This Week in HIV Research: The Case for Pre-Pregnancy Treatment

Starting antiretroviral therapy before becoming pregnant rather than after conception appears to protect infants from severe infections early in life, a Belgian prospective cohort study published in Clinical Infectious Diseases found.

Data on 132 babies born to women living with HIV (WLWH) and 123 babies born to HIV-negative women were analyzed. All infants were HIV-negative. A baby’s risk of infection-related hospitalization was four times higher when the mother began treatment during pregnancy compared to HIV-negative mothers or mothers already on antiretrovirals before conception. Post-conception initiation of HIV treatment was also associated with higher activation of monocytes in both mother and child right after birth, and fewer maternal antibodies in the child’s cord blood. All of these factors were related to a higher risk of infant hospitalization.

Participants living with HIV did not breastfeed, but most HIV-negative participants did. The impact of breastfeeding could therefore not be determined directly, but appears to be minor, given similar results for WLWH already on treatment before pregnancy and women not living with HIV.

Study authors called for similar research in low- and middle-income countries to determine the applicability of these results in those settings.

Between 2008 and 2016, new HIV diagnoses among men who have sex with men (MSM) rose 3% a year among the under-30 crowd, while dropping 4% annually among the middle-aged, the U.S. Centers for Disease Control and Prevention reported in its Morbidity and Mortality Weekly Report. More diagnoses among young people may reflect higher testing rates in that historically underdiagnosed group, rather than just more transmissions, study authors cautioned.

African-American men were diagnosed with HIV at disproportionate rates, accounting for 49% of all diagnoses during the study period in the 13- to 29-year age group, for example. Diagnoses among young American Indians/Alaska Natives rose by 14.8% during these 8 years, although the total number was relatively small.

The rate of new diagnoses remained stable among MSM over 50, but the number of men living with HIV in that age group increased by 11% per year, likely due to better survival rates on current antiretrovirals.

Study authors recommended interventions tailored to specific age groups that include provision of pre-exposure prophylaxis and achieving higher rates of viral suppression to prevent sexual transmission of the virus.

While pre-exposure prophylaxis (PrEP) is not of economic value to the health care sector if the partner living with HIV in a serodiscordant couple is virally suppressed, it is cost-effective when that partner is not reliably on antiretroviral therapy, a simulation published in AIDS showed.

Researchers considered various HIV prevention scenarios for heterosexual couples who want to conceive and in which the male partner is living with HIV. In addition to factoring in the cost of HIV care and PrEP, as well as quality-of-life measurements, the study also considered the lifetime cost of HIV care if the baby is born seropositive.

If the male partner’s viral load is undetectable and he will therefore not transmit the virus to his female partner, nothing is gained by additional prophylaxis, especially if sex without a condom is limited to around the woman’s ovulation, the study found. However, PrEP is worth its cost when the male partner’s treatment adherence is less than stellar, or when he may not be taking HIV drugs at all.

Despite these findings, study authors cautioned that cost-benefit calculations don’t take all factors into account, such as a woman’s greater ability to control PrEP than her male partner's condom use.

Low-dose methotrexate (LDMTX) does not improve arterial function in people living with HIV (PLWH) who are at risk for artherosclerotic cardiovascular disease (ASCVD), a phase II trial published in Clinical Infectious Diseases found.

The trial randomized 176 PLWH age 40 or older who had ASCVD or were at risk for it to the study drug or a placebo. All participants were on antiretroviral treatment, with a baseline CD4 cell count of at least 400 cells/mm3 (median CD4 count was 726 cells/mm3). Participants were mostly male (90%), but the cohort was racially diverse: 42% were white, 42% black, and 15% Latinx.

The drug or placebo were administered for 24 weeks and follow-up continued for 12 weeks thereafter. Rates of brachial artery flow-mediated dilation and hyperemic flow velocity -- measures of arterial function -- were unchanged in both groups. Safety events (particularly a large CD4 count drop) were more likely to occur among participants receiving LDMTX, but such events were uncommon overall, and the difference fell within the study's non-inferiority margin.

Standard anti-inflammatory treatments, such as statins, pentoxifylline, aspirin and hydroxychloroquine, have previously been shown to have little effect in PLWH, study authors noted. They hypothesized that T-cell abnormalities related to HIV itself may be stronger than methotrexate, thus mitigating the effect of the medication. Further study is warranted, they concluded.