Impact of maternal HIV infection on perinatal outcomes: A systematic review.

BACKGROUND: Maternal HIV infection remains a significant global health concern with potential repercussions on perinatal outcomes. Emphasis on early intervention to improve peri- and postnatal outcomes in infected mothers and infants is a valid therapeutic concern. OBJECTIVES: To comprehensively analyze perinatal outcomes associated with maternal HIV infection and evaluate adverse effects associated with the HIV infection in the existing literature. SEARCH STRATEGY: A comprehensive search of PubMed, MEDLINE, and Google Scholar was conducted from 2013 to September 2023, using relevant MeSH terms. SELECTION CRITERIA: The included studies encompassed original studies, cross-sectional, prospective, retrospective studies and observational studies focused on perinatal outcomes in the context of maternal HIV infection. DATA COLLECTION AND ANALYSIS: The selected studies underwent rigorous data collection and comprehensive quality checks and adhered to the PRISMA guidelines. MAIN RESULTS: Nine eligible studies from Brazil, China, India, Malawi, Nigeria, Tanzania, the USA, and Canada were included. These studies have consistently demonstrated that maternal HIV infection is associated with adverse perinatal outcomes. The analysis revealed a higher risk of preterm birth (OR 1.57, 95% CI: 1.39-1.78), low birth weight (OR 1.33, 95% CI: 1.18-1.49), and small for gestational age (OR 1.38, 95% CI: 1.24-1.53) among infants born to mothers living with HIV. Notably, the impact of antiretroviral treatment (ART) on these outcomes varied, but maternal HIV infection remained a significant risk factor regardless of income level and geographic region. CONCLUSION: Maternal HIV infection is consistently associated with adverse perinatal outcomes, emphasizing the need for targeted interventions and improved prenatal care in pregnant women with HIV infection.

A case of a false positive HIV antigen/antibody screen in a pregnant woman at delivery and the clinical importance of reviewing signal-to-cutoff ratio values.

We present a unique case not previously touched upon in the literature, and its ensuing management, of a falsely reactive HIV (human immunodeficiency virus) screening test which resulted in a woman during active labor, hours after rupture of membranes. The patient was screened for HIV using the ARCHITECT 4th generation HIV 1 and 2 Antigen/Antibody (Ag/Ab) Combo assay, and the results were repeatedly reactive. A cesarean delivery was recommended, and the patient received intrapartum antiretroviral therapy. Due to rapid progression of labor, the infant was delivered vaginally and received multiple doses of antiretroviral therapy. For confirmation, a viral load PCR test was obtained which resulted undetectable, and it was concluded that the screening results were falsely positive. While the cause of the inaccurate screening result is still unclear, a COVID-19 vaccination in close proximity to the delivery remains suspicious. Four months after delivery, the patient's screening test was no longer reactive.

Maternal and infant renal safety following tenofovir disoproxil fumarate exposure during pregnancy in a randomized control trial.

BACKGROUND: Tenofovir disoproxil fumarate (TDF) in combination with other antiretroviral (ARV) drugs has been in clinical use for HIV treatment since its approval in 2001. Although the effectiveness of TDF in preventing perinatal HIV infection is well established, information about renal safety during pregnancy is still limited. TRIAL DESIGN: The IMPAACT PROMISE study was an open-label, strategy trial that randomized pregnant women to one of three arms: TDF based antiretroviral therapy (ART), zidovudine (ZDV) based ART, and ZDV alone (standard of care at start of enrollment). The P1084s substudy was a nested, comparative study of renal outcomes in women and their infants. METHODS: PROMISE participants (n = 3543) were assessed for renal dysfunction using calculated creatinine clearance (CrCl) at study entry (> 14 weeks gestation), delivery, and postpartum weeks 6, 26, and 74. Of these women, 479 were enrolled in the P1084s substudy that also assessed maternal calcium and phosphate as well as infant calculated CrCl, calcium, and phosphate at birth. RESULTS: Among the 1338 women who could be randomized to TDF, less than 1% had a baseline calculated CrCl below 80 mL/min. The mean (standard deviation) maternal calculated CrCl at delivery in the TDF-ART arm [147.0 mL/min (51.4)] was lower than the ZDV-ART [155.0 mL/min (43.3); primary comparison] and the ZDV Alone [158.5 mL/min (45.0)] arms; the mean differences (95% confidence interval) were - 8.0 mL/min (- 14.5, - 1.5) and - 11.5 mL/min (- 18.0, - 4.9), respectively. The TDF-ART arm had lower mean maternal phosphate at delivery compared with the ZDV-ART [- 0.14 mg/dL (- 0.28, - 0.01)] and the ZDV Alone [- 0.17 mg/dL (- 0.31, - 0.02)] arms, and a greater percentage of maternal hypophosphatemia at delivery (4.23%) compared with the ZDV-ART (1.38%) and the ZDV Alone (1.46%) arms. Maternal calcium was similar between arms. In infants, mean calculated CrCl, calcium, and phosphate at birth were similar between arms (all CIs included 0). CONCLUSIONS: Although mean maternal calculated CrCl at Delivery was lower in the TDF-ART arm, the difference between arms is unlikely to be clinically significant. During pregnancy, the TDF-ART regimen had no observed safety concerns for maternal or infant renal function. TRIAL REGISTRATION: NCT01061151 on 10/02/2010 for PROMISE (1077BF). NCT01066858 on 10/02/2010 for P1084s.

Prevalence of Prenatal HIV Screening in Massachusetts: Examining Patterns in Prenatal HIV Screening Using the Massachusetts Pregnancy Risk Assessment Monitoring System (PRAMS), 2007-2016.

Prenatal HIV screening is critical to eliminate mother-to-child (MTC) HIV transmission. Although Massachusetts (MA) has near-zero MTC transmission rates, recent trends in statewide prenatal HIV testing are unknown. This study examined variations in prenatal HIV screening across race/ethnicity, socioeconomic status, and prenatal care settings in MA, in the period following national and state-level changes in guidance encouraging routine prenatal HIV testing.According to the MA Pregnancy Risk Assessment Monitoring System (PRAMS) data, 68.3% of pregnant women in MA were screened for HIV between 2007 and 2016. There were significant differences in prenatal screening rates across race/ethnicity, with 83.38% of Black non-Hispanic (NH), 85.5% of Hispanic women, and 62.4% of White NH women reporting being tested for HIV at some point during their pregnancy (P <.0001). Multivariate regression found that differences in screening were explained by race/ethnicity, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) status, prenatal care site, type of insurance, nativity, and marital status. Annual rates of prenatal HIV screening did not change significantly in MA from 2007 to 2016 (P = .27).The results of the analysis revealed that prenatal HIV screening rates differ based on race/ethnicity, with higher rates in Black NH and Hispanic women when compared to White NH women. The racial disparities in prenatal HIV screening and lack of universal screening in MA raises questions about the effectiveness of the state's approach.

HIV knowledge and attitudes among minority pregnant patients and their non-pregnant partners in an urban hospital clinic.

OBJECTIVE: HIV seroconversion during pregnancy disproportionately affects urban, minority pregnant individuals. In order to prevent perinatal HIV transmission, it is essential that individuals are aware of HIV risk factors and effective transmission prevention strategies are employed. Thus, we aimed to examine knowledge about HIV transmission and attitudes about HIV among low-income, minority pregnant individuals and their partners living in a high HIV prevalence area. METHODS: In this qualitative study, pregnant participants were HIV-seronegative individuals receiving publicly-funded prenatal care in an urban academic center in the United States. Pregnant individuals and their partners were recruited to participate in a quality improvement program offering HIV testing to partners of pregnant people. Semi-structured guides were used to conduct individual interviews about participant sources of information about HIV, knowledge about transmission, and attitudes regarding those living with HIV. Transcripts were analyzed using the constant comparative method to determine themes and subthemes. RESULTS: Of 51 participants, 29 were pregnant individuals and 22 were non-pregnant partners. We found that inaccurate knowledge about perinatal HIV transmission was prevalent. Sources of information about HIV included reputable literary information or educational experiences, broadcast media, and word-of-mouth sources. Participants held dichotomous perceptions of people living with HIV. CONCLUSIONS: Among low-income, minority pregnant people and their partners in a high HIV prevalence area, inaccuracies and lack of knowledge about HIV transmission were common. Efforts to educate pregnant individuals and their partners about HIV and perinatal HIV transmission should address common misconceptions and use popular sources of information.

Third-trimester repeat HIV testing: it is time we make it universal.

Since the 1990s, perinatal transmission of HIV has decreased substantially, largely as a result of improved detection secondary to routine HIV screening in pregnancy and the use of antiretroviral therapy. However, despite reductions in HIV transmission, elimination of perinatal transmission, defined as an incidence of perinatal HIV infection of <1 per 100,000 live births and a transmission rate of <1%, remains elusive. An estimated 80% of perinatal transmissions occur after 36 weeks' gestation, which highlights the importance of diagnosis and treatment of maternal HIV infection before the highest-risk period for perinatal transmission. With timely identification of seroconversion, intrapartum and neonatal interventions can lower the risk of perinatal transmission from 25% to 10%, substantially reducing perinatal transmission events. The American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention recommend that routine HIV testing be performed in all pregnancies, as early in the prenatal course as possible. Third-trimester repeat testing is only recommended for individuals known to be at high risk of acquiring HIV (ie, those who are incarcerated; who reside in jurisdictions with elevated HIV incidence; who are receiving care in facilities that have an HIV incidence in pregnant women > 1 per 1000 per year; or have signs or symptoms of acute HIV). However, among reproductive-age women, heterosexual intercourse is the most common mode of HIV transmission, and the risk of HIV seroconversion is greater during pregnancy than outside of pregnancy. Furthermore, state statutes for HIV testing in pregnancy are largely lacking. In this clinical opinion, we reviewed the evidence in support of universal third-trimester repeat HIV testing in pregnancy using a successful state-mandated testing program in Illinois. In addition, we provided clinical recommendations to further reduce missed perinatal transmission cases by implementing universal third-trimester repeat testing, obtaining hospital buy-in, monitoring testing adherence, bridging communications across multidisciplinary teams, and engaging clinicians in advocacy work.

Elimination of the Perinatal Transmission of HIV and Syphilis in Puerto Rico and Sustained Success since 2007: Convergence of Science, Women-Centered Care, and Policy.

OBJECTIVE: There have been significant successes in the fight against HIV/AIDS due to the access to rapid HIV testing, interventions to reduce the mother-to-child transmission (MTCT) risk, potent and effective antiviral medications, and other biomedical prevention strategies. The purpose of this work is to demonstrate that Puerto Rico eliminated Mother-to-Child Transmission of HIV (MTCT) following the 2017 World Health Organization (WHO) criteria for validating the elimination of MTCT and Syphilis. METHODS: Existing epidemiological data from Puerto Rico was used to document the elimination of MTCT and Syphilis. Data to calculate the indicators was obtained from the various divisions of the Puerto Rico Department of Health, including vital statistics, surveillance data, and programmatic outcomes. RESULTS: Puerto Rico eliminated MTCT and syphilis, according to the WHO indicators, earlier than other countries. We can trace the outcomes to 1994 using the incidence rate of perinatally-acquired HIV of <50/100,000; to 2007 using HIV perinatal transmission rates for non-breastfeeding countries (<2%), to 2008 using 90% of women receiving ART at delivery, and to 2005 using the incidence rate of congenital syphilis of <50/100,000. CONCLUSION: Not only have we eliminated the MTCT of HIV and syphilis, but the efforts have been sustained since 2000. The elimination of transmission of infectious diseases requires the intersection of scientific feasibility, coordinated interventions, and political will, successfully attained in Puerto Rico.

[The experience in the application of nikavir in the schemes of perinatal chemoprophylactics of HIV infection: evaluation of the immunological and virusological effectiveness.]

OBJECTIVES: The goal of this work was to study the immunological and virological efficacy of the domestic antiretroviral drug nicavir (at the optimal dose, as proven by previous clinical studies) with lamivudine, in comparison with other drugs of the group of nucleoside reverse transcriptase inhibitors in combination with kaletra in perinatal HIV chemoprophylaxis regimens. METHODS: 658 pregnant women aged 16-39 years and children born to them were examined. The first group (281 people) and the third group (66 people) received the nicavir (manufactured by AZT PHARMA KB LLC) with lamivudine in combination with calyx; the second (281 people) and the fourth (30 people) of the comparison group, stag and zidovudine, respectively, with lamivudine in combination with calyx. The effectiveness of CP was assessed from the increase in the number of CD4 lymphocytes, reduction of the viral load, and the number of children born without HIV DNA in the blood. RESULTS: Against the backdrop of the therapy, the viral load below the detectable level and the positive dynamics of CD4 lymphocytes were registered in all examined women prior to childbirth. When applying the scheme of niacavir + lamivudine + kaletra, a more rapid decrease in the level of BH, most pronounced by week 4 of therapy, was found, as compared with the rate of decline of the same index in pregnant comparison groups. CONCLUSIONS: The obtained results allow us to consider ART with the inclusion of nicavir effective and recommend its priority use in perinatal prevention of mother-to-child transmission of HIV.

Offering pre-exposure prophylaxis for HIV prevention to pregnant and postpartum women: a clinical approach.

INTRODUCTION: HIV prevention during pregnancy and lactation is critical for both maternal and child health. Pregnancy provides a critical opportunity for clinicians to elicit women's vulnerabilities to HIV and offer HIV testing, treatment and referral and/or comprehensive HIV prevention options for the current pregnancy, the postpartum period and safer conception options for future pregnancies. In this commentary, we review the safety of oral pre-exposure prophylaxis with tenofovir/emtricitabine in pregnant and lactating women and suggest opportunities to identify pregnant and postpartum women at substantial risk of HIV. We then describe a clinical approach to caring for women who both choose and decline pre-exposure prophylaxis during pregnancy and postpartum, highlighting areas for future research. DISCUSSION: Evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine is safe in pregnancy and lactation. Identifying women vulnerable to HIV and eligible for pre-exposure prophylaxis is challenging in light of the myriad of individual, community, and structural forces impacting HIV acquisition. Validated risk calculators exist for specific populations but have not been used to screen and offer HIV prevention methods. Partner testing and engagement of men living with HIV are additional means of reaching at-risk women. However, women's vulnerabilities to HIV change over time. Combining screening for HIV vulnerability with HIV and/or STI testing at standard intervals during pregnancy is a practical way to prompt providers to incorporate HIV screening and prevention counselling. We suggest using shared decision-making to offer women pre-exposure prophylaxis as one of multiple HIV prevention strategies during pregnancy and postpartum, facilitating open conversations about HIV vulnerabilities, preferences about HIV prevention strategies, and choosing a method that best meets the needs of each woman. CONCLUSION: Growing evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine during pregnancy and lactation is safe and effective. Shared decision-making provides one approach to identify at-risk women and offers pre-exposure prophylaxis but requires implementation research in diverse clinical settings. Including pregnant and breastfeeding women in future HIV prevention research is critical for the creation of evidence-driven public health policies and clinical guidelines.

Assessing the Impact of Perinatal HIV Case Management on Outcomes Along the HIV Care Continuum for Pregnant and Postpartum Women Living With HIV, Philadelphia 2005-2013.

To evaluate the impact of a Perinatal Medical Case Management (PCM) Program for women living with HIV (WLWH). Characteristics of pregnant and postpartum WLWH were compared between those who engaged in PCM and those who did not. Using secondary data collected from routine HIV surveillance, multivariable regression models were used to evaluate the association between PCM and four outcomes adapted from the HIV care continuum. In multivariable models, compared to WLWH not in PCM, participants (n = 448, 52.8%) were almost twice as likely to achieve HIV suppression before delivery (aOR 1.90 [1.33, 2.71], p = 0.0005); were more likely to be retained in HIV care 1 year postpartum (aOR 1.59 [1.17, 2.16], p = 0.0029); and were equally likely to engage in HIV care within 90-days of delivery (aOR 1.21 [0.88, 1.65], p = 0.236) and be virally suppressed 1 year postpartum (aOR 1.26 [0.90, 1.77], p = 0.178). PCM is an important intervention for preventing perinatal HIV transmission and closings gaps in the HIV care continuum for WLWH during pregnancy and postpartum.

HIV-infected mothers' experiences during their infants' HIV testing.

Both survival with HIV and rates of perinatal HIV infection have significantly declined during the past decade, due to antiretroviral therapies that interrupt HIV transmission to the fetus and newborn. Although HIV is no longer routinely fatal to mothers or transmitted to fetuses, and the testing of newborns for HIV has been improved, evidence about HIV-infected mothers' experiences during the months of their infants' HIV testing predates these improvements. This qualitative study on 16 mothers was an analysis of interviews conducted several weeks after testing was completed and all infants had been determined to be uninfected. Mothers reported that their experiences evolved during the months of testing. Initial reactions included maternal trauma and guilt associated with infant testing. They then reported learning to cope with the roller coaster ride of repeated testing with the help of information from clinicians. By the end of the testing period, ambiguity began to resolve as they engaged in tentative maternal-infant attachment and expressed desire for a sense of normalcy. Need for support and fear of stigma persisted throughout. These findings expand current knowledge about this experience and suggest clinical strategies to guide HIV-infected women during this stressful period.