Angiogenesis, Lymphangiogenesis, and the Immune Response in South African Preeclamptic Women Receiving HAART

Persistent hypertension among postpartum women with comorbid HIV and preeclampsia in Zambia

BACKGROUND

Persistent hypertension is common after preeclampsia and is causally tied to later cardiovascular risks. This study examined whether being HIV-infected and on antiretroviral therapy (ART) is associated with persistent postpartum hypertension among women diagnosed with preeclampsia.

METHODS

We conducted a six-month prospective cohort study at Kanyama and Women and Newborn hospitals from January 01, 2022, to June 30, 2023, among 190 women diagnosed with preeclampsia (59 HIV-positive, 131 HIV-negative). Sociodemographic and clinical characteristics were collected at delivery, six weeks, three months and six months after giving birth. Persistent hypertension was diagnosed if a participant presented with elevated blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg and/or taking medication for hypertension at the study visit. We used a generalized estimating equation to describe the relationship between treated HIV and persistent hypertension six months following delivery.

RESULTS

We retained 136 participants (71.6%) to six months postpartum, at a median age of 30 years. Overall, persistent hypertension at six weeks, three months, and six months postpartum was common (37.4%, 17.1% and 16.9%, respectively). Six-week postpartum prevalence was higher in the HIV group than HIV-negative group (54.6% vs 28.8%, p<0.001), with no measurable difference at three months (24.3% vs 13.2%, p = 0.145) or six months (18.2% vs 16.3%, p = 0.787). Multivariable analysis demonstrates higher odds (adjusted odds ratio [aOR] = 1.68, 95% CI: 1.09-2.60) of persistent hypertension among the HIV+treatment group than HIV-negative counterparts after accounting for age, body mass index and time since delivery.

CONCLUSION

We demonstrate an elevated risk of persistent hypertension among postpartum women with comorbid preeclampsia and treated HIV. Peripartum patients in HIV-endemic settings may benefit from timely detection of hypertension and treatment interventions to improve health outcomes.

Differential expression of the angiotensin receptors (AT1, AT2, and AT4) in the placental bed of HIV-infected preeclamptic women of African ancestry

The Renin-Angiotensin-Aldosterone System (RAAS) is implicated in the pathophysiology of preeclampsia (PE). There is a paucity of data on uteroplacental angiotensin receptors AT1-2 and 4. We evaluated the immunoexpression of AT1R, AT2R, and AT4R within the placental bed of PE vs. normotensive (N) pregnancies stratified by HIV status. Placental bed (PB) biopsies (n = 180) were obtained from N and PE women. Both groups were stratified by HIV status and gestational age into early-and late onset-PE. Immuno-labeling of AT1R, AT2R, and AT4R was quantified using morphometric image analysis. Immunostaining of PB endothelial cells (EC) and smooth muscle cells of spiral arteries (VSMC) displayed an upregulation of AT1R expression compared to the N group (p < 0.0001). Downregulation of AT2R and AT4R expression was observed in PE vs. N group (p = 0.0042 and p < 0.0001), respectively. AT2R immunoexpression declined between HIV+ve and HIV-ve groups, while AT1R and AT4R displayed an increase. An increase in AT1R expression was noted in the EOPE-ve/+ve and LOPE-ve/+ve compared to N-ve/N+ve. In contrast, AT2R and AT4R expression decreased in EOPE-ve/+ve and LOPE-ve/+ve compared to N-ve/N+ve. We demonstrate a significant downregulation of AT2R and AT4R with a concomitant elevated AT1R immunoexpression within PB of HIV-infected PE women. In addition, a decline in AT2R and AT4R with an increase in AT1R immunoexpression in PE, EOPE, and LOPE vs. normotensive pregnancies, irrespective of HIV status. Thus highlighting differential immunoexpression of uteroplacental RAAS receptors based on pregnancy type, HIV status, and gestational age.

A Systematic Review on Cardiometabolic Risks and Perinatal Outcomes among Pregnant Women Living with HIV in the Era of Antiretroviral Therapy

Antiretroviral therapy (ART) regimens have been shown to cause metabolic changes in people living with HIV (PLWH), predisposing them to cardiometabolic disease (CVMD). However, such evidence is less established in pregnant women living with HIV (pWLWH) on ART. Pregnancy-induced cardiometabolic risks (CMR) can predispose to unfavourable pregnancy outcomes and further persist in the postpartum period, resolve, and recur in subsequent pregnancies, or emerge as newly diagnosed chronic diseases of ageing. Therefore, this systematic review aimed at synthesizing evidence on CMR and perinatal outcomes among pWLWH in the era of ART. We considered prospective and retrospective cohorts, case-control, cross-sectional, and interventional studies published in English. Specific keywords were used to conduct a thorough literature search on PubMed-Medline and Scopus following the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline. Two investigators independently screened the search outputs and reviewed full texts of potentially eligible articles. Data extraction was conducted by one investigator and verified by the second investigator. Thirty-one relevant studies conducted on 20,904 pWLWH on ART across Africa, Asia, Europe, and America were included. Studies demonstrate inconclusive findings, especially on perinatal outcomes, but significant risks of gestational hypertension and dyslipidemia were reported in pWLWH on ART compared to the control group. Therefore, future studies should focus more on these perinatal outcomes, and their impact on postpartum maternal health and growth trajectories of uninfected infants born from pWLWH who are either on ART or ART-naïve in comparison to infants born of HIV-negative mothers over the life course, especially in HIV-burdened African countries.

Assessment of the Cardiovascular Risk Profile of Infants Exposed to Pre-eclampsia in-utero: A Prospective Case-Control Study in South African Children of African Ancestry

Background: It has been reported that maternal gestational environment may be programmed to have a significant impact on foetal and offspring health later in life. Studies have shown that children born to pre-eclamptic mothers are prone to obesity, hypertension, and diabetes in their adult life. However, such findings are yet to be established in an African population. This protocol is for a study aiming to investigate the relationship between pre-eclampsia (PE) and cardiovascular risk in children born to pre-eclamptic mothers in a South African population of African descents.

Methods: A prospective case-control design will be employed to recruit pre-eclamptic and normotensive pregnant women and their offspring after birth. Pregnant women will be assessed for cardiovascular risk factors including PE, obesity, haemodynamics, lipids, glycaemic indices, oxidative stress, and vascular function at 30 weeks of gestation. The cardiovascular risk profile of their offspring will be assessed at birth and 6 weeks later. The difference in cardiovascular risk profile between children born to the pre-eclamptic and normotensive mothers will be compared and the correlation between maternal and offspring cardiovascular risks will be investigated.

Discussion: This will be the first prospective study to assess the in-utero effect of cardiovascular risk in offspring born to pre-eclamptic women of African ancestry. It is expected that findings from this study will provide information on the cardiovascular effect of in-utero exposure to PE in a population of African ancestry. This knowledge will advise policy on the management of women with PE with a view of protecting cardiovascular health in offspring.

Assessment of the impact of HIV infection and anti-retroviral treatment on the cardiometabolic health of pregnant mothers and their offspring (ARTMOMSBABES)

BACKGROUND

The risk of cardiovascular diseases (CVDs) is becoming more prevalent in pregnant women though not much data is available for pregnant women with human immunodeficiency virus (HIV). Foetoplacental vascular endothelial dysfunction is thought to be at the origin of chronic diseases such as diabetes and obesity later on in life. Because HIV and anti-retroviral treatment (ARTs) are associated with endothelial dysfunction, children exposed in utero to these conditions may be at greater risk of developing CVDs. Despite the high prevalence of HIV in pregnant South African women, little is known about the effects of ART on the cardiovascular health of the mother and offspring. Hence, the proposed study intends to investigate how HIV/ARTs may affect the cardiovascular health of the mother and offspring at different time points during the pregnancy and up to 2 years after birth.

METHODS

A longitudinal case-control study in HIV positive pregnant women on ART and HIV negative pregnant women will be conducted. All pregnant women will be assessed for cardio-metabolic risk factors and markers (lipids, anthropometric and glycaemic indies, oxidative stress), hemodynamic status (blood pressure parameters) and vascular function (arterial compliance, retinal microvasculature, uterine artery mean pulsatility index). Child health will be monitored in utero and postnatally via routine foetal health screening, placental integrity, anthropometry, blood pressure parameters, markers of oxidative stress and endothelial function in cord blood and cardiovascular epigenetic markers in urine.

DISCUSSION

There is a paucity of studies in South Africa and sub-Sahara Africa as a whole that utilised a longitudinal study model to assess the effects of ARTs on vascular endothelial changes in pregnant women living with HIV and the cardiometabolic health of their offspring. This study will therefore help to monitor changes in cardiometabolic risk during pregnancy and in children exposed in utero to HIV-infection and ART use. Findings from this study will provide useful information for developing guidelines on the use of ARTs in pregnancy and management of cardiometabolic health of the offspring of HIV positive mothers.

The role of Tenascin-C in HIV associated pre-eclampsia

INTRODUCTION

Pre-eclampsia (PE) accounts for 14.8% of maternal deaths in South Africa. Tenascin C (TN-C) is an anti-inflammatory cytokine expressed in the extracellular matrix and may be dysregulated in the hyperinflammatory PE microenvironment.

MATERIAL AND METHODS

This study examined serum TN-C in normotensive pregnant (n = 36) and pre-eclamptic (n = 36) HIV positive and negative women using an immunoassay.

RESULTS

TN-C was significantly upregulated in PE vs normotensive pregnant women (p = 0.0075) and HIV-positive vs negative pregnant women (p = 0.0009). TN-C levels across all groups was statistically different (p < 0.0001).

CONCLUSION

This study demonstrates an elevation of TN-C in HIV-associated PE. The potential benefit of TN-C as a biomarker to detect PE development requires investigation.

The function of adipsin and C9 protein in the complement system in HIV-associated preeclampsia

OBJECTIVE

In preeclampsia, there are excessive complement components expressed due to increased complement activation; therefore, this study investigated the concentration of adipsin and C9 in HIV-associated preeclampsia.

METHOD

The study population (n = 76) was stratified by pregnancy type (normotensive pregnant and preeclampsia) and by HIV status. Serum was assayed for the concentration of adipsin and C9 using a Bioplex immunoassay procedure.

RESULTS

Maternal weight did not differ (p = 0.1196) across the study groups. The concentration of adipsin was statistically different between the PE vs normotensive pregnant groups, irrespective of HIV status (p = 0.0439). There was no significant difference in adipsin concentration between HIV-negative vs HIV-positive groups, irrespective of pregnancy type (p = 0.6290). Additionally, there was a significant difference in adipsin concentration between HIV-negative normotensive vs HIV-negative preeclampsia (p < 0.05), as well as a difference between HIV-negative preeclampsia vs HIV-positive preeclampsia (p < 0.05). C9 protein expression was not statistically different between the normotensive and PE groups, regardless of HIV status (p = 0.5365). No statistical significance in C9 expression was found between HIV-positive vs HIV-negative groups, regardless of pregnancy type (p = 0.3166). Similarly, no statistical significance was noted across all study groups (p = 0.0774).

CONCLUSION

This study demonstrates that there is a strong correlation between the up-regulation of adipsin and PE and that adipsin is a promising biomarker to use as a diagnostic tool for PE.

Maternal endothelial dysfunction in HIV-associated preeclampsia comorbid with COVID-19: a review

This review assesses markers of endothelial dysfunction (ED) associated with the maternal syndrome of preeclampsia (PE). We evaluate the role of antiretroviral therapy (ART) in human immunodeficiency virus (HIV)-infected preeclamptic women. Furthermore, we briefly discuss the potential of lopinavir/ritonavir (LPV/r), dolutegravir (DTG) and remdesivir (RDV) in drug repurposing and their safety in pregnancy complicated by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In HIV infection, the trans-activator of transcription protein, which has homology with vascular endothelial growth factor, impairs angiogenesis, leading to endothelial injury and possible PE development despite neutralization of their opposing immune states. Markers of ED show strong evidence supporting the adverse role of ART in PE development and mortality compared to treatment-naïve pregnancies. Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2 infection, exploits angiotensin-converting enzyme 2 (ACE 2) to induce ED and hypertension, thereby mimicking angiotensin II-mediated PE in severe cases of infection. Upregulated ACE 2 in pregnancy is a possible risk factor for SARS-CoV-2 infection and subsequent PE development. The potential effectiveness of LPV/r against COVID-19 is inconclusive; however, defective decidualization, along with elevated markers of ED, was observed. Therefore, the safety of these drugs in HIV-positive pregnancies complicated by COVID-19 requires attention. Despite the observed endothelial protective properties of DTG, there is a lack of evidence of its effects on pregnancy and COVID-19 therapeutics. Understanding RDV-ART interactions and the inclusion of pregnant women in antiviral drug repurposing trials is essential. This review provides a platform for further research on PE in the HIV-COVID-19 syndemic.

The Role of Highly Active Antiretroviral Therapy (HAART) on Interleukin 17A (IL-17A) in Normotensive and Preeclamptic Black South African Women

Introduction

Interleukin 17A has been implicated in the pathophysiology of both human immune deficiency virus and preeclampsia. This study evaluated serum levels of IL-17A based on pregnancy type, gestational age, HIV status, and duration of HAART. Material and Methods. A sample size of 250 was analysed: normotensives (n = 150; N) and preeclamptics (n = 100; PE). Normotensives were further stratified into HIV negative (n = 90), HAART-acute (n = 30), and HAART-chronic (n = 30). The PE group was divided into early onset (n = 50; EOPE) and late onset (n = 50; LOPE). The EOPE and LOPE groups were subdivided into HIV negative (n = 30), HAART-acute (n = 10), and HAART-chronic (n = 10). Analysis of IL-17A was performed using a multiple Bio-Plex immunoassay method.

Results

Pregnancy type: the levels of IL-17A were increased in PE compared to N (P = 0.0014). Gestational age: the levels of IL-17A were increased in EOPE compared to N group (P = 0.0113). A significant increase in the levels of IL-17A in LOPE compared to N was observed (P = 0.0063). HIV status: the levels of IL-17A were increased in PE compared to N (P = 0.0114) and in EOPE compared to N groups (P = 0.0071). HAART duration: the concentration of IL-17A was increased in HAART-chronic PE compared to N groups (P = 0.0062). There was also an increase in the levels of IL-17A in EOPE compared to N (P = 0.0029).

Conclusion

The study demonstrates that IL-17A is involved in the pathophysiology of PE and that in the presence of HIV infection, chronic HAART administration predisposes women to the development of EOPE.