Perinatal outcomes associated with combination antiretroviral therapy compared with monotherapy

Portwood, Clara; Sexton, Harriet; Kumarendran, Mary; Brandon, Zoe; Johnson, Bradley; Kirtley, Shona; Hemelaar, Joris

doi:10.1097/qad.0000000000003432

Cited by 2 publications

(2 citation statements)

References 58 publications

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“…Recent metanalyses and systemic review of Sub-Saharan African cohorts and RCT data have shown that preconception and antenatal triple ART are associated with PTB, low birth weight and small for gestational age babies in women living with HIV compared to those receiving ZDVm and to uninfected women [ 59 ]. It is possible that the continued association of triple ART with adverse birth outcomes may be drug specific, with another large meta-analyses from the same group demonstrating that compared with ZDVm, non-nucleoside reverse transcriptase inhibitor-based triple ART was associated with an increased risk of PTB, LBW, and stillbirth, and PI-based triple ART with PTB [ 60 ]. Increasing safety data for ART in pregnancy has resulted in more ART choices for pregnant women including Integrase Stand Transfer Inhibitors, with Dolutegravir now a preferred third drug in many international pregnancy guidelines due to its efficacy, reassuring safety profile and fewer drug interactions [ 28 , 61 , 62 ].…”

Section: Discussionmentioning

confidence: 99%

Pregnancy Management in HIV Viral Controllers: Twenty Years of Experience

Short,

Byrne,

Hagan-Bezgin

et al. 2024

Pathogens

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(1) Background: The evidence base for the management of spontaneous viral controllers in pregnancy is lacking. We describe the management outcomes of pregnancies in a series of UK women with spontaneous HIV viral control (<100 copies/mL 2 occasions before or after pregnancy off ART). (2) Methods: A multi-centre, retrospective case series (1999–2021) comparing pre- and post-2012 when guidelines departed from zidovudine-monotherapy (ZDVm) as a first-line option. Demographic, virologic, obstetric and neonatal information were anonymised, collated and analysed in SPSS. (3) Results: A total of 49 live births were recorded in 29 women, 35 pre-2012 and 14 post. HIV infection was more commonly diagnosed in first reported pregnancy pre-2012 (15/35) compared to post (2/14), p = 0.10. Pre-2012 pregnancies were predominantly managed with ZDVm (28/35) with pre-labour caesarean section (PLCS) (24/35). Post-2012 4/14 received ZDVm and 10/14 triple ART, p = 0.002. Post-2012 mode of delivery was varied (5 vaginal, 6 PLCS and 3 emergency CS). No intrapartum ZDV infusions were given post-2012 compared to 11/35 deliveries pre-2012. During pregnancy, HIV was detected (> 50 copies/mL) in 14/49 pregnancies (29%) (median 92, range 51–6084). Neonatal ZDV post-exposure prophylaxis was recorded for 45/49 infants. No transmissions were reported. (4) Conclusion: UK practice has been influenced by the change in guidelines, but this has had little impact on CS rates.

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Section: Discussionmentioning

confidence: 99%

Pregnancy Management in HIV Viral Controllers: Twenty Years of Experience

Short,

Byrne,

Hagan-Bezgin

et al. 2024

Pathogens

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“…This finding is supported by the largest numbers of studies and WLHIV in our analyses, compared to other perinatal outcomes assessed. However, it remains the case that WLHIV receiving ART are at higher risk of PTB compared to WLHIV receiving ZDV monotherapy and HIV-negative women ( 11 , 58 ). Our findings indicate that choice of ART regimen does not impact the elevated risk of PTB among pregnant WLHIV and hence other interventions are urgently needed to reduce the burden of PTB among WLHIV.…”

Section: Discussionmentioning

confidence: 99%

Comparative risk of adverse perinatal outcomes associated with classes of antiretroviral therapy in pregnant women living with HIV: systematic review and meta-analysis

Beck,

Cowdell,

Portwood

et al. 2024

Front. Med.

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BackgroundIntegrase strand transfer inhibitor (INSTI) dolutegravir (DTG)-based antiretroviral therapy (ART) is recommended by World Health Organisation as preferred first-line regimen in pregnant women living with human immunodeficiency virus (HIV) (WLHIV). Non-nucleoside reverse transfer inhibitor (NNRTI)-based ART and protease inhibitor (PI)-based ART are designated as alternative regimens. The impact of different ART regimens on perinatal outcomes is uncertain. We aimed to assess the comparative risk of adverse perinatal outcomes in WLHIV receiving different classes of ART.Materials and methodsA systematic literature review was conducted by searching PubMed, CINAHL, Global Health, and EMBASE for studies published between Jan 1, 1980, and July 14, 2023. We included studies reporting on the association of pregnant WLHIV receiving different classes of ART with 11 perinatal outcomes: preterm birth (PTB), very PTB, spontaneous PTB, low birthweight (LBW), very LBW, term LBW, preterm LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Pairwise random-effects meta-analyses compared the risk of each adverse perinatal outcome among WLHIV receiving INSTI-ART, NNRTI-ART, PI-ART, and nucleoside reverse transfer inhibitor (NRTI)-based ART, and compared specific “third drugs” from different ART classes. Subgroup and sensitivity analyses were conducted based on country income status and study quality.ResultsThirty cohort studies published in 2006–2022, including 222,312 pregnant women, met the eligibility criteria. Random-effects meta-analyses found no evidence that INSTI-ART is associated with adverse perinatal outcomes compared to NNRTI-ART and PI-ART. We found that PI-ART is associated with a significantly increased risk of SGA (RR 1.28, 95% confidence interval (95% CI) [1.09, 1.51], p = 0.003) and VSGA (RR 1.41, 95% CI [1.08, 1.83], p = 0.011), compared to NNRTI-ART. Specifically, lopinavir/ritonavir (LPV/r) was associated with an increased risk of SGA (RR 1.40, 95% CI [1.18, 1.65], p = 0.003) and VSGA (RR 1.84, 95% CI [1.37, 2.45], p = 0.002), compared to efavirenz, but not compared to nevirapine. We found no evidence that any class of ART or specific “third drug” was associated with an increased risk of PTB.ConclusionOur findings support the recommendation of INSTI-ART as first-line ART regimen for use in pregnant WLHIV. However, the increased risks of SGA and VGSA associated with PI-ART, compared to NNRTI-ART, may impact choice of second- and third-line ART regimens in pregnancy.Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42021248987.

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Perinatal outcomes associated with combination antiretroviral therapy compared with monotherapy

Cited by 2 publications

References 58 publications

Pregnancy Management in HIV Viral Controllers: Twenty Years of Experience

Pregnancy Management in HIV Viral Controllers: Twenty Years of Experience

Comparative risk of adverse perinatal outcomes associated with classes of antiretroviral therapy in pregnant women living with HIV: systematic review and meta-analysis

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