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Owuroola Adewale
A new analysis by researchers at Oxford Population Health’s Infectious Disease Epidemiology Unit has provided robust evidence in support of current World Health Organization (WHO) guidelines for treating pregnant women living with HIV. The study is published in Clinical Microbiology and Infection.
Each year an estimated 1.3 million women with HIV are pregnant. Most of these women live in sub-Saharan Africa. Pregnant women living with untreated HIV have an increased risk of adverse perinatal outcomes including preterm birth, stillbirth, and babies being born with low birthweight or small for their gestational age when compared with women without HIV.
Since 2013, WHO has recommended that all pregnant women with HIV receive antiretroviral therapy (ART) to improve maternal health outcomes and reduce the risk of mothers transmitting HIV to their unborn babies. This has resulted in an increase in the global proportion of pregnant women receiving ART from 44% in 2010 to 82% in 2022.
However, even with treatment, pregnant women with HIV still have an increased risk of adverse perinatal outcomes. Data on pregnancy outcomes associated with different drugs that are part of triple drug ART regimens is limited, as very few and small randomised controlled trials of ART regimens in pregnant women with HIV have been conducted. In particular, specific drugs that are part of every triple drug ART regimen called nucleoside reverse transcriptase inhibitors (NRTIs) have not been compared with regard to pregnancy outcomes.
To address this evidence gap, the researchers collated and reviewed data from 22 cohort studies on four different NRTI drugs as part of ART regimens and their impact on a broad range of adverse perinatal outcomes. Current WHO guidelines recommend that pregnant women are treated with ART regimens containing the NRTIs tenofovir disoproxil fumarate (TDF) and either lamivudine (3TC) or emtricitabine (FTC) as the first option. Zidovudine (ZDV), abacavir (ABC) and tenofovir alafenamide (TAF) are recommended for use when the first options don’t work well for the patient.
Key findings:
- ART containing TDF was associated with a lower risk of preterm birth, being born small for gestational age, stillbirth, and neonatal death when compared with ART not containing TDF;
- ART containing ZDV was associated with an increased risk of adverse perinatal outcomes when compared with ART not containing ZDV;
- In ART regimens that also included 3TC or FTC, ZDV was associated with an increased risk of adverse perinatal outcomes when compared with ART containing TDF;
- ART containing ABC was not associated with any adverse perinatal outcomes;
- ART containing TAF was not associated with an increased risk of low birthweight when compared with TDF, but there were no data available for any other adverse perinatal outcomes.
Joris Hemelaar, Associate Professor at Oxford Population Health’s Infectious Disease Epidemiology Unit and senior author of the study, said ‘Our findings support international clinical guidelines for treating pregnant women with HIV. However, despite treatment, pregnant women with HIV remain at increased risk of adverse pregnancy outcomes, compared to their HIV-negative counterparts, and further efforts should be made to improve outcomes for pregnant women with HIV.
‘To further strengthen the evidence base for best practice treatment of pregnant women with HIV, more and larger randomised controlled trials are needed to investigate current ART regimens as well as newer treatments, such as long-acting injectables and dual drug therapies, and their impact on a broad range of perinatal outcomes.’