Hematological Changes in Women and Infants Exposed to an AZT-Containing Regimen for Prevention of Mother-to-child-transmission of HIV in Tanzania.

Tanzanian guidelines for prevention of mother-to-child-transmission of HIV (PMTCT) recommend an antiretroviral combination regimen involving zidovudine (AZT) during pregnancy, single-dosed nevirapine at labor onset, AZT plus Lamivudine (3TC) during delivery, and AZT/3TC for 1-4 weeks postpartum. As drug toxicities are a relevant concern, we assessed hematological alterations in AZT-exposed women and their infants. A cohort of HIV-positive women, either with AZT intake (n = 82, group 1) or without AZT intake (n = 62, group 2) for PMTCT during pregnancy, was established at Kyela District Hospital, Tanzania. The cohort also included the infants of group 1 with an in-utero AZT exposure ≥4 weeks, receiving AZT for 1 week postpartum (n = 41), and infants of group 2 without in-utero AZT exposure, receiving a prolonged 4-week AZT tail (n = 58). Complete blood counts were evaluated during pregnancy, birth, weeks 4-6 and 12. For women of group 1 with antenatal AZT intake, we found a statistically significant decrease in hemoglobin level, red blood cells, white blood cells, granulocytes, as well as an increase in red cell distribution width and platelet count. At delivery, the median red blood cell count was significantly lower and the median platelet count was significantly higher in women of group 1 compared to group 2. At birth, infants from group 1 showed a lower median hemoglobin level and granulocyte count and a higher frequency of anemia and granulocytopenia. At 4-6 weeks postpartum, the mean neutrophil granulocyte count was significantly lower and neutropenia was significantly more frequent in infants of group 2. AZT exposure during pregnancy as well as after birth resulted in significant hematological alterations for women and their newborns, although these changes were mostly mild and transient in nature. Research involving larger cohorts is needed to further analyze the impact of AZT-containing regimens on maternal and infant health

Adherence to Combination Prophylaxis for Prevention of Mother-to-Child-Transmission of HIV in Tanzania

BACKGROUND: Since 2008, Tanzanian guidelines for prevention of mother-to-child-transmission of HIV (PMTCT) recommend combination regimen for mother and infant starting in gestational week 28. Combination prophylaxis is assumed to be more effective and less prone to resistance formation compared to single-drug interventions, but the required continuous collection and intake of drugs might pose a challenge on adherence especially in peripheral resource-limited settings. This study aimed at analyzing adherence to combination prophylaxis under field conditions in a rural health facility in Kyela, Tanzania. METHODS AND FINDINGS: A cohort of 122 pregnant women willing to start combination prophylaxis in Kyela District Hospital was enrolled in an observational study. Risk factors for decline of prophylaxis were determined, and adherence levels before, during and after delivery were calculated. In multivariate analysis, identified risk factors for declining pre-delivery prophylaxis included maternal age below 24 years, no income-generating activity, and enrolment before 24.5 gestational weeks, with odds ratios of 5.8 (P = 0.002), 4.4 (P = 0.015) and 7.8 (P = 0.001), respectively. Women who stated to have disclosed their HIV status were significantly more adherent in the pre-delivery period than women who did not (P = 0.004). In the intra- and postpartum period, rather low drug adherence rates during hospitalization indicated unsatisfactory staff performance. Only ten mother-child pairs were at least 80% adherent during all intervention phases; one single mother-child pair met a 95% adherence threshold. CONCLUSIONS: Achieving adherence to combination prophylaxis has shown to be challenging in this rural study setting. Our findings underline the need for additional supervision for PMTCT staff as well as for clients, especially by encouraging them to seek social support through status disclosure. Prophylaxis uptake might be improved by preponing drug intake to an earlier gestational age. Limited structural conditions of a healthcare setting should be taken into serious account when implementing PMTCT combination prophylaxis

Emergence of Minor Drug-Resistant HIV-1 Variants after Triple Antiretroviral Prophylaxis for Prevention of Vertical HIV-1 Transmission

Background: WHO-guidelines for prevention of mother-to-child transmission of HIV-1 in resource-limited settings recommend complex maternal antiretroviral prophylaxis comprising antenatal zidovudine (AZT), nevirapine single-dose (NVP-SD) at labor onset and AZT/lamivudine (3TC) during labor and one week postpartum. Data on resistance development selected by this regimen is not available. We therefore analyzed the emergence of minor drug-resistant HIV-1 variants in Tanzanian women following complex prophylaxis. Method: 1395 pregnant women were tested for HIV-1 at Kyela District Hospital, Tanzania. 87/202 HIV-positive women started complex prophylaxis. Blood samples were collected before start of prophylaxis, at birth and 1–2, 4–6 and 12–16 weeks postpartum. Allele-specific real-time PCR assays specific for HIV-1 subtypes A, C and D were developed and applied on samples of mothers and their vertically infected infants to quantify key resistance mutations of AZT (K70R/T215Y/T215F), NVP (K103N/Y181C) and 3TC (M184V) at detection limits of,1%. Results: 50/87 HIV-infected women having started complex prophylaxis were eligible for the study. All women took AZT with a median duration of 53 days (IQR 39–64); all women ingested NVP-SD, 86 % took 3TC. HIV-1 resistance mutations were detected in 20/50 (40%) women, of which 70 % displayed minority species. Variants with AZT-resistance mutations were found in 11/50 (22%), NVP-resistant variants in 9/50 (18%) and 3TC-resistant variants in 4/50 women (8%). Three wome

Adverse effects of antiretroviral prophylaxis for prevention of mother-to- child transmission of HIV-1 in Tanzania

Einleitung Die Leitlinien der Weltgesundheitsorganisation (WHO) von 2006 für die Prävention der Mutter-Kind-Übertragung des Humanen Immundefizienz-Virus Typ 1 (HIV-1) für ressourcenarme Regionen empfehlen eine komplexe antiretrovirale Prophylaxe. Diese beinhaltet die Einnahme von Zidovudin (AZT) während der Schwangerschaft, eine Einmaldosis Nevirapin (NVP) zur Geburt und AZT sowie Lamivudin (3TC) ab Beginn der Wehen bis Ende der ersten postnatalen Woche. Untersucht wurden hämatologische Veränderungen, Depletion und Mutationen mitochondrialer DNA (mtDNA) sowie HIV-Resistenzentwicklung unter der Prophylaxe bei Frauen in einer ländlichen Gegend in Tansania. Methoden Eine Kohorte von HIV-positiven schwangeren Frauen mit AZT-Einnahme (Gruppe 1) oder ohne (Gruppe 2) wurde im Kyela District Hospital, Tansania etabliert. Blutparameter der Studienteilnehmerinnen und ihrer Neugeborenen wurden während der Schwangerschaft, der Geburt, vier bis sechs und zwölf Wochen nach der Geburt ausgewertet. Mitochondriale DNA in Plazenta und Nabelschnur wurden mittels Echtzeit-PCR quantifiziert und auf mitochondriale Deletion dmtDNA4977 hin untersucht. Allel-spezifische Echtzeit-PCR-Messung spezifisch für HIV-1-Subtypen A, C und D wurden eingesetzt, um Resistenzmutationen von AZT (K70R/T215Y/T215F), NVP (K103N/Y181C) und 3TC (M184V) bei Nachweisgrenzen von bis zu 1% zu identifizieren. Ergebnisse Es zeigten sich statistisch signifikante Veränderungen im Blutbild bei Frauen unter AZT-Einnahme im Verlauf der Schwangerschaft. Zur Geburt war die mediane Erythrozytenzahl signifikant niedriger und die mediane Thrombozytenzahl signifikant höher bei Frauen der Gruppe 1 im Vergleich zu Gruppe 2. Bei der Geburt zeigten Säuglinge aus Gruppe 1 zusätzlich niedrigere mediane Hämoglobinwerte und Granulozytenzahlen. Die mediane mtDNA-Konzentration in Plazenta- und Nabelschnurgewebe war signifikant höher bei AZT-exponierten Frauen und Säuglingen gegenüber nichtexponierten. Die dmtDNA4977 wurde in Plazentaproben von jeweils einer Frau pro Gruppe und in Nabelschnurgewebeproben von drei Kindern in Gruppe 2, aber in keiner von Gruppe 1 identifiziert. HIV-1-Resistenzmutationen wurden bei 20/50 Frauen erfasst, darunter 70% Minoritätenspezies. Resistenz gegenüber AZT wurden in 11/50 (22%), NVP in 9/50 (18%) und 3TC im HIV bei 4/50 Frauen (8%) gefunden. Drei Frauen zeigten Resistenzen gegen mehr als ein Medikament. Drei von sieben vertikal infizierten Säuglingen zeigten resistente Viren. Schlussfolgerung AZT während der Schwangerschaft sowie nach der Geburt führte zu signifikanten, jedoch überwiegend milden und transienten hämatologischen Veränderungen bei Frauen und ihren Säuglingen. Pränatale AZT-Einnahme führt nicht zu einer Erhöhung des Risikos für die Entstehung von dmtDNA4977. Unter der Kombinationsprophylaxe kam es zu weniger NVP-Resistenzmutationen im Vergleich zur Prophylaxe mit einer Einmaldosis NVP, jedoch wurden AZTresistente HIV bei einem erheblichen Anteil der Frauen nachgewiesen.Introduction WHO-guidelines from 2006 for prevention of mother-to-child transmission of HIV-1 in resource-limited settings recommend complex antiretroviral prophylaxis comprising antenatal zidovudine (AZT), nevirapine single-dose (NVP-SD) at labor onset and AZT/lamivudine (3TC) during labor and one week postpartum. We assessed drug toxicities as haematological alterations and depletion and mutation of mtDNA and analysed the emergence of minor drug- resistant HIV-1 variants in Tanzanian women following complex prophylaxis in a rural area in Tanzania. Methods A cohort of HIV-positive pregnant women either with AZT intake (group 1) or without AZT intake (group 2) was established at Kyela District Hospital, Tanzania. Complete blood counts of mothers and newborns were evaluated during pregnancy, birth, weeks four to six and twelve postpartum. Mitochondrial DNA levels in placentas and umbilical cords were quantified using real-time PCR. We checked for the mitochondrial deletion mtDNA4977. Allele-specific real-time PCR assays specific for HIV-1 subtypes A, C and D were developed to quantify key resistance mutations of AZT (K70R/T215Y/T215F), NVP (K103N/Y181C) and 3TC (M184V) at detection limits of 1%. Results We found statistically significant alterations in blood count during AZT intake in pregnancy. At delivery, the median red blood cell count was significantly lower and the median platelet count was significantly higher in women of group 1 compared to group 2. At birth, infants from group 1 showed a lower median hemoglobin level and granulocyte count. The median mtDNA levels in placentas and umbilical cords of women and infants exposed to AZT were significantly higher than in AZT-unexposed women and infants. The dmtDNA4977 was found in placentas of one woman of each group and in 3 umbilical cords of AZT-unexposed infants but not in umbilical cords of AZT-exposed infants. HIV-1 resistance mutations were detected in 20/50 women, of which 70% displayed minority species. Variants of HIV-1 with AZT-resistance mutations were found in 11/50 (22%), NVP-resistant variants in 9/50 (18%) and 3TC-resistant variants in 4/50 women (8%). Three women harbored resistant HIV-1 against more than one drug. 3/7 vertically infected infants exhibited drug-resistant virus. Conclusion AZT exposure during pregnancy as well as after birth resulted in significant hematological alterations for women and their newborns, although these changes were mostly mild and transient in nature. Antenatal AZT intake did not increase the risk for the common mitochondrial deletion dmtDNA4977. Complex prophylaxis resulted in lower levels of NVP-selected resistance as compared to NVP-SD, but AZT-resistant HIV-1 emerged in a substantial proportion of women

Zidovudine Exposure in HIV-1 Infected Tanzanian Women Increases Mitochondrial DNA Levels in Placenta and Umbilical Cords

Background: Zidovudine (AZT) constitutes part of the recommended regimens for prevention and treatment of HIV-1 infection. At the same time, AZT as well as HIV-1 infection itself may induce mitochondrial damage. In this study, we analyzed the impact of prenatal AZT-exposure on mitochondrial alterations in HIV-infected women and their infants. Methods: Mitochondrial DNA (mtDNA) levels in placentas of HIV-1 infected Tanzanian women with and without prenatal AZT exposure, and in the umbilical cords of their AZT-exposed/unexposed infants were quantified using real-time PCR. Furthermore, we checked for the most common mitochondrial deletion in humans, the 4977 base pair deletion (dmtDNA4977) as a marker for mitochondrial stress. Results: 83 women fulfilled the inclusion criteria. 30 women had been treated with AZT (median duration 56 days; IQR 43–70 days) while 53 women had not taken AZT during pregnancy. Baseline maternal characteristics in the two groups were similar. The median mtDNA levels in placentas and umbilical cords of women (311 copies/cell) and infants (190 copies/cell) exposed to AZT were significantly higher than in AZT-unexposed women (187 copies/cell; p = 0.021) and infants (127 copies/cell; p = 0.037). The dmtDNA4977 was found in placentas of one woman of each group and in 3 umbilical cords of AZT-unexposed infants but not in umbilical cords of AZT-exposed infants. Conclusions: Antenatal AZT intake did not increase the risk for the common mitochondrial deletion dmtDNA4977. Our data suggests that AZT exposure elevates mtDNA levels in placentas and umbilical cords possibly by positively influencing the course of maternal HIV-1 infection

Influence of sociodemographic, economic and health-related factors on pre-delivery AZT adherence level.

<p>*Mann-Whitney U-Test.</p

Summary of used adherence outcome measures.

<p>*among hospital deliveries.</p

Profile of cohort and analyses.

<p>This figure is illustrating the formation of the cohort and of its different subgroups, including women observed in the antenatal period, women accepting/declining antenatal prophylaxis, women lost to follow-up (LTFU), women observed intra/postpartumly and infants observed postpartumly. It is indicated which analyses have been performed within the respective subgroups and where the results of those analyses are shown.</p

Risk factors for decline of pre-delivery prophylaxis.

<p>OD = odds ratio; CI = confidence interval; AOR = adjusted odds ratio.</p><p>‡Threshold calculated with software JRip.</p><p>*Variables included into multivariate analyses.</p><p>**Fisher's exact test.</p