Pregnancy in women living with perinatally acquired HIV: Perinatal outcomes and drug resistance profile

Osmundo Junior, Gilmar de Souza; Costa, Rafaela Alkmin da; Ruocco, Rosa Maria Aveiro; Francisco, Rossana Pulcineli Vieira

doi:10.1016/j.clinsp.2023.100174

Brasil

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Original articles • Clinics 78 • 2023 • https://doi.org/10.1016/j.clinsp.2023.100174 linkcopy

Pregnancy in women living with perinatally acquired HIV: Perinatal outcomes and drug resistance profile

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives: To analyze the perinatal outcomes of Perinatally acquired HIV Infection (PHIV) in pregnant women.

Method: This retrospective cohort study included singleton pregnancies in Women Living with HIV (WLH) between 2006 and 2019. Patient charts were revised, and maternal characteristics, type of HIV infection (perinatal vs. behavioral), Antiretroviral Therapy (ART) exposure, and obstetric and neonatal outcomes were assessed. The HIV-related aspects considered were: Viral Load (VL), CD4+ cell count, opportunistic infections, and genotype testing. Laboratory analyses were performed at baseline (first appointment) and 34 weeks of gestation.

Results: There were 186 WLH pregnancies, and 54 (29%) patients had PHIV. Patients with PHIV were younger (p < 0.001), had less frequently stable partnerships (p < 0.001), had more commonly serodiscordant partners (p < 0.001), had a longer time on ART (p < 0.001), and had lower rates of undetectable VL at baseline (p = 0.046) and at 34 weeks of gestation (p < 0.001). No association was observed between PHIV and adverse perinatal outcomes. Among patients with PHIV, third trimester anemia was associated with preterm birth (p = 0.039). Genotype testing was available only for 11 patients with PHIV, who presented multiple mutations related to ART resistance.

Conclusions: PHIV did not seem to increase the risk of adverse perinatal outcomes. However, PHIV pregnancies have a higher risk of viral suppression failure and exposure to complex ARTs.

Keywords: HIV; Perinatology; Antiretroviral therapy; High-risk pregnancy

HIGHLIGHTS

HIV viral resistance in pregnancy.

Adverse perinatal outcomes in pregnant women living with HIV.

Perinatally acquired HIV can increase the risk of viral suppression failure.

Parameters	Measure
Maternal age, years, mean (± SD)	27.8 (± 7.7)
GA at delivery, weeks	37.5 (± 1.8)
Birth weight, grams	2767.5 (± 556.3)
Nulliparous, n (%)	77 (41.4%)
HIV transmission
Perinatally	54 (29%)
Behaviorally	132 (71%)
Undetectable Baseline VL	74 (39.8%)¹ 1 missing information for 5 cases;
Undetectable VL at 34-weeks	108 (58.1%)
Mode of delivery
- C-section	160 (95.2%)
- Vaginal	8 (4.8%)
Preterm birth	28 (16.7%)
Low birth weight	40 (24%)
MTCT	1 (0.6%)² 2 missing information for 12 cases.

Variables	PHIV (n = 54) Number of Cases / Total available (%)	BHIV (n = 132) Number of Cases / Total available (%)	p
Maternal age, years, mean (± SD)	19.5 ± 2.9	31.2 ± 6.4	< 0.001^a a Student’s t-test.
Unplanned pregnancy	49 / 51 (96.1%)	112 / 128 (87.5%)	0.085^b b Fisher’s exact test / Chi-square test.
Serodiscordant partners	26 / 28 (92.9%)	31 / 61 (50.8%)	< 0.001^b b Fisher’s exact test / Chi-square test.
Stable partnership	20 / 52 (38.5%)	95 / 128 (74.2%)	< 0.001^b b Fisher’s exact test / Chi-square test.
Smoking	6 /54 (11.1%)	31 / 128 (24.2%)	0.045^b b Fisher’s exact test / Chi-square test.
Alcohol intake	1 / 54 (1.9%)	11 / 128 (8.6%)	0.113^b b Fisher’s exact test / Chi-square test.
Recreational drugs	4 / 54 (7.4%)	22 / 128 (17.2%)	0.085^b b Fisher’s exact test / Chi-square test.
Systemic Hypertension	0 (0%)	14 / 128 (10.9%)	0.011^b b Fisher’s exact test / Chi-square test.
Baseline Anemia	15 / 50 (30%)	27 / 120 (22.5%)	0.302^b b Fisher’s exact test / Chi-square test.
Baseline Lymphopenia	5 / 49 (10.2%)	6 / 117 (5.1%)	0.304^b b Fisher’s exact test / Chi-square test.
Anemia 3rd trimester	23 / 50 (46%)	29 / 117 (24.8%)	0.007^b b Fisher’s exact test / Chi-square test.
Lymphopenia 3rd trimester	2 / 50 (4.0%)	3 / 116 (2.6%)	0.638^b b Fisher’s exact test / Chi-square test.

Variables	PHIV (n = 54) Number of Cases / Total available (%)	BHIV (n = 132) Number of Cases / Total available (%)	p
Time of HIV infection, years, mean (±SD)¹ 1 Data available for 170 cases.	19.2 (± 3.1)	6.1 (± 5.2)	<0.001^a a Student’s t-test.
Time of ART, years, mean (±SD)² 2 Data available for 161 cases.	14.2 (± 6.6)	3.5 (± 4.3)	<0.001^a a Student’s t-test.
ART
- PI	51/54 (94.4%)	96/132 (72.7%)	0.001^b b Fisher’s exact test / Chi-square test.
- NRTI	53/54 (98.1%)	130/132 (98.5%)	1.0^b b Fisher’s exact test / Chi-square test.
- NNRTI	2/54 (3.7%)	31/132 (23.5%)	0.001^b b Fisher’s exact test / Chi-square test.
- Raltegravir	13/54 (24.1%)	6/132 (4.5%)	<0.001^b b Fisher’s exact test / Chi-square test.
- Enfuvirtide	1/54 (1.9%)	1/132 (0.8%)	0.497^b b Fisher’s exact test / Chi-square test.
- Maraviroc	2/54 (3.7%)	0 (0%)	0.083^b b Fisher’s exact test / Chi-square test.
Previous OI	11/50 (22%)	25/128 (19.5%)	0.712^b b Fisher’s exact test / Chi-square test.
OI on pregnancy	5/54 (9.3%)	4/132 (3.0%)	0.124^b b Fisher’s exact test / Chi-square test.
Undetectable baseline VL	15/50 (30%)	59/127 (46.5%)	0.046^b b Fisher’s exact test / Chi-square test.
Undetectable VL at 34-weeks	23/51 (45.1%)	85/111 (76.6%)	<0.001^b b Fisher’s exact test / Chi-square test.
Baseline CD4+ cells count, /mm³, median (IQR)³ 3 Data available for 175 cases.	441.5 (259.7–658.7)	440 (311.5–670)	0.691^c c ann-Whitney U test.
Baseline VL count, copies/mL, median (IQR)⁴ 4 Information available for 103 cases presenting detectable baseline viral load.	2968 (495–50,239)	3270.5 (633.5–23,211)	0.437^c c ann-Whitney U test.
CD4+ cells count at 34-weeks, /mm³, median (IQR)⁵ 5 Data available for 161 cases.	480 (243–662)	504.5 (332.2–703)	0.210^c c ann-Whitney U test.
VL count at 34-weeks, copies/mL, mean (±SD)⁶ 6 Information available for 54 cases presenting detectable viral load at 34 weeks;.	3.1 (± 0.9)	2.8 (± 1.1)	0.237^c c ann-Whitney U test.

Variables	PHIV (n = 54) Number of Cases / Total available (%)	BHIV (n = 132) Number of Cases / Total available (%)	p^a a Chi-square test.	OR^b b Unconditional logistic regression.	95% CI
Hospital admission	11/54 (20.4%)	21/132 (15.9%)	0.522	1.35	0.6–3.0
gestational diabetes	2/51 (3.9%)	9/121 (7.4%)	0.510	0.51	0.1–2.4
preeclampsia	2/51 (3.9%)	7/113 (5.8%)	0.726	0.7	0.1–3.3
Fetal growth restriction	8/51 (15.7%)	20/121 (16.5%)	1.0	0.9	0.4–2.3
Fetal loss	3/54 (5.6%)	13/132 (9.8%)	0.405	0.5	0.1–1.9
Preterm birth	7/51 (13.7%)	21/117 (17.9%)	0.499	0.7	0.3–1.8
Low birth weight	11/50 (22%)	29/117 (24.8%)	0.262	0.8	0.4–1.9
MTCT	0/49 (0%)	1/107 (0.9%)	1.0	-	-

Patient	Age	CD4 (34 weeks)	VL (34 weeks) (log)	ART	PI	NRTI	NNRTI	Intermediate	Resistant
1	22	480	Undetected	DRV/R, RAL, AZT, 3TC, MVQ	L10V, K20T, L33F, M36I, M46I, I54V, T74P, V82A, L90M	K65R, M184V, 214F	V108I, Y181C	DRV, ETV	ATV, FPV, IDV, LPV, SQV, 3TC, ABC, EFV, NVP, TDF
2	20	134	426 (2.63)	TDF, 3TC, DRV/R	L10V, K20I, M36I, M46I, L63P, L90M	M184V, 214F	K103N, V179E, P225H	IDV, LPV, SQV, ABC	ATV, 3TC, EFV, NVP
3	21	991	Undetected	TDF, 3TC, ATV	-	M184V, 211 K, 214F, T215S/Y	K101P, K103N/S	ABC, DDI	3TC, EFV, ETV, NVP
4	22	548	Undetected	3TC, RAL, DRV/R, MVQ	M36I, I54V, A71V, V82A, L90M	M41L, E44D, D67N, V75M, V118I, 211 K, 214F, T215Y, K219R	K101E, V106I, Y188L, G190A	3TC, ABC, DDI, ATV, FPV, IDV	AZT, EFV, TDF, ETV, NVP, SQV
5	21	105	837 (2.92)	TDF, 3TC, RAL, DRV/R, MVQ, T20	L10F, K20T, N88S	D67N, T215F, K219Q	V90I, K101P	IDV, ETV	ATV, NFV, AZT, EFV, NVP
6	20	322	176 (2.25)	TDF, 3TC, RAL, DRV/R	L10F, K20R, M36I, M46I, I47V, F53L, I54V, V82A	M41L, M184V, T215Y	-	ABC, AZT, DDI, DRV	3TC, ATV, FPV, IDV, LPV, SQV
7	19	327	Undetected	TDF, 3TC, LPV/R, RAL	I13V, L63P, V77I	M184V, D67N, T69D, V75M, M184V, L210W, T215Y, K219Q	V108I, Y181C	ETV	3TC, ABC, AZT, DDI, EFV, NVP, TDF
8	19	131	4303 (3.63)	AZT, 3TC, NVP	M36I, I62V, L63P, V77I	M41L, D67N, T69D, V118I, L210W, T215Y	-	3TC, ABC	AZT, d4T, DDI

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Faculdade de Medicina / USP Rua Dr Ovídio Pires de Campos, 225 - 6 and., 05403-010 São Paulo SP - Brazil, Tel.: (55 11) 2661-6235 - São Paulo - SP - Brazil
E-mail: clinics@hc.fm.usp.br

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Acessibilidade / Reportar erro

[TFN1] MTCT, Mother To Child Transmission; SD, Standard Deviation; VL, Viral Load.

[TFN2] ¹
missing information for 5 cases;

[TFN3] ²
missing information for 12 cases.