Fertility intentions of HIV-infected women in the United Kingdom

In the United Kingdom (UK), the number of pregnancies in HIV-infected women has increased dramatically over the last decade, but attitudes towards childbearing among infected women have not been previously described. The aim of this survey was to explore fertility intentions among HIV-infected women and to assess the effect of HIV treatment and interventions for prevention of mother-to-child transmission (PMTCT) on these intentions. HIV-infected women, aged between 16 and 49 years, attending one of seven HIV clinics in the UK between July 2003 and January 2004 were asked to complete a questionnaire. Information on demographic factors, HIV test history, pregnancy history and fertility intentions (i.e., desire for children) was collected. Eighty-six per cent of eligible women (450/521) completed the questionnaire. Three quarters of women (336/450) reported that they wanted (more) children. Forty-five per cent (201/450) reported that HIV diagnosis did not affect their fertility intentions, 11% (50/450) that it made them want children sooner, and 10% (44/450) did not know or reported other views. About one third of women (155/450) decided they no longer wanted children after their HIV diagnosis, but 41% of these (59/144) had changed their mind following advances in HIV management and treatment. Factors associated with an increase in fertility intentions after advances in HIV management and treatment were being in a partnership and having fewer than two children. In this survey of HIV-infected women, the majority wanted children and women were more likely to want children after improvements in HIV management and treatment. These findings highlight the need for specialised family planning and reproductive health services targeting this population.     

Use of antiretroviral therapy in pregnant HIV-infected women and the risk of premature delivery: a meta-analysis

BACKGROUND: The use of antiretroviral agents in pregnant HIV-infected women has been reported to increase the risk of premature delivery in some studies. We performed a meta-analysis on relevant studies to address this question. METHODS: We searched Medline, Embase and the Cochrane Controlled Clinical Trials Register for English language articles. Studies that reported premature delivery for HIV-infected women treated with antiretroviral regimens during pregnancy were selected. Meta-analyses were performed using a random effects model. RESULTS: Thirteen prospective cohorts and one retrospective study met the inclusion criteria. Antiretroviral therapy during pregnancy did not increase the risk of premature delivery overall [odds ratio (OR) 1.01, 95% confidence interval (CI) 0.76-1.34]. In subgroup analyses, compared with no therapy, monotherapy (mostly zidovudine) conferred an OR of 0.86 (95% CI 0.73-1.01), whereas combination therapy conferred an OR of 1.13 (95% CI 0.79-1.63). The use of protease inhibitor (PI)-containing combinations resulted in an OR for premature delivery of 1.24 (95% CI 0.76-2.02), compared with combinations without PI. The initiation of combination therapy before pregnancy or in the first trimester resulted in an OR of 1.71 (95% CI 1.09-2.67) compared with therapy initiation in the second trimester and beyond. There was a large degree of heterogeneity between studies. CONCLUSION: Evidence indicates that antiretroviral therapy during pregnancy is not associated with an overall increased risk of premature delivery. The use of combination regimens before or early in pregnancy may slightly increase the risk of prematurity. Continued surveillance will be necessary to quantify such a risk accurately.     

Antiretroviral therapies associated with lipoatrophy in HIV-infected women

We previously demonstrated that HIV infection is associated with peripheral and central lipoatrophy in women. We now describe the association of specific antiretroviral drugs (ARV) with body fat changes over a four-year period from 1999 to 2003. 775 HIV-positive and 205 HIV-negative women in the Women's Interagency HIV Study with anthropometric measurements, weight, bioelectric impedance analysis and ARV collected semiannually were included in analysis. Exposure to ARV was defined as report of use for 3 consecutive semiannual study visits. The average 6-month change in weight, percent total body fat, and circumference measurements (i.e., hip, waist, chest, arm, and thigh) was compared between those exposed and those unexposed to the specific ARV for any of the same three consecutive visits. Weight, percent total body fat, and hip, waist, thigh, chest, and arm circumferences decreased in HIV-positive women, but increased in HIV-negative women on average for every six-month interval over the 4-year study period. Among the HIV-positive women, didanosine was the only ARV associated with decreases in circumference measures in the hip (-0.65 cm, 95% confidence interval [CI]: -1.18, -0.12), waist (-0.71 cm, 95% CI: -1.37, -0.04), chest (-0.71 cm, 95% CI: -1.17, -0.26), and arm (-0.23 cm, 95% CI: -0.48, 0.03; p = 0.08). These prospective data suggest that fat loss continues to predominate in HIV-positive women and exposure to didanosine for at least 12 months may further worsen fat loss.     

Vertically acquired HIV diagnosed in adolescence and early adulthood in the United Kingdom and Ireland: findings from national surveillance

Objective

The aim of the study was to describe the characteristics of young people with vertically acquired HIV diagnosed aged ≥13 years.

Methods

A retrospective review of HIV diagnoses reported to well‐established national paediatric and adult HIV surveillance systems in the United Kingdom/Ireland was conducted.

Results

Forty‐two young people with vertically acquired HIV diagnosed aged ≥13 years were identified; 23 (55%) were female, 40 (95%) were black African and 36 (86%) were born in sub‐Saharan Africa. The median age at HIV diagnosis was 14 years (range, 13–20 years). Half of the patients presented with symptoms; the remainder were screened for HIV following diagnosis of a relative. The median CD4 count at diagnosis was 210 cells/μL (range, 0–689 cells/μL), 12 patients (29%) were diagnosed with AIDS at HIV diagnosis or subsequently, and 34 (81%) started combination antiretroviral therapy (ART), most (31 of 34) within a year of diagnosis.

Conclusion

A small number of young people with vertically acquired HIV survive childhood without ART and are diagnosed at age ≥13 years in the United Kingdom/Ireland. Half of the patients were asymptomatic, highlighting the importance of considering HIV testing for all offspring of HIV‐infected women, regardless of age or symptoms. Increased awareness among clinicians and parents is required to reduce delayed presentation with advanced disease and to avoid onward transmission as these young people become sexually active.     

Antiretroviral drug concentrations and HIV RNA in the genital tract of HIV-infected women receiving long-term highly active antiretroviral therapy.

OBJECTIVE: Our objective was to determine antiretroviral drug concentrations and human immunodeficiency virus (HIV) RNA rebound in cervicovaginal fluid (CVF) in relation to blood plasma (BP) in women receiving suppressive highly active antiretroviral therapy (HAART). METHODS: Thirty-four HIV-infected women who had plasma HIV RNA levels < or =80 copies/mL for at least 6 months were enrolled. Sixty-eight paired CVF and BP drug concentrations and HIV RNA levels were determined before and 3-4 h after drug administration. For each woman and antiretroviral drug, the CVF:BP drug concentration ratios before and after drug administration were calculated. The nonparametric Wilcoxon rank sum test was used to determine if these ratios were different from 1.0. RESULTS: Lamivudine (administered to 20 patients) and tenofovir (administered to 16) had significantly higher concentrations in CVF than in BP before drug administration, with mean CVF:BP concentration ratios of 3.19 (95% confidence interval, 1.2-8.5) and 5.2 (95% confidence interval, 1.2-22.6), respectively. Efavirenz (administered to 13 patients) and lopinavir (administered to 6) had significantly lower concentrations in CVF, with mean CVF:BP concentration ratios of 0.01 (95% confidence interval, 0.00-0.03) and 0.03 (0.01-0.11), respectively. During the study visit (median time after enrollment, 6 months), BP and CVF detectable HIV RNA levels were observed 7 patients (20.6%) and 1 patient (2.9%), respectively. CONCLUSION: Despite lower CVF concentrations of key HAART components, such as efavirenz and lopinavir, virologic rebound was rare. The high concentrations of tenofovir and lamivudine in CVF may have implications for the prevention of sexual transmission during HAART and for pre-exposure or postexposure prophylaxis.     

Antiretroviral therapy in HIV-infected children: the metabolic cost of improved survival

Although highly active antiretroviral therapy (HAART) has positively altered the morality rates in HIV-infected children, these drugs have the potential to cause significant morbidity. These drugs cause changes in fat distribution, lipid profiles, glucose, homeostasis, and bone turnover. The direct relationship between duration of drug exposure and increased risk of cardiovascular disease is particularly concerning for HIV-infected infants and children, who likely will have longer cumulative exposure to HAART. It is unclear whether the metabolic effects of decades of exposure would be reversible with cessation of therapy. The benefits of HAART in HIV infection are indisputable, but the impetus to find a cure or design more tolerable therapy is clear. Infarction may replace infection as the major cause of morbidity and mortality from HIV.     

The practice of coronary surgery in the United Kingdom and Ireland: a survey

The author has sent a questionnaire to 172 members of the Society of Cardiothoracic Surgeons but has received only 49 answers. However, about one third of the members do not practice coronary surgery, so an estimated 40% of active members submitted answers. The questionnaire was mainly distributed to Consultants in the National Health Service. The questions refer to cardiopulmonary bypass, myocardial protection, grafts, closure of the chest, and postoperative medication.     

Participation of HIV-infected pregnant women in research in the United States

Previous studies suggested that some groups of HIV-infected women were underrepresented in studies of antiretrovirals (ARVs). We assessed rates of and reasons for nonenrollment in a U.S. prospective cohort study (protocol P1025), and differences in the characteristics of HIV-infected pregnant women who were and were not enrolled. Forty-one percent of women invited to participate were not enrolled. Clinic-related reasons for nonenrollment included staffing or site resources (26.7% of women) and clinician refusal because of the woman's nonadherence to prenatal care and/or poor research candidacy (10.8%). Patient-related reasons for nonenrollment included unavailability of women for enrollment (e.g., difficulty enrolling during labor/delivery, loss of clinic contact) (20.3%), refusal because of mistrust (10.1%), refusal because of time requirements (8.3%), refusal because of distance to the clinic (4.7%), and spontaneous abortion (4.7%). P1025 participants (N = 530) were significantly more likely to be Hispanic (32.1% vs. 19.8%), and less likely to be non-Hispanic black), to present in the first or second trimester for prenatal care (91.5% vs. 77.6%), and to be ARV-naive (32.8% vs. 23.0%) than nonparticipants (N = 2222). This high rate of nonenrollment can bias study results and generate findings that are applicable only to particular groups of women. Efforts should be taken to design protocols that facilitate enrollment of HIV-infected pregnant women.     

Idiopathic interstitial pneumonitis in children: a national survey in the United Kingdom and Ireland

Interstitial lung disease (ILD) of unknown etiology in immunocompetent patients is rare in children. A national survey was carried out in the United Kingdom and Ireland over a 3-year period in order to identify prevalence, age distribution, histopathology, natural history of the illness, and response to current treatment.Forty-six cases were identified, including 29 males and 17 females. Seventy-six percent presented in the first year of life. Nine (16%) occurred within four families. Conventional treatment with pulsed methylprednisolone, prednisolone, or hydroxychloroquine, singly or in combination, resulted in an excellent response in 65% of cases. Seven children died (15%). The recurrence risk for further children within the same family to develop ILD is estimated to be approximately 10%. The prevalence rate of this condition in the United Kingdom and Ireland during the period of study for children aged 0-16 years is estimated to be 3.6 cases/million.     

Antiretroviral therapy during pregnancy and premature birth: analysis of Swiss data

Background

There is an ongoing debate as to whether combined antiretroviral treatment (cART) during pregnancy is an independent risk factor for prematurity in HIV‐1‐infected women.

Objective

The aim of the study was to examine (1) crude effects of different ART regimens on prematurity, (2) the association between duration of cART and duration of pregnancy, and (3) the role of possibly confounding risk factors for prematurity.

Method

We analysed data from 1180 pregnancies prospectively collected by the Swiss Mother and Child HIV Cohort Study (MoCHiV) and the Swiss HIV Cohort Study (SHCS).

Results

Odds ratios for prematurity in women receiving mono/dual therapy and cART were 1.8 [95% confidence interval (CI) 0.85–3.6] and 2.5 (95% CI 1.4–4.3) compared with women not receiving ART during pregnancy (P=0.004). In a subgroup of 365 pregnancies with comprehensive information on maternal clinical, demographic and lifestyle characteristics, there was no indication that maternal viral load, age, ethnicity or history of injecting drug use affected prematurity rates associated with the use of cART. Duration of cART before delivery was also not associated with duration of pregnancy.

Conclusion

Our study indicates that confounding by maternal risk factors or duration of cART exposure is not a likely explanation for the effects of ART on prematurity in HIV‐1‐infected women.