Benefits Outweigh Pregnancy Risks with HIV Treatment

Beginning antiretroviral therapy before conception in HIV-positive women was linked to preterm delivery, but the benefits outweighed the risks.

Antiretroviral therapy (ART) is able to improve and extend the lives of people living with the human immunodeficiency virus (HIV). This is the frontline treatment for patients—including pregnant women—and in 2015 the World Health Organization (WHO) recommended that pregnant women initiate lifelong ART. However, data are lacking on how ART initiation before conception impacts pregnancy outcomes.

Olalekan A. Uthman, PhD, of the University of Warwick, along with colleagues across the United States, Canada, and Switzerland, aimed to find the significance of timing ART initiation in pregnancy women. They used 11 studies consisting of 19,189 mother-infant pairs from low-, middle-, and high-income countries. The randomized, quasi-randomized, and prospective cohort studies all took place between 1980 and mid-2016.

The team used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach—which is used to make judgements on the quality of evidence—to assess the relationship between ART initiation and pregnancy outcomes.

“Women who started ART before conception were significantly more likely to deliver preterm (pooled risk ratio (RR) 1.20) or very preterm (1.53), or to have low-birthweight infants (1.30) than those who began ART after conception,” the authors wrote in the report. However, time of ART initiation didn’t impact very low birthweight, stillbirth, congenital anomalies, or small or severe small for gestational age.

Past research indicated that preterm delivery took place as a result of protease-inhibitor-based ART; but various different ART regimens were used in this analysis.

One cohort included 5,652 deliveries in the United Kingdom and Ireland between 2007 and 2011. Of the 2,105 women who began ART before conception, only four transmitted HIV to their child. Another study in France reported zero transmission rates for women who began treatment before becoming pregnant.

“The benefits of ART for maternal health and prevention of perinatal transmission outweigh risks, but data for the extent and severity of these risks are scarce and of low quality,” the team concluded.

Some women started ART later in their pregnancies than others—which could skew outcomes. Regardless of this and other limitations, the researchers said that “there is no question that ART should be initiated in all pregnant women and continued thereafter.”

The full study, “Timing of initiation of antiretroviral therapy and adverse pregnancy outcomes: a systematic review and meta-analysis,” was published in The Lancet HIV.

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