregnancy cohort study in Soweto, South Africa. The pro-inflammatory cytokine IP-10 was detected in each trimester in all WLHIV, which was significantly more than in HIV-negative women. The anti-viral cytokine IFNλ1 was detected more frequently in WLHIV, whereas IFNβ and IFNλ2/3 were detected more frequently in HIV-negative women. Th1 cytokines IL-12 and IL-12p70, Th2 cytokine IL-5, and Th17 cytokine IL-17A were detected more frequently in WLHIV throughout pregnancy. Il-6, IL-9, and IL-10 were more commonly detected in WLHIV in the first trimester. Trends of increased detection of Th1 (IL-2, IL-12p70), Th2 (IL-4, Il-5, Il-13) and Th17 (IL-17A, Il-17F, IL-21, IL-22) cytokines were associated with small-for-gestational-age babies. Our findings indicate that maternal HIV/ART is associated with distinct systemic cytokine profiles throughout pregnancy.
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12
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IKUMI NM, MALABA TR, PILLAY K, COHEN MC, MADLALA HP, MATJILA M, ANUMBA D, MYER L, NEWELL ML, GRAY CM. Differential impact of antiretroviral therapy initiated before or during pregnancy on placenta pathology in HIV-positive women. AIDS 2021; 35:717-726. [PMID: 33724257 PMCID: PMC8630811 DOI: 10.1097/qad.0000000000002824] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the association between timing of antiretroviral treatment (ART) initiation in HIV-infected women and placental histopathology. DESIGN A nested substudy in a larger cohort of HIV-infected women which examined the association between ART status and birth outcomes. METHODS Placentas (n = 130) were examined for histopathology from two ART groups: stable (n = 53), who initiated ART before conception and initiating (n = 77), who started ART during pregnancy [median (interquartile range) 15 weeks gestation (11-18)]. Using binomial regression we quantified associations between ART initiation timing with placental histopathology and pregnancy outcomes. RESULTS One-third of all placentas were less than 10th percentile weight-for-gestation and there was no significant difference between ART groups. Placental diameter, thickness, cord insertion position and foetal-placental weight ratio were also similar by group. However, placentas from the stable group showed increased maternal vascular malperfusion (MVM) (39.6 vs. 19.4%), and decreased weight (392 vs. 422 g, P = 0.09). MVM risk was twice as high [risk ratios 2.03 (95% confidence interval: 1.16-3.57); P = 0.01] in the stable group; the increased risk remaining significant when adjusting for maternal age [risk ratios 2.04 (95% confidence interval: 1.12-3.72); P = 0.02]. Furthermore, MVM was significantly associated with preterm delivery and low birth weight (P = 0.002 and <0.0001, respectively). CONCLUSION Preconception initiation of ART was associated with an increased MVM risk, and may contribute to placental dysfunction. The association between MVM with preterm delivery and low birth weight suggests that a placenta-mediated mechanism likely links the putative association between long-term use of ART and adverse birth outcomes.
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Affiliation(s)
- Nadia M IKUMI
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Thokozile R MALABA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Komala PILLAY
- Division of Anatomical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
| | - Marta C COHEN
- Department of Histopathology, Sheffield Children’s NHS Foundation Trust , Sheffield, UK
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK, Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town South Africa
| | - Hlengiwe P MADLALA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Mushi MATJILA
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town South Africa
| | - Dilly ANUMBA
- Academic Unit of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Landon MYER
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Marie-Louise NEWELL
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Clive M GRAY
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
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Anderson K, Mutemaringa T, Technau KG, Johnson LF, Braithwaite K, Mokotoane E, Boulle A, Davies On Behalf Of IeDEA-Sa Pediatrics MA. The next generation: Pregnancy in adolescents and women living with perinatally acquired HIV in South Africa. S Afr Med J 2021; 111:260-264. [PMID: 33944749 PMCID: PMC8847806 DOI: 10.7196/samj.2021.v111i3.14987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND An increasing number of girls living with perinatally acquired HIV (PHIV) are reaching adolescence and adulthood and becoming pregnant. Youth living with PHIV (YLPHIV) may have HIV-associated infections/complications, long-term exposure to antiretroviral treatment (ART), drug resistance and increased psychosocial challenges, which may adversely affect pregnancy outcomes. There is a lack of published studies on pregnancy in YLPHIV in sub-Saharan Africa. Objectives. To describe characteristics of pregnant South African (SA) YLPHIV and their pregnancy outcomes. METHODS We retrospectively identified pregnancies in YLPHIV, who were diagnosed with HIV when they were <12 years old and before their first pregnancy (as a proxy for perinatal route of infection), from routinely collected data in Western Cape Province, SA (2007 - 2018). We combined these with pregnancies from a Johannesburg cohort of YLPHIV. Results. We identified 258 pregnancies among 232 females living with likely PHIV; 38.8% of pregnancies occurred in YLPHIV ≤16 years old, 39.1% at age 17 - 19 years and 22.1% at age ≥20 years. In recent years, a steady increase in the number of pregnancies in YLPHIV was noted; more than two-thirds occurred during 2016 - 2018. ART was commenced prior to pregnancy in 84.9% of YLPHIV, during pregnancy in 6.6% and was not commenced by pregnancy end date in 8.5%. Of the pregnancies in young women with documented outcomes (88.8%; n=229), 80.3% were live births, 14.4% terminations, 3.1% miscarriages and 2.2% stillbirths. Mother-to-child transmission of HIV occurred in 2.2% of infants, 75.3% were uninfected when last tested and 22.6% had unknown HIV status. Among YLPHIV with CD4 counts available within 12 months of pregnancy end date (n=202), 20.3% had a CD4 count <200 cells/μL, 43.1% CD4 count 200 - 499 cells/μL and 36.6% CD4 count ≥500 cells/μL. Among those with a viral load (VL) available within 12 months of pregnancy end date (n=219), 66.7% had a VL <400 copies/mL, 5.0% VL 400 - 999 copies/mL and 28.3% VL ≥1 000 copies/mL. Of 186 neonates, 20.4% were preterm deliveries (<37 weeks' gestation). Among neonates with known birthweight (n=176), the mean birthweight was 2 900 g (95% confidence interval (CI) 2 747 - 2 935 g) and 20.5% had a low birthweight (<2 500 g). One congenital malformation (musculoskeletal) and 2 neonatal deaths were recorded. CONCLUSIONS In recent years, the number of pregnancies in YLPHIV has increased. A considerable proportion of pregnancies occurred in YLPHIV ≤16 years old. A high proportion of pregnancies was electively terminated. The prevalence of elevated VL and poor immunological status among pregnant YLPHIV is concerning.
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Affiliation(s)
- K Anderson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
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Onono M, Odwar T, Wahome S, Helova A, Bukusi EA, Hampanda K, Turan J, Abuogi L. Behavioral Interventions can Mitigate Adverse Pregnancy Outcomes Among Women Conceiving on ART and Those Initiated on ART During Pregnancy: Findings From the MOTIVATE Trial in Southwestern Kenya. J Acquir Immune Defic Syndr 2021; 86:46-55. [PMID: 33306563 PMCID: PMC7851482 DOI: 10.1097/qai.0000000000002521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Antiretroviral therapy (ART) is essential for the elimination of mother-to-child transmission and improved health outcomes for women living with HIV (WLWH). However, adverse pregnancy outcomes (APOs) among pregnant women on ART are a growing concern. METHODS We investigated the associations between timing of ART initiation and APOs among pregnant WLWH receiving behavioral interventions (community mentor mothers and text messaging) in the Mother-Infant Visit Adherence and Treatment Engagement (MOTIVATE) study in southwestern Kenya. Log binomial models were used for estimation of relative risks (RRs) (adjusted for the clustered nature of data) evaluating APOs with 3 exposure comparisons: (1) preconception ART initiation vs. postconception initiation; (2) among postconception ART initiating women, comparisons across gestational ages at cART initiation (first versus second and third trimester exposure), and (3) intervention allocation. RESULTS Of the 1275 women included in this analysis, 388 (30%) had an APO: 306 preterm births, 38 low birth weight infants, 33 stillbirths, and 11 miscarriages. In multivariable analysis, viral load ≥1000 copies/mL, moderate and severe anemia at baseline increased risk of APOs. Among women initiating ART before and after conception, no difference was observed in the composite APO. Women who received community mentor mother visits alone (aRR 0.74: 95% CI: 0.71 to 0.76) or text messages alone (aRR 0.79: 95% CI: 0.70 to 0.89) had lower risks of experiencing any APOs. CONCLUSIONS Receiving supportive behavioral interventions may mitigate the risk of experiencing an APO among WLWH on ART. Further studies are needed to investigate the underlying mechanisms and optimize the benefits of these interventions.
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Affiliation(s)
- Maricianah Onono
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Tobias Odwar
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Samuel Wahome
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Anna Helova
- Department of Health Care Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, United States
| | | | - Karen Hampanda
- Department of Community and Behavioral Health, School of Public Health, University of Colorado Denver, Aurora, United States
| | - Janet Turan
- Department of Health Care Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, United States
| | - Lisa Abuogi
- Department of Pediatrics, University of Colorado Denver, Aurora, United States
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Akoto C, Chan CYS, Tshivuila-Matala COO, Ravi K, Zhang W, Vatish M, Norris SA, Hemelaar J. Innate lymphoid cells are reduced in pregnant HIV positive women and are associated with preterm birth. Sci Rep 2020; 10:13265. [PMID: 32764636 PMCID: PMC7413261 DOI: 10.1038/s41598-020-69966-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 07/21/2020] [Indexed: 01/13/2023] Open
Abstract
Preterm birth is the leading cause of neonatal and child mortality worldwide. Globally, 1.4 million pregnant women are estimated to be living with HIV/AIDS, the majority of whom live in sub-Saharan Africa. Maternal HIV infection and antiretroviral treatment (ART) have been associated with increased rates of preterm birth, but the underlying mechanisms remain unknown. Acute HIV infection is associated with a rapid depletion of all three subsets of innate lymphoid cells (ILCs), ILC1s, ILC2s and ILC3s, which is not reversed by ART. ILCs have been found at the maternal-fetal interface and we therefore investigated the potential association between maternal HIV infection, peripheral ILC frequencies and preterm birth. In our study of pregnant South African women with accurately dated pregnancies, we show that maternal HIV infection is associated with reduced levels of all three ILC subsets. Preterm birth was also associated with lower levels of all three ILC subsets in early pregnancy. ILC frequencies were lowest in HIV positive women who experienced preterm birth. Moreover, ILC levels were reduced in pregnancies resulting in spontaneous onset of preterm labour and in extreme preterm birth (< 28 weeks gestation). Our findings suggest that reduced ILC frequencies may be a link between maternal HIV infection and preterm birth. In addition, ILC frequencies in early pregnancy may serve as predictive biomarkers for women who are at risk of delivering preterm.
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Affiliation(s)
- Charlene Akoto
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Christina Y S Chan
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Chrystelle O O Tshivuila-Matala
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK.,South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Krithi Ravi
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Wei Zhang
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Manu Vatish
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Shane A Norris
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK.,South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Joris Hemelaar
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK. .,South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.
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Akoto C, Chan CYS, Ravi K, Zhang W, Vatish M, Norris SA, Hemelaar J. γδ T cell frequencies are altered in HIV positive pregnant South African women and are associated with preterm birth. PLoS One 2020; 15:e0235162. [PMID: 32584913 PMCID: PMC7316337 DOI: 10.1371/journal.pone.0235162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 06/10/2020] [Indexed: 12/24/2022] Open
Abstract
Background Preterm birth is the leading cause of neonatal and child mortality worldwide. Maternal HIV infection and antiretroviral treatment (ART) increase the rate of preterm birth, but the underlying mechanisms remain unknown, limiting progress in prediction, prevention and treatment. While overall γδ T cell levels remain constant, acute HIV infection is associated with a depletion of the Vδ2 subset and an increase in the Vδ1 subset, which do not return to baseline with ART. γδ T cells have also been implicated in adverse pregnancy outcomes and we therefore investigated the potential association between maternal HIV infection, peripheral γδ T cell frequencies and preterm birth. Methods Study participants were HIV positive (n = 47) and HIV negative (n = 45) women enrolled in a prospective pregnancy cohort study at Chris Hani Baragwanath Academic Hospital in Soweto, South Africa. Women were enrolled in early pregnancy and gestational age was accurately determined by first trimester ultrasound scan. Peripheral blood samples were collected in each trimester and peripheral blood mononuclear cells isolated. Frequencies of γδ T cells, Vδ1+ and Vδ2+ γδ T cell subsets, and CCR6 chemokine receptor expression were determined by flow cytometry. Results Total γδ T cell levels were similar between HIV positive and HIV negative women throughout pregnancy. However, in each trimester maternal HIV infection was associated with reduced levels of the Vδ2+ subset and increased levels of the Vδ1+ subset, leading to a reversal of the Vδ1/Vδ2 ratio. Timing of ART initiation among HIV positive women did not affect levels of γδ T cells, the Vδ1+ and Vδ2+ subsets, or the Vδ1/Vδ2 ratio. Importantly, preterm birth was associated with lower total γδ T cell levels in early pregnancy and γδ T cell frequencies were lowest in HIV positive women who delivered preterm. Moreover, in the first trimester the proportion of Vδ1+ T cells that were CCR6+ was significantly reduced in HIV+ women and women who delivered preterm, resulting in the lowest proportion of CCR6+ Vδ1 T cells in HIV positive women who delivered preterm. Conclusions Our findings suggest that altered γδ T cell frequencies may link maternal HIV infection and preterm birth. γδ T cell frequencies in early pregnancy may serve as predictive biomarkers to identify women at risk of delivering preterm.
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Affiliation(s)
- Charlene Akoto
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Christina Y. S. Chan
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Krithi Ravi
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Wei Zhang
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Manu Vatish
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Shane A. Norris
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
- Department of Paediatrics, South African Medical Research Council Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Joris Hemelaar
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
- Department of Paediatrics, South African Medical Research Council Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
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Eckard AR, Kirk SE, Hagood NL. Contemporary Issues in Pregnancy (and Offspring) in the Current HIV Era. Curr HIV/AIDS Rep 2020; 16:492-500. [PMID: 31630334 DOI: 10.1007/s11904-019-00465-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Although antiretroviral therapy (ART) has dramatically reduced mother to child transmission of HIV, data continue to mount that infants exposed to HIV in utero but are not infected (HEU) have serious negative health consequences compared to unexposed infants. This review evaluates recent literature on contemporary issues related to complications seen in pregnant women with HIV and their offspring. RECENT FINDINGS Current studies show that HEU infants are at a high risk of adverse outcomes, including premature birth, poor growth, neurodevelopmental impairment, immune dysfunction, infectious morbidity, and death. Etiologies for the observed clinical events and subclinical alterations are complex and multifactorial, and the long-term consequences of many findings are yet unknown. HEU infants have an unacceptable rate of morbidity and mortality from perinatal HIV and ART exposure, even in the modern ART era. Continual monitoring and reporting is imperative to protect this vulnerable population in our everchanging landscape of HIV treatment and prevention.
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Affiliation(s)
- Allison Ross Eckard
- Departments of Pediatrics and Medicine, Divisions of Infectious Diseases, Medical University of South Carolina, 135 Rutledge Ave., MSC 752, Charleston, SC, USA.
| | - Stephanie E Kirk
- Departments of Pediatrics and Medicine, Divisions of Infectious Diseases, Medical University of South Carolina, 135 Rutledge Ave., MSC 752, Charleston, SC, USA
| | - Nancy L Hagood
- Departments of Pediatrics and Medicine, Divisions of Infectious Diseases, Medical University of South Carolina, 135 Rutledge Ave., MSC 752, Charleston, SC, USA
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dos Reis HLB, Boldrini NAT, Rangel AFR, Barros VF, Merçon de Vargas PR, Miranda AE. Placental growth disorders and perinatal adverse outcomes in Brazilian HIV-infected pregnant women. PLoS One 2020; 15:e0231938. [PMID: 32352999 PMCID: PMC7192492 DOI: 10.1371/journal.pone.0231938] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 04/03/2020] [Indexed: 12/18/2022] Open
Abstract
Fetal and placental growth disorders are common in maternal human immunodeficiency virus (HIV) infection and can be attributed to both the infection and comorbidities not associated with HIV. We describe placental growth disorders and adverse reproductive outcomes in HIV-infected pregnant women whose delivery occurred between 2001-2014 in Vitoria, Brazil. Cases with gestational age (GA) ≥ than 22 weeks validated by ultrasonography, with placental and fetal weight dimensions at birth, were studied. Outcomes were summarized as proportions of small (SGA), appropriate (AGA), and large (LGA) for GA when the z-score values were below -1.28, between -1.28 and +1.28, or above +1.28, respectively. Of 187 fetal attachment requisitions, 122(65.2%) women and their newborns participated in the study. The median maternal age was 28 years and 81(66.4%) underwent ≥ 6 prenatal visits. A total of 81(66.4%) were diagnosed before current pregnancy; 68(55.7%) exhibited criteria for acquired immunodeficiency syndrome (AIDS); 64(52.4%) had detectable viral load; 25(20.5%) cases presented SGA placental weight and 6(4.9%) SGA placental thickness. SGA placental area was observed in 41(33.6%) cases, and among the SGA placental weight cases 12(48%) were also SGA fetal weight. Preterm birth (PTB) occurred in 15.6%(19/122) of cases; perinatal death in 4.1%(5/122) and HIV vertical transmission in 6 of 122 (4.9%). Women, ≥36 years old, were 5.7 times more likely to have PTB than those under 36. Also, patients with AIDS-defining criteria were 3.7 times more likely to have PTB. Prenatal care was inversely associated with PTB. Statistically significant associations were observed between AGA placental area and Protease Inhibitor usage and between SGA placental weight and SGA area. We found a prevalence of placental growth disorders in HIV-infected pregnant women and values higher than international reference values. The restriction of placental growth was a common disorder, possibly attributed to virus effects or a combination of antiretroviral regimens.
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Affiliation(s)
- Helena Lucia Barroso dos Reis
- Post-Graduate Program of Infectious Diseases, Federal University of Espírito Santo, Vitória, Espírito Santo State, Brazil
- * E-mail:
| | | | - Ana Fernanda Ribeiro Rangel
- Department of Pathology, Pathology Laboratory of Cassiano Antonio Moraes University Hospital, Federal University of Espírito Santo, Vitória, Espírito Santo State, Brazil
| | - Vinicius Felipe Barros
- Department of Pathology, Pathology Laboratory of Cassiano Antonio Moraes University Hospital, Federal University of Espírito Santo, Vitória, Espírito Santo State, Brazil
| | - Paulo Roberto Merçon de Vargas
- Department of Pathology, Pathology Laboratory of Cassiano Antonio Moraes University Hospital, Federal University of Espírito Santo, Vitória, Espírito Santo State, Brazil
| | - Angélica Espinosa Miranda
- Post-Graduate Program of Infectious Diseases, Federal University of Espírito Santo, Vitória, Espírito Santo State, Brazil
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Onwughara CE, Moodley D, Valashiya N, Sebitloane M. Preterm prelabour rupture of membranes (PPROM) and pregnancy outcomes in association with HIV-1 infection in KwaZulu-Natal, South Africa. BMC Pregnancy Childbirth 2020; 20:204. [PMID: 32272919 PMCID: PMC7146876 DOI: 10.1186/s12884-020-02911-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/30/2020] [Indexed: 12/22/2022] Open
Abstract
Background SubSaharan Africa has a disproportionate burden of HIV and preterm births (PTB). We hypothesized that PTB in HIV-1 infected women are more likely a result of prelabour rupture of membranes (PROM) and could lead to worse birth outcomes than HIV-uninfected women. We also hypothesized that PPROM increased the risk of mother-to-child transmission (MTCT) of HIV-1. Current clinical management protocols for PPROM do not include a differential treatment plan for HIV-infected women. Methods The maternity register at a regional hospital in a high HIV-burden district in South Africa was reviewed to identify all preterm births over a 3 month-period in 2018. We determined the incidence of PPROM using predefined criteria. Maternal age, parity, previous pregnancy complications, antenatal care, body mass index, history of smoking or alcohol, HIV infection and syphilis were computed on chi-square contingency tables to determine risk of PPROM. Overall pregnancy outcomes that included mode of delivery, fetal survival, birth weight, gestational age and newborn apgar scores were compared between HIV-infected and HIV-uninfected women whose pregnancies were complicated by PPROM. HIV-exposed newborns are routinely tested at birth for HIV by PCR. Results A total of 1758 deliveries were recorded for Jan-Mar, 2018, and 295 (16.8%) were preterm. Maternity charts were retrieved for 236 (80.0%) PTB; 47 of PTB (19.9%; 95%CI 15.0–25.6) were further complicated by PROM which translates to 2.7% (95%CI 1.9–3.4) of all deliveries. None of the risk variables including HIV-positive status (48.9% vs 47.6%) were different between PPROM and non-PPROM groups and the majority of women were receiving cART (94.7 and 92.0%). There were no differences in the proportion of low birth weight (RR 1.2 95%CI 0.6–2.1) or severe preterm birth (RR 1.6; 95%CI 0.9–2.9) between HIV-infected and HIV-uninfected women whose pregnancies were complicated by PPROM. None of the 22 HIV-exposed newborns in the PPROM group were HIV-infected at birth. Conclusion The PPROM incidence is not higher among HIV-infected women and our findings suggest that HIV-infected women who are virally suppressed on cART and presenting with PPROM are less likely to transmit HIV to their infants and do not have worse birth outcomes than HIV-uninfected women.
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Affiliation(s)
- Chidebere E Onwughara
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Dhayendre Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Nthabiseng Valashiya
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Motshedisi Sebitloane
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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Tiam A, Kassaye SG, Machekano R, Tukei V, Gill MM, Mokone M, Letsie M, Tsietso M, Seipati I, Barasa J, Isavwa A, Tylleskär T, Guay L. Comparison of 6-week PMTCT outcomes for HIV-exposed and HIV-unexposed infants in the era of lifelong ART: Results from an observational prospective cohort study. PLoS One 2019; 14:e0226339. [PMID: 31877153 PMCID: PMC6932788 DOI: 10.1371/journal.pone.0226339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/25/2019] [Indexed: 01/04/2023] Open
Abstract
Background Lifelong antiretroviral therapy (ART) reduces mother-to-child HIV transmission (MTCT) and improves maternal health. Data on the outcomes of HIV-exposed infants (HEI) compared to their unexposed counterparts in the era of universal ART is limited. We compared birth and 6-week outcomes among infants born to HIV-positive and HIV-negative women in Lesotho. Methods 941 HIV-negative and 653 HIV-positive pregnant women were enrolled in an observational cohort to evaluate the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) program after implementation of universal maternal ART in 14 health facilities. Pregnancy, delivery, birth, and 6-week data were collected through participant interviews and medical record review. DNA PCR testing for HEI was conducted within 2 weeks of birth and at around 6 weeks of age. Data were analysed to estimate the distribution of birth outcomes, mortality, HIV transmission and HIV-free survival at 6 weeks. Results HIV-positive women were older (mean age of 28.7 vs. 24.4 years) and presented for antenatal care earlier (mean gestational age of 23.0 weeks vs 25.3 weeks) than HIV-negative women. Prematurity was more frequent among HEI, 7.8% vs. 3.6%. There was no difference in rates of congenital anomalies between HEI (1.0%) and HIV-unexposed infants (HUI) (0.6%). Cumulative HIV transmission was 0.9% (N = 4/431) (95% CI:0.25–2.36) at birth and 1.0% (N = 6/583) (95% CI:0.38–2.23) at 6 weeks. Overall mortality, including stillbirths, was 5.2% and 6.0% by 6 weeks for HUI and HEI respectively. Among liveborn infants, 6-week HIV-free survival for HEI was 95.6% (95% CI:93.7–97.1) compared to 96.8% (95% CI:95.4–97.9) survival for HUI. Conclusions Implementation of universal maternal ART lowers MTCT at 6 weeks of age with no differences in congenital anomalies or early mortality between HIV exposed Infants and HIV unexposed infants. However, HIV exposed infants continue to have high rates of prematurity despite improved maternal health on ART.
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Affiliation(s)
- Appolinaire Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
- Centre for International Health, University of Bergen, Bergen, Norway
- * E-mail:
| | - Seble G. Kassaye
- Department of Medicine Georgetown University School of Medicine, Washington D.C., United States of America
| | - Rhoderick Machekano
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
| | - Vincent Tukei
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
| | | | | | | | | | - Janety Barasa
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Anthony Isavwa
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | | | - Laura Guay
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
- Department of Epidemiology and Biostatistics, George Washington University Milken Institute School of Public Health, Washington D.C., United States of America
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Harrington BJ, DiPrete BL, Jumbe AN, Ngongondo M, Limarzi L, Wallie SD, Chagomerana MB, Hosseinipour MC. Safety and efficacy of Option B+ ART in Malawi: few severe maternal toxicity events or infant HIV infections among pregnant women initiating tenofovir/lamivudine/efavirenz. Trop Med Int Health 2019; 24:1221-1228. [PMID: 31381233 DOI: 10.1111/tmi.13296] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Malawi's Option B+ universal antiretroviral therapy (ART) program for pregnant and breastfeeding women does not include routine laboratory monitoring. We report safety outcomes of pregnant women who initiated ART through Option B+. METHODS We analysed 12-month data from an observational cohort study on Option B+ among women newly initiating tenofovir/lamivudine/efavirenz (TDF/3TC/EFV) at a government antenatal clinic in Lilongwe, Malawi. Proportions of women engaged in care, incidence of DAIDS grade ≥ 2 laboratory toxicity, grade ≥ 3 adverse events (AEs), viral suppression (<1000 copies/mL), birth outcomes and infant HIV infections are reported. RESULTS At ART initiation, participants (n = 299) had a median age of 26 years (IQR 22-30), median CD4 count of 352 cells/μl (IQR 231-520) and 94% were in WHO Stage 1. We noted 76 incident DAIDS Grade ≥ 2 laboratory results among 58 women, most commonly elevated liver function tests (n = 30 events) and low haemoglobin (n = 27). No women had elevated creatinine. Clinical AEs (n = 45) were predominantly infectious diseases and Grade 3. Five participants (2%) discontinued TDF/3TC/EFV due to virologic failure (3) or toxicity (2). Twelve months after ART initiation, most women were engaged in care (89%) and had HIV RNA < 1000 copies/ml (90%). 8% of pregnancies resulted in preterm birth, 9% were low birthweight (<2500 g), and 2% resulted in infant HIV infection at 6 weeks post-delivery. CONCLUSION Most women remained on ART and were virally suppressed 12 months after starting Option B+. Few infants contracted HIV perinatally. While some women experienced adverse laboratory events, clinical symptom monitoring is likely reasonable.
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Affiliation(s)
- Bryna J Harrington
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bethany L DiPrete
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allan N Jumbe
- UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Laura Limarzi
- UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | | | - Mina C Hosseinipour
- UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Ejigu Y, Magnus JH, Sundby J, Magnus MC. Pregnancy outcome among HIV-infected women on different antiretroviral therapies in Ethiopia: a cohort study. BMJ Open 2019; 9:e027344. [PMID: 31383698 PMCID: PMC6687026 DOI: 10.1136/bmjopen-2018-027344] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/19/2019] [Accepted: 06/21/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The objective of the study was to compare pregnancy outcomes according to maternal antiretroviral treatment (ART) regimens. DESIGN A retrospective cohort study. PARTICIPANTS AND SETTINGS Clinical data was extracted from ART exposed pregnancies of HIV-infected Ethiopian women attending antenatal care follow-up in public health facilities in Addis Ababa between February 2010 and October 2016. OUTCOMES The primary outcomes evaluated were preterm birth, low birth weight and small-for-gestational-age. RESULTS A total 1663 of pregnancies exposed to ART were included in the analyses. Of these pregnancies, 17% resulted in a preterm birth, 19% in low birth weight and 32% in a small-for-gestational-age baby. Compared with highly active antiretroviral therapy (HAART) initiated during pregnancy, zidovudine monotherapy was less likely to result in preterm birth (adjusted OR 0.35, 95% CI 0.19 to 0.64) and low birth weight (adjusted OR 0.48, 95% CI 0.24 to 0.94). We observed no differential risk of preterm birth, low birth weight and small-for-gestational-age, when comparing women who initiated HAART during pregnancy to women who initiated HAART before conception. The risk for preterm birth was higher in pregnancies exposed to nevirapine-based HAART (adjusted OR 1.44, 95% CI 1.06 to 1.96) compared with pregnancies exposed to efavirenz-based HAART. Comparing nevirapine-based HAART with efavirenz-based HAART indicated no strong evidence of increased risk of low birth weight or small-for-gestational-age. CONCLUSIONS We observed a higher risk of preterm birth among women who initiated HAART during pregnancy compared with zidovudine monotherapy. Pregnancies exposed to nevirapine-based HAART also had a greater risk of preterm births compared with efavirenz-based HAART.
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Affiliation(s)
- Yohannes Ejigu
- Health Metrics and Evaluation, Jimma University College of Public Health and Medical Sciences, Jimma, Ethiopia
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jeanette H Magnus
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Johanne Sundby
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Maria C Magnus
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Department of Population Health Sciences, University of Bristol Medical School, Bristol, UK
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
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Perinatal outcomes associated with maternal HIV and antiretroviral therapy in pregnancies with accurate gestational age in South Africa. AIDS 2019; 33:1623-1633. [PMID: 30932959 DOI: 10.1097/qad.0000000000002222] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the association of maternal HIV infection and antiretroviral therapy (ART) with perinatal outcomes among women with accurate pregnancy dating and birth weights. DESIGN Prospective pregnancy cohort study in Soweto, South Africa. METHODS Gestational age was estimated by first-trimester ultrasound and birth weight was measured in a standardized manner within 24 h of birth. The primary composite outcome 'adverse perinatal outcome' included preterm birth, low birth weight, small for gestational age, stillbirth and neonatal death (NND). Specific adverse perinatal outcomes were secondary outcomes. Logistic regression models adjusted for multiple confounders. RESULTS Of 633 women included in the analysis, 229 (36.2%) were HIV positive and 404 (63.8%) HIV negative. Among 125 HIV-positive women who provided detailed information on HIV and ART, 96.7% had clinical stage 1 of HIV disease and 98.4% were on ART during pregnancy, mostly WHO-recommended efavirenz-based ART. Among 109 HIV-positive women with information on timing of ART initiation, 38 (34.9%) initiated ART preconception and 71 (65.1%) antenatally. No newborns were HIV positive. In univariable analysis, maternal HIV infection was associated with increased risk of the composite 'adverse perinatal outcome' [odds ratio (OR) 1.44; 95% confidence interval (CI) 1.03, 2.03], NND (OR 6.15; 95% CI 1.27, 29.88) and small for gestational age (OR 1.55; 95% CI 1.01, 2.37). After adjusting for confounders, maternal HIV infection remained associated with 'adverse perinatal outcome' (adjusted OR 1.47; 95% CI 1.01, 2.14) and NND (adjusted OR 7.82; 95% CI 1.32, 46.42). No associations with timing of ART initiation were observed. CONCLUSION Despite high ART coverage, good maternal health and very low vertical HIV transmission rate, maternal HIV infection remained associated with increased risk of adverse perinatal outcomes. Larger studies using first trimester ultrasound for pregnancy dating are needed to further assess associations with specific adverse perinatal outcomes.
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