Trends in a Cohort of HIV-infected pregnant women in Rio de Janeiro, 1996-2004

HIV-1 Diversity and Drug Resistance in Treatment-Naïve Children and Adolescents from Rio de Janeiro, Brazil

The human immunodeficiency virus type 1 (HIV-1) can be transmitted via parenteral, sexual, or vertical exposure routes. The number of HIV-1 cases detected yearly in children and adolescents in Brazil did not decrease over the last decade, representing ~5% of total cases described in the country. In recent years, the HIV-1 diversity and the prevalence of transmitted drug resistance mutations (TDRM) are moving toward a marked increase. In this study, we retrospectively evaluated the diversity of HIV-1 subtypes and the TDRM prevalence in 135 treatment-naïve HIV-1 vertically infected children and adolescents born in between 1993 and 2012. These children were assessed in either 2001–2007 or 2008–2012 when they were 0 to 17 years old. The individuals assessed in 2001–2007 (n = 38) had median CD4+ T cell counts of 1218 cells/mm³ (IQR: 738–2.084) and median HIV-1 plasma viral load of 4.18 log10 copies/mL (IQR: 3.88–4.08). The individuals (n = 97) evaluated in 2008–2012 showed median CD4+ T cell counts of 898.5 cells/mm³ (IQR: 591.3–1.821) and median HIV-1 plasma viral load of 4.69 log10 copies/mL (IQR: 4.26–5.33). A steady decrease in the median CD4 T+ cell counts was observed with age progression, as expected. The majority HIV-1 pol sequences (87%) were classified as pure HIV-1 subtypes (77% subtype B, 9% subtype F1 and 1.5% subtype C), while 13% of sequences were classified as recombinants (CRF45_cpx, n = 4; CRF28/29_BF1, n = 2; CRF02_AG, n = 1; CRF40_BF1, n = 1, CRF99_BF1, n = 1, URF_BF1, n = 8). The overall prevalence of TDRM was 14% (19/135), conferring resistance to the nucleoside reverse transcriptase inhibitors (NRTI, 13/135–9.6%), non-nucleoside reverse transcriptase inhibitors (NNRTI, 8/135–5.9%), and protease inhibitors (PI, 2/135–1.5%). The main TDRM observed for NNRTI was the K103N (n = 8), while the mutations T215I/Y/D/E (n = 7) and M184V (n = 4) were the main TDRM for NRTI. Only two TDRM were observed for PI in one individual each (M46I and V82A). Most TDRM were found in the HIV-1 subtype B (84%) sequences. This study reveals an HIV-1 epidemic with high diversity and moderate prevalence of TDRM in the pediatric population of Rio de Janeiro, indicating the existence of possible problems in the clinical management of prophylactic therapy to prevent mother-to-child transmission and future treatment options for the affected children.

Efficacy of Three Antiretroviral Regimens Initiated during Pregnancy: Clinical Experience in Rio de Janeiro

Few studies have compared the clinical efficacy and adverse events of combined antiretroviral therapy (cART) regimens in pregnant women seeking obstetrical care. The objective of this study was to compare the efficacy (virus load response), adverse events, and obstetrical and neonatal outcomes of three different regimens of cART in HIV-infected pregnant women initiating treatment in Rio de Janeiro, Brazil. This was a retrospective cohort study of cART-naive pregnant women who initiated either ritonavir-boosted protease inhibitors (atazanavir or lopinavir), efavirenz, or raltegravir plus a backbone regimen. From 2014 to 2018, 390 pregnant women were followed over time. At baseline, the median viral load (VL) for HIV was 4.1 log copies/ml. Among participants who received cART for 2 to 7 weeks, the VL decline was greater for raltegravir (2.24 log copies/ml) than for efavirenz or protease inhibitors (P < 0.001). Virologic suppression was achieved in 87% of women on raltegravir near delivery versus 73% on efavirenz and 70% on protease inhibitors (P = 0.011). Patients on raltegravir achieved virologic suppression faster than those on other regimens (P = 0.019). Overall, the HIV perinatal infection rate was 1.5%. This clinical study compared three potent and well-tolerated cART regimens and demonstrated that a higher proportion of participants on raltegravir achieved an undetectable HIV VL near delivery (P = 0.011) compared to the other arms. These findings suggest that raltegravir-containing regimens are optimal regimens for women with HIV initiating treatment late in pregnancy.

Mother to child transmission of HIV in Brazil: Data from the "Birth in Brazil study", a national hospital-based study

AIMS

to estimate the mother to child transmission (MTCT) of HIV among infected pregnant women identified in the "Birth in Brazil" study and to evaluate care practices provided in order to identify missed opportunities at preventing the MTCT of HIV infection in the country.

METHODS

Descriptive study using data obtained from the consultation of different databases: the "Birth in Brazil" study database and the Brazilian National Information Systems (NIS) databases. We used cases of pregnant women infected with HIV identified in the "Birth in Brazil" study, and cases of AIDS in children under 5 years old identified in the NIS, to estimate the MTCT of HIV infection in the country, with a 95% confidence interval. We also estimated the HIV cascade (HIV diagnosis; use of antiretroviral treatment (ART) during pregnancy, labour, and for the newborn; adequate care during childbirth considering viral load at birth; and no breastfeeding) using data from the same sources.

RESULTS

MTCT of HIV of 2.0% (95% CI 0.3%-13.8%). At birth, 84.0% of HIV infected woman showed a positive HIV diagnosis, 74.9% received combined ART during pregnancy, 80.7% received ART during childbirth, 77.1% received adequate care during childbirth, 86.8% of newborns received ART within the first 24 hours after birth, and 2.8% of newborns were breastfed. Considering all steps, 61.3% of the women (95% CI 48.3%-72.8%) received all available medical interventions. In the analysis restricted to women identified in the NIS, 65.3% (95% CI 48.0%-79.3%) of HIV infected women received all available medical interventions.

CONCLUSION

Brazil has healthcare policies that guarantee free access to tests, ART and substitutes for maternal milk. However, missed opportunities to prevent MTCT of HIV were identified in at least one-third of women and may be making it difficult to reach HIV-elimination targets especially in the less developed country regions.

Accuracy of a rapid real-time polymerase chain reaction assay for diagnosis of group B Streptococcus colonization in a cohort of HIV-infected pregnant women

OBJECTIVE

There are limited data regarding Xpert performance to detect Group B Streptococcus (GBS) in HIV-infected pregnant women. We evaluated the accuracy of a rapid real-time polymerase chain reaction (PCR) test in a cohort of HIV-infected women.

METHODS

At 35-37 weeks of pregnancy, a pair of combined rectovaginal swabs were collected for two GBS assays in a cohort of sequentially included HIV-infected women in Rio de Janeiro: (1) culture; and (2) real-time PCR assay [GeneXpert GBS (Cepheid, Sunnyvale, CA)]. Using culture as the reference, sensitivity, specificity, positive and negative-likelihood ratios were estimated.

RESULTS

From June 2012 to February 2015, 337 pregnant women met inclusion criteria. One woman was later excluded, due to failure to obtain a result in the index test; 336 were included in the analyses. The GBS colonization rate was 19.04%. Sensitivity and specificity of the GeneXpert GBS assay were 85.94% (95% CI: 75.38-92.42) and 94.85% (95% CI: 91.55-96.91), respectively. Positive and negative predictive values were 79.71% (95% CI: 68.78-87.51) and 96.63% (95% CI: 93.72-98.22), respectively.

CONCLUSIONS

GeneXpert GBS is an acceptable test for the identification of GBS colonization in HIV-infected pregnant women and represents a reasonable option to detect GBS colonization in settings where culture is not feasible.

Prenatal testing and prevalence of HIV infection during pregnancy: data from the "Birth in Brazil" study, a national hospital-based study

BACKGROUND

The rate of vertical HIV transmission has decreased in Brazil, but regional inequalities suggest problems in implementing control measures during pregnancy and delivery. The aims of this study were to ascertain the coverage of HIV testing during prenatal care and estimate the prevalence of HIV infection during pregnancy in Brazil.

METHODS

This was a national hospital-based study of 23,894 women that was conducted in 2011-2012. The data came from interviews with mothers during postpartum hospitalization, from hospital medical files and from prenatal cards. All the pregnant women with reactive serological results for HIV infection marked on their cards or with diagnoses of HIV infection during the hospital stay for delivery were considered cases of HIV infection. Univariate and multivariable logistic regression were performed to investigate factors associated with the prevalence of HIV infection and with performing at least one HIV test during pregnancy.

RESULTS

Among participating women, the coverage of testing for HIV infection was 81.7% among those who presented with prenatal card and the prevalence of HIV infection among pregnant women was 0.4% (95% CI: 0.32-0.51%). In the adjusted analysis, there was higher coverage of testing among women living in the South and Southeast regions; of women aged 35 years and over; with greater schooling levels; who self-reported as white; with prenatal care provided in private services; with an early start to prenatal care; and with an adequate number of consultations, defined as a minimum of six for a term pregnancy. In the adjusted analyses there was a greater odds ratio of HIV infection among women living in the South region, aged 35 years and over, with schooling of less than 8 years, who self-reported race as black, without a partner, with syphilis coinfection and who were attended by public services.

CONCLUSIONS

The prevalence of HIV infection among pregnant women in Brazil remains below 1% and the coverage of testing for HIV infection is over 80%. However, the regional and social inequalities in access to healthcare services and the missed opportunities for diagnoses of HIV infection indicate the importance of strengthening HIV infection control programs during pregnancy.

Transmissão vertical do HIV em população atendida no serviço de referência

OBJETIVO: Identificar a taxa de transmissão vertical do HIV e avaliar os fatores envolvidos em partes materna e fetal. MÉTODOS: Estudo transversal realizado no Serviço de Atendimento Especializado. Foram investigados 102 prontuários de mulheres com HIV que deram à luz a recém-nascidos vivos. RESULTADOS: A prevalência de 6,6% de transmissão vertical. Entre as crianças infectadas: 40,0% de mães sem pré-natal e 75% sem a profilaxia com anti-retrovirais durante o pré-natal, 50,0% sem profilaxia com AZT com oral e amamentado. Entre as crianças não infectadas: 91,5% iniciaram a profilaxia com AZT oral ao nascimento e 84,1% das mães receberam ARV. CONCLUSÃO: A ocorrência de transmissão vertical do HIV no serviço de referência correspondeu a 6,6%, o que indica uma alta prevalência.

Transmissão vertical do HIV, da sífilis e da hepatite B no município de maior incidência de AIDS no Brasil: um estudo populacional no período de 2002 a 2007

OBJETIVO: O objetivo deste trabalho foi verificar a prevalência em gestantes e a taxa de transmissão vertical do HIV, sífilis e hepatite B no município de Itajaí - SC, no período de 2002 a 2007. MÉTODOS: Este foi um estudo longitudinal retrospectivo, de base populacional, compreendendo os períodos de 2002 a 2007 para HIV e 2004 a 2007 para sífilis e hepatite B, utilizando os dados sistematizados dos sistemas de informação estadual e municipal. RESULTADOS: A prevalência das infecções virais em gestantes foi de 1,7% para HIV, 0,41% para hepatite B aguda, 0,46% para hepatite B crônica e 0,43% para sífilis. A transmissão vertical do HIV foi de 6,28%, sendo menor que 5% quando HIV foi diagnosticado antes ou durante a gravidez, comparado com 20% e 55% quando o diagnóstico foi feito durante ou após o parto. A transmissão vertical da sífilis foi de 68,89%. Não houve uma tendência estatisticamente significativa da transmissão vertical segundo ano de diagnóstico ou faixa etária para HIV e sífilis. Quase 44% das gestantes infectadas por HIV conheciam seu status sorológico antes da gravidez; a transmissão vertical neste grupo ficou menor que 5%. Não foi registrado nenhum caso da transmissão vertical da hepatite B. CONCLUSÕES: A transmissão vertical do HIV atingiu a meta do Ministério da Saúde quando o diagnóstico foi feito durante o pré-natal, mas foi expressivamente elevada quando o diagnóstico ocorreu somente no parto. A transmissão vertical da sífilis foi muito maior do que a preconizada, mostrando a importância de se reforçar os procedimentos estabelecidos para diminuí-la.

Infant outcomes after maternal antiretroviral exposure in resource-limited settings

BACKGROUND AND OBJECTIVE

The impact of maternal antiretrovirals (ARVs) during pregnancy, labor, and postpartum on infant outcomes is unclear.

METHODS

Infants born to HIV-infected mothers in ARV studies were followed for 18 months.

RESULTS

Between June 2006 and December 2008, 236 infants enrolled from Africa (n = 36), India (n = 47), Thailand (n = 152), and Brazil (n = 1). Exposure to ARVs in pregnancy included ≥ 3 ARVs (10%), zidovudine/intrapartum ARV (81%), and intrapartum ARV (9%). There were 4 infant infections (1 in utero, 3 late postpartum) and 4 deaths with 1.8% mortality (95% confidence interval [CI], 0.1%-3.5%) and 96.4% HIV-1-free survival (95% CI, 94.0%-98.9%). Birth weight was ≥ 2.5 kg in 86%. In the first 6 months, Indian infants (nonbreastfed) had lowest median weights and lengths and smallest increases in growth. After 6 months, African infants had the lowest median weight and weight-for-age z scores. Infants exposed to highest maternal viral load had the lowest height and height-for-age z scores. Serious adverse events occurred in 38% of infants, did not differ by country, and correlated with less maternal ARV exposure. Clinical diagnoses were seen in 84% of Thai, 31% of African, and 9% of Indian infants. Congenital defects/inborn errors of metabolism were seen in 18 (7.6%) infants, of which 17 were Thai (11%: 95% CI, 6.7%-17.0%); none had first trimester ARV exposure.

CONCLUSIONS

Infant follow-up in large international cohorts is feasible and provides important safety and HIV transmission data following maternal ARV exposure. Increased surveillance increases identification of congenital/inborn errors.

Pregnancy in HIV vertically infected adolescents and young women: a new generation of HIV-exposed infants

BACKGROUND

Vertically infected individuals are reaching childbearing age and the new generation of HIV-exposed infants is coming to pediatric care.

METHODS

Chart review of pregnancies among HIV vertically infected adolescents and young women.

RESULTS

Fifteen pregnancies were reviewed. Girls had HIV diagnosis at median age 10.1 years (range 1.3-20). They started sexual life at median age 15 years (range 13-19); median age at pregnancy was 16.9 years (range 14-21.5); 36.4% had presented an AIDS-defining clinical event; have been followed for median 8.5 years (range 2.9-15.8) and had used median two antiretroviral regimens (range 0-7). Fourteen (93.3%) received antiretroviral drugs during pregnancy; median CD4 cell count during pregnancy was 394 (range 117-651) cells/μl and median viral load was 4800 copies/ml (range 50-100 000); 54% had undetectable viral load near delivery. All patients delivered by elective c-section. Median birth weight was 2650 g (range 2085-3595), median length was 47.3 cm (range 42-51) and median gestational age 38 weeks (range 37-39). All newborn received zidovudine for 6 weeks of life and none was breastfed. Fourteen (93%) infants were considered HIV-uninfected; one was lost to follow-up.

CONCLUSIONS

This group of adolescents seems to have sexual behavior similar to that of HIV-uninfected. Since this is an experimented antiretroviral population, new drugs may be necessary for adequate viral suppression to avoid HIV mother-to-child transmission. Follow-up of this third generation of HIV-exposed infants needs to be addressed within HIV adolescent care.

Maternal antiretroviral use during pregnancy and infant congenital anomalies: the NISDI perinatal study

BACKGROUND

We evaluated the association between maternal antiretrovirals (ARVs) during pregnancy and infant congenital anomalies (CAs), utilizing data from the National Institute of Child Health and Human Development International Site Development Initiative Perinatal Study.

METHODS

The study population consisted of first singleton pregnancies on study, > or =20 weeks gestation, among women enrolled in NISDI from Argentina and Brazil who delivered between September 2002 and October 2007. CAs were defined as any major structural or chromosomal abnormality, or a cluster of 2 or more minor abnormalities, according to the conventions of the Antiretroviral Pregnancy Registry. CAs were identified from fetal ultrasound, study visit, and death reports. Prevalence rates [number of CAs per 100 live births (LBs)] were calculated for specific ARVs, classes of ARVs, and overall exposure to ARVs.

RESULTS

Of 1229 women enrolled, 995 pregnancy outcomes (974 LBs) met the inclusion criteria. Of these, 60 infants (59 LBs and 1 stillbirth) had at least 1 CA. The overall prevalence of CAs (per 100 LBs) was 6.2 [95% confidence interval (CI) 4.6 to 7.7]. The prevalence of CAs after first trimester ARVs (6.2; 95% CI 3.1 to 9.3) was similar to that after second (6.8; 95% CI 4.5 to 9.0) or third trimester (4.3; 95% CI 1.5 to 7.2) exposure. The rate of CAs identified within 7 days of delivery was 2.36 (95% CI 1.4 to 3.3).

CONCLUSIONS

The prevalence of CAs after first trimester exposure to ARVs was similar to that after second or third trimester exposure. Continued surveillance for CAs among children exposed to ARVs during gestation is needed.

Increased infant human immunodeficiency virus-type one free survival at one year of age in sub-saharan Africa with maternal use of highly active antiretroviral therapy during breast-feeding

BACKGROUND

Reduction of HIV-1 breast-feeding transmission remains a challenge for prevention of pediatric infections in Sub-Saharan Africa. Provision of formula decreases transmission but often increases child mortality in this setting.

METHODS

A prospective observational cohort study of HIV-1 exposed infants of mothers receiving pre and postnatal medical care at Drug Resource Enhancement Against AIDS and Malnutrition centers in Mozambique was conducted. Live-born infants of HIV-1-infected women receiving medical care were enrolled. HIV-1 testing was performed at 1, 6, and 12 months of age using branched DNA. Mothers were counseled to breast-feed exclusively for 6 months and were provided HAART antenatally and postnatally for the first 6 months. Women with CD4 cell counts less than 350/cmm at baseline continued HAART indefinitely.

RESULTS

Of 341 infants followed from birth, 313 mother-infant pairs (92%) completed 6 months and 283 (83%) completed 12 months of follow-up. HIV-1 diagnosis was ascertained in 287 infants (84%) including 4 who died. There were 8 cases of HIV-1 transmission: 4 of 341 (1.2%) at 1 month, 2 of 313 (0.6%) at 6 months, and 2 of 276 (0.7%) at 12 months (cumulative rate: 2.8%). Two mothers (0.6%) and 11 infants (3.2%) died. Maternal and infant mortality rates were 587 of 100,000 and 33 of 1000, while country rates are 1000 of 100,000 and 101 of 1000. HIV risk reduction was 93% and HIV-free survival at 12 months was 94%.

CONCLUSIONS

Late postnatal transmission of HIV-1 is significantly decreased by maternal use of HAART with high infant survival rates up to 12 months of age.