Slower clearance of nevirapine resistant virus in infants failing extended nevirapine prophylaxis for prevention of mother-to-child HIV transmission

Nevirapine resistance mutations arise commonly following single or extended-dose nevirapine (ED-NVP) prophylaxis to prevent mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV), but decay within 6-12 months of single-dose exposure. Use of ED-NVP prophylaxis in infants is expected to rise, but data on decay of nevirapine resistance mutations in infants in whom ED-NVP failed remain limited. We assessed, in Ethiopian infants participating in the Six-Week Extended Nevirapine (SWEN) Trial, the prevalence and persistence of nevirapine resistance mutations at 6 and 12 months following single-dose or up to 6 weeks of ED-NVP, and correlated their presence with the timing of infection and the type of resistance mutations. Standard population genotyping followed by high-throughput cloning were done on dried blood spot samples collected during the trial. More infants who received ED-NVP had nevirapine resistance detected by standard population genotyping (high frequencies) at age 6 months compared with those who received single-dose nevirapine (SD-NVP) (58% of 24 vs. 26% of 19, respectively; p = 0.06). Moreover, 56% of ED-NVP-exposed infants with nevirapine resistance at age 6 months still had nevirapine resistance mutations present at high frequencies at age 1 year. Infants infected before 6 weeks of age who received either SD- or ED-NVP were more likely to have Y181C or K103N; these mutations were also more likely to persist at high frequencies through 1 year of age. HIV-infected infants in whom ED-NVP prophylaxis fails are likely to experience delayed clearance of nevirapine-resistant virus in the first year of life, which in turn places them at risk for early selection of multidrug-resistant HIV after initial therapy with nonnucleoside reverse transcriptase inhibitor-based regimens.

Extended-dose nevirapine to 6 weeks of age for infants to prevent HIV transmission via breastfeeding in Ethiopia, India, and Uganda: an analysis of three randomised controlled trials

BACKGROUND

UNICEF/WHO recommends that infants born to HIV-infected mothers who do not have access to acceptable, feasible, affordable, sustainable, and safe replacement feeding should be exclusively breastfed for at least 6 months. The aim of three trials in Ethiopia, India, and Uganda was to assess whether daily nevirapine given to breastfed infants through 6 weeks of age can decrease HIV transmission via breastfeeding.

METHODS

HIV-infected women breastfeeding their infants were eligible for participation. Participants were randomly assigned to receive either single-dose nevirapine (nevirapine 200 mg to women in labour and nevirapine 2 mg/kg to newborns after birth) or 6 week extended-dose nevirapine (nevirapine 200 mg to women in labour and nevirapine 2 mg/kg to newborn babies after birth plus nevirapine 5 mg daily from days 8-42 for the infant). The randomisation sequences were generated by computer at a central data coordinating centre. The primary endpoint was HIV infection at 6 months of age in infants who were HIV PCR negative at birth. Analyses were by modified intention to treat, excluding infants with missing specimens and those with indeterminate or confirmed HIV infection at birth. These studies are registered with ClinicalTrials.gov, numbers NCT00074399, NCT00061321, and NCT00639938.

FINDINGS

2024 liveborn infants randomised in the study had at least one specimen tested before 6 months of age (1047 infants in the single-dose group and 977 infants in the extended-dose group). The modified intention-to-treat population included 986 infants in the single-dose group and 901 in the extended-dose group. At 6 months, 87 children in the single-dose group and 62 in the extended-dose group were infected with HIV (relative risk 0.80, 95% CI 0.58-1.10; p=0.16). At 6 weeks of age, 54 children in the single-dose group and 25 in the extended-dose group were HIV positive (0.54, 0.34-0.85; p=0.009). 393 infants in the single-dose group and 346 in the extended-dose group experienced grade 3 or 4 serious adverse events during the study (p=0.54).

INTERPRETATION

Although a 6-week regimen of daily nevirapine might be associated with a reduction in the risk of HIV transmission at 6 weeks of age, the lack of a significant reduction in the primary endpoint-risk of HIV transmission at 6 months-suggests that a longer course of daily infant nevirapine to prevent HIV transmission via breast milk might be more effective where access to affordable and safe replacement feeding is not yet available and where the risks of replacement feeding are high.

FUNDING

US National Institutes of Health; US National Institute of Allergy and Infectious Diseases; Fogarty International Center.

Pseudo-Meig's syndrome: parasitic leiomyoma with ascites in a 52-year old lady

There is a possibility that a pedunculated subserous leiomyoma loses its vascular connection with the uterus and gets new blood vessel supply from other pelvic or nearby structure and continues its parasitic growth. A 52-year-old lady presented with abdominal distension of 12 years duration and laparotomy was done with preoperative diagnosis of possible malignant ovarian tumour. Intraoperative finding was very big non-specific but well demarcated and easily excisable mass located partly in the utero-vesical pouch with blood supply entirely from the greater omentum and anterior abdominal wall. There was about 3600 ml clear ascitic fluid in the paracolic gutters. The mass was sent for histo-pathologic examination and the report was compatible with leiomyoma of uterine origin. Patient's recovery was quiet dramatic and subsequent out patient follow-ups were uneventful. The presence of ascites of different amount doesn't necessarily signify malignancy of any visceral primary or secondary origin. Therefore, benign tumours of ovarian or uterine origin should be included in the differential diagnosis of pelvic or abdominal mass with ascites to come up with scientifically sound deduction and intervention that may bring about remarkable impact on ameliorating mortality and morbidity.

Obstetric outcome of teenage pregnancy in northwestern Ethiopia

OBJECTIVE

To investigate and compare the difference in pregnancy outcome in teenage pregnancies and pregnancy in an older age group.

DESIGN

A cross sectional observational study.

SETTING

Department of Obstetrics and Gynaecology, Gondar College of Medical Sciences (GCMS) Hospital.

SUBJECTS

All teenage pregnant women and older pregnant women who delivered in the hospital over one year period were evaluated.

MAIN OUTCOME MEASURES

Antenatal care (ANC) attendance, pregnancy induced hypertension, cephalo-pelvic-disproportion (CPD), low birthweight (LBW), prolonged labour, preterm delivery, assisted delivery, stillbirth and low Apgar score.

RESULTS

Mean age of teenagers and older age group was 17.6 +/- 1 and 28.6 +/- 5.7 years, respectively. Statistically significant difference (p < 0.05) was observed in the following variables when teenagers were compared to the older age group: ANC attendance 60.9% versus 74.8%; weight less than 50 kg. 40% versus 18.9%; height less than 150 cms 21.2% versus 7.3%; CPD 11.8% versus 2.1%; prolonged labour 9.2% versus 5.6%; delayed second stage 18.3% versus 4.4%; preterm delivery 21.8% versus 11.3%; assisted delivery 21.8% versus 9.3% and LBW 27% versus 10%. No significant difference was observed in the mean Apgar score and stillbirth rate in the two groups.

CONCLUSION

Teenage pregnancy is associated with adverse outcome; and teenagers perform poorly in labour and delivery. We recommend the initiation of a programme which should create a means of easily reaching the adolescent to promote family life education, contraception, counselling and education related to early marriage.