Factors Associated With Lack of Viral Suppression at Delivery Among Highly Active Antiretroviral Therapy–Naive Women With HIV

Katz, Ingrid T.; Leister, Erin; Kacanek, Deborah; Hughes, Michael D.; Bardeguez, Arlene; Livingston, Elizabeth; Stek, Alice; Shapiro, David E.; Tuomala, Ruth

doi:10.7326/m13-2005

Cited by 42 publications

(36 citation statements)

References 48 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…The percentage of birth defects we observed is similar to that reported in the APR [14] and in Europe [15]. Our cohort demonstrated a relatively high proportion of preterm births (31.6%) and a similar proportion of SGA infants (15.8%) compared to other cohorts of WLWH [3,8]; the proportion of preterm deliveries and SGA infants among pregnant WLWH receiving DTG-based therapy from other cohorts has ranged between 11–22% [14,16] and 17–25% [3,17], respectively, in resource-rich and resource-limited settings. Because of the short-term and long-term consequences of both preterm birth and SGA, future studies need to assess the safety profile of DTG for infants, and explore potential mechanisms of adverse outcomes, such as the role of DTG in reducing estradiol in pregnancy [17].…”

Section: Discussionsupporting

confidence: 87%

Evaluating outcomes of mother–infant pairs using dolutegravir for HIV treatment during pregnancy

Grayhack

Sheth

Kirby

et al. 2018

Aids

View full text Add to dashboard Cite

Objectives:Dolutegravir (DTG), a second-generation integrase inhibitor, is an effective treatment for HIV but its safety and efficacy are not well established in pregnancy. Here, we assess maternal and infant outcomes of mother–infant pairs using DTG-containing regimens during pregnancy.Methods:We performed a retrospective cohort analysis of pregnant women with HIV on DTG from two urban clinics in the United States, 2015–2018. Maternal outcomes included viral suppression (viral load of <20 copies/ml prior to delivery), development of resistance, and tolerability to DTG. Infant outcomes included preterm delivery (birth at <37 weeks), small for gestational age (SGA, weight <10th percentile), infant HIV status at birth, birth defect(s), and Appearance, Pulse, Grimace, Activity, Respiration (APGAR) scores. We performed a trend analysis to assess DTG use over time.Results:A total of 66 women used DTG during pregnancy and the proportion on DTG increased each year: in 2015, 8% (5/60) of women were on DTG, versus 22% (15/67) in 2016, 42% (30/71) in 2017, and 59% (16/27) in 2018 (P < 0.05). Among women who delivered (n = 57), 77.2% were undetectable at delivery. There were no drug resistance and no reported side effects during pregnancy. Infants had a mean APGAR score of 8 (SD 1.5) at 1 min and 9 (SD 0.8) at 5 min; 31.6% were born prematurely and 15.8% were SGA, and 2 infants had a birth defect. No cases of HIV transmission occurred.Conclusion:Our findings suggest that DTG can be an effective treatment during pregnancy. Infant outcomes (preterm deliveries and birth defects) need to be investigated in larger studies.

show abstract

Section: Discussionsupporting

confidence: 87%

Evaluating outcomes of mother–infant pairs using dolutegravir for HIV treatment during pregnancy

Grayhack

Sheth

Kirby

et al. 2018

Aids

View full text Add to dashboard Cite

show abstract

“…2,3 Unsuppressed HIV viral load at the time of delivery remains one of the most important risk factors for perinatal HIV transmission. 4–6 Despite massive public health efforts in the US, perinatal HIV transmission still occurs, often among women who present late in pregnancy with a high viral load due to antiretroviral drug resistance issues, non-adherence to prescribed ART or late entry into HIV care. 6 Challenges also remain in settings where provider adherence to HIV perinatal guidelines may be suboptimal.…”

Section: Introductionmentioning

confidence: 99%

Integrase inhibitors in late pregnancy and rapid HIV viral load reduction

Rahangdale

Cates

Potter

et al. 2016

American Journal of Obstetrics and Gynecology

Self Cite

View full text Add to dashboard Cite

Background Minimizing time to Human Immunodeficiency Virus (HIV) viral suppression is critical in pregnancy. Integrase strand transfer inhibitors (INSTIs), like raltegravir, are known to rapidly suppress plasma HIV ribonucleic acid (RNA) in nonpregnant adults. There is limited data in pregnant women. Objective We describe time to clinically relevant reduction in HIV RNA in pregnant women using INSTI-containing and non-INSTI-containing ART options. Study Design We conducted a retrospective cohort study of pregnant HIV-infected women in the U.S. from 2009 to 2015. We included women who initiated antiretroviral therapy (ART), intensified their regimen or switched to a new regimen due to detectable viremia (HIV RNA > 40c/mL) at ≥ 20 weeks gestation. Among women with a baseline HIV RNA permitting one-log reduction, we estimated time to one-log RNA reduction using the Kaplan-Meier estimator comparing women starting/adding an INSTI in their regimen versus other ART. To compare groups with similar follow-up time, we also conducted a subgroup analysis limited to women with ≤14 days between baseline and follow-up RNA data. Results This study describes 101 HIV-infected pregnant women from 11 U.S. clinics. Seventy-five percent (76/101) women were not taking ART at baseline; 24 were taking non-INSTI containing ART, and 1 received zidovudine monotherapy. Thirty-nine percent (39/101) of women started an INSTI-containing regimen or added an INSTI to their ART regimen. Among 90 women with a baseline HIV RNA permitting one-log reduction, the median time to one-log RNA reduction was 8 days [Interquartile Range (IQR): 7, 14] in the INSTI group versus 35 days [IQR: 20, 53] in the non-INSTI ART group (p<0.01). In a subgroup of 39 women with first and last RNA measurements ≤14 days apart, median time to one-log reduction was 7 days [IQR: 6, 10] in the INSTI group versus 11 days [IQR: 10, 14] in the non-INSTI group (p<0.01). Conclusion ART that includes INSTIs appears to induce more rapid viral suppression than other ART regimens in pregnancy. Inclusion of an INSTI may play a role in optimal reduction of HIV-RNA for HIV-infected pregnant women presenting late to care or failing initial therapy. Larger studies are urgently needed to assess the safety and effectiveness of this approach.

show abstract

“…IMPAACT Protocol 1025 is a prospective cohort study and was designed to “assess maternal and infant safety, and the effectiveness of new and existing interventions prescribed for prevention of mother-to-child transmission (MTCT) of HIV and/or women's health.” 14 Beginning in 2002, mothers were enrolled during pregnancy at ≥14 weeks gestation, ≥8 weeks beginning in 2007, or postpartum within 2 weeks after delivery. Study participant follow-up continued for at least 6 months after delivery.…”

Section: Methodsmentioning

confidence: 99%

Complications and Route of Delivery in a Large Cohort Study of HIV-1–Infected Women—IMPAACT P1025

Livingston

Huo

Patel

et al. 2016

JAIDS Journal of Acquired Immune Deficiency Syndromes

Self Cite

View full text Add to dashboard Cite

Objective Investigate complications of cesarean section in a cohort of HIV-infected pregnant women. Methods IMPAACT P1025 is a prospective cohort study of HIV-1-infected women and infants, enrolled 2002 to 2013, at clinical sites in the United States and Puerto Rico. Demographic, medical, and obstetric data were collected and analyzed including cesareans indications. Delivery route was categorized as elective cesarean (ECS, before labor and <5 minutes before membrane rupture), non-elective cesarean (NECS, all other cesareans) or vaginal delivery. Logistic regression models evaluated associations between delivery route and maternal intrapartum/postpartum morbidities. Composite morbidity of vaginal delivery was compared to ECS and NECS. Results This study included 2297 women. 99% used antiretroviral medication and 89% were on a combination antiretroviral therapy regimen. 84% had a HIV-1 viral load ≤400 copies/mL before delivery. 46% (1055) delivered vaginally, 35% (798) by ECS, and 19% (444) by NECS. While interruption of HIV-1 infection was the second most frequent indication for cesarean after repeat cesarean, it decreased as an indication over time. There were no delivery-related maternal mortalities. Overall 19% of women had ≥1 complication(s) - primarily wound complications (14%) or other infections (11%). Vaginal delivery had the lowest complication rate (13%), followed by ECS (23%), and highest NECS (28%) with an overall p<0.001. HIV-1 mother-to-child transmission rates were low and did not differ by delivery mode group. Conclusions HIV interruption as cesarean indicator declined during the study. Morbidity was more common in HIV-infected women delivering by NECS than ECS and lowest with vaginal delivery.

show abstract

Factors Associated With Lack of Viral Suppression at Delivery Among Highly Active Antiretroviral Therapy–Naive Women With HIV

Cited by 42 publications

References 48 publications

Evaluating outcomes of mother–infant pairs using dolutegravir for HIV treatment during pregnancy

Evaluating outcomes of mother–infant pairs using dolutegravir for HIV treatment during pregnancy

Integrase inhibitors in late pregnancy and rapid HIV viral load reduction

Complications and Route of Delivery in a Large Cohort Study of HIV-1–Infected Women—IMPAACT P1025

Contact Info

Product

Resources

About