There are many things for clinicians to consider in terms of HIV risk, treatment adherence, or adverse events for patients during and after pregnancy. And yet, too few studies focus on pregnancy for cisgender women living with or vulnerable to HIV. But at the recent Conference on Retroviruses and Opportunistic Infections (CROI), several studies presented dealt with different aspects of health and wellbeing for cisgender women when pregnant or postpartum.
The Role of STIs in HIV Acquisition During Pregnancy
In many countries, including the U.S., pregnant people are routinely tested for HIV. However, testing for syphilis is less common, Melanie Taylor, M.D., M.P.H., of the World Health Organization (WHO), said. If diagnosed, at least one shot of benzathine penicillin 30 days before birth can prevent complications, including stillbirth and congenital syphilis in the newborn. A 2017 global shortage of that form of penicillin, which is produced by three manufacturers in China, was resolved by mid-2019, she explained. WHO is also testing an alternative treatment for women who are allergic to penicillin: cefixime. That antibiotic is already in use for other bacterial infections, including gonorrhea.
Gonorrhea in pregnancy can cause neonatal conjunctivitis, explained Nicola Low, M.D., of the University of Bern, Switzerland. That eye infection is rare in high-income countries, because newborns are routinely given preventative eye drops. However, in low- and middle-income countries, only syndromic management of gonorrhea and chlamydia is often available. Chlamydia can cause neonatal pneumonia. Both sexually transmitted infections (STIs) are “silent germs” that are frequently asymptomatic. The good news: “The presence of chlamydia and gonorrhea is not consistently associated with a risk of mother-to-child transmission of HIV,” Low noted.
However, STIs can increase a woman’s risk of acquiring HIV. Globally, the population-attributable fraction of HIV attributable to herpes simplex virus (HSV-2) is 30%, said Anna Wald, M.D., M.P.H., of the University of Washington in Seattle. Among women, that STI is most common in sub-Saharan Africa, which also has a high HIV prevalence. In the U.S., 6% of neonatal deaths are due to herpes. Birth by cesarean section protects against transmitting HSV-2 to the newborn, and daily acyclovir for the mother also helps. Tenofovir disoproxil fumarate (TDF), used to prevent HIV seroconversion, reduces the risk of HSV-2 acquisition in the mother. “It works also as HSV PrEP, but obviously not nearly as effectively as against HIV,” Wald commented.
Achieving Viral Suppression With Different ART Regimens During Pregnancy
TDF is one of the HIV medications tested in the IMPAACT 2010 trial among antiretroviral therapy (ART)–naive pregnant women. The study includes three arms: dolutegravir + emtricitabine + tenofovir alafenamide (TAF), dolutegravir + emtricitabine + TDF, or efavirenz + emtricitabine + TDF in a fixed-dose combination, Lameck Chinula, M.D., of the University of North Carolina, who works in Malawi, reported. Follow-up is still ongoing, to 50 weeks postpartum. At delivery, virologic suppression rates were higher in the dolutegravir arms than in the efavirenz arm (98% versus 91%), and TAF may be safer for the babies than TDF. “The lower risk of TAF was due primarily to lower rates of preterm delivery and small for gestational age,” Chinula said. Women in the dolutegravir/TAF arm also gained more weight during pregnancy than those in the other groups.
Postpartum Weight Gain Is a Sign of Good Health
That weight gain may persist postpartum, the DolPHIN-2 study in southern Africa is showing. “Postpartum weight is an important indicator of women’s health over time,” Thoko Malaba, an epidemiologist at the University of Cape Town, South Africa, explained. However, there were local differences among the 232 participants—those in South Africa gained weight, while those in Uganda lost it after giving birth. That difference—13 kg—was larger than the 4.4 kg difference between the dolutegravir and efavirenz arms. That trial is still ongoing, as well.
Another study in southern Africa shows persistently higher postpartum weight among women taking dolutegravir compared to efavirenz, Jennifer Jao, M.D., M.P.H., of Northwestern University in Chicago, said. Her Botswana study compared women taking dolutegravir to those on efavirenz and to HIV-negative women. The greater weight retained on dolutegravir was comparable to that of the HIV-negative control group.
When you’re trying to take care of a newborn, concerns such as weight may fall by the wayside. Statistics show that HIV medication adherence often drops postpartum, as well, Jasantha Odayar, an epidemiologist at the University of Cape Town, South Africa, explained. Poor adherence not only affects the mother’s health, but also increases the risk of transmitting HIV to the infant. Her study in Gugulethu, a neighborhood in Cape Town, showed that fewer participants who attended adherence clubs designed for women with newborns had viral loads greater than 1,000 copies/mL than women attending standard clinic visits (29% versus 37%). Adherence clubs are small groups of people living with HIV who meet for counseling and medication pickup. This trial only evaluated the club model for the mothers, with separate clinic visits for the infants.
However, the two could be integrated, said Odayar: “It is something that should be considered and that requires more research.”
The need for more research was a familiar refrain, mentioned by many presenters. Clinical trials among pregnant women face the additional challenge of considering the implications for both the consenting mother and her child. Nonetheless, pregnant people need to be included in clinical trials in order to close our knowledge gaps, insisted Wame Jallow of the International Treatment Preparedness Coalition, in a presentation on contraceptive choice. Some of the studies described above are helping to close that knowledge gap.