Graduate School

Journal #1

Contemporary issues in Pregnancy (and Offspring) in the Current HIV Era

Allison Rose Eckard, Stephanie E. Kirk, Nancy L. Hagood

Course:

Contemporary Issues on Professional Practice

Jennilyn P. Talavera-Nopueto MD
Masters in Hospital Administration
Contemporary issues in Pregnancy (and Offspring) in the Current HIV Era

Allison Rose Eckard, Stephanie E. Kirk, Nancy L. Hagood

SUMMARY
HIV infection has been an ongoing pandemic that does not cease to increase
exponentially. Although the prognosis for this infection has long been improved, several issues in
treatment and management of infected patients still exists.

One such dilemma is treating HIV positive mothers during pregnancy.

The benefit of anti-retroviral treatment (ART) has been established. It has also been
proven that treatment with ART dramatically decrease the chances of transmitting the virus thru
the placenta while pregnant.

However, occurrences of other health problems in the newborn have been documented in
mothers taking ART. This paper aims to look into these instances and attempt to shed light on
the role of ART in pregnant women and how the therapy may cause health concerns for their
newborn.

The most commonly used antiretroviral for prevention of maternal to child transmission
(PMTCT) is Zidovudine. This has caught the attention of researchers for it appears to have a
significant effect on mitochondrial DNA (mtDNA) levels. There were reports of seizures,
developmental delays, and other anomalies in newborns whose mothers were treated with this.
It, however, is reassuring that these clinical findings were found to be rare and have not been
seen in other studies.

There were also instances of newborn who were SGA (Small for Gestational Age), Low
Birth Weight (LBW) and born prematurely. The authors believe that this might be due to several
biomechanisms associated with therapy arising from immunosuppression. Preterm delivery was
seen to be highest with pregnant women treated with Lopinavir/Ritonavir (LPV/r).

On infant growth and weight, there appears to be an impairment on both aspects. It was
shown in a recent research that infants born to mothers undergoing ART had significant stunting
by one year of age. This finding, however, was known to be multifactorial, and so needs additional
validation and continuous research to determine causation.
 Metabolic concerns were also raised. A number of HIV-Exposed Uninfected (HEU) infants
were known to have developed altered insulin metabolism at 6 weeks of age. Long term
complications, however, is still left to be seen.

There is an increased in mortality in HEU infants compared to HIV-Unexposed Uninfected

(HUU) infants. Comparably, there is a 60-70% risk of death in HEU over the first 24 months of
life. Recent studies show that this might be associated with an increased infection rate. Although
this finding was seen to be multifactorial as well, infants who were born in more favorable
environments with better maternal status seemed to have no apparent immunity from this
condition.

Several other conditions were stated and analyzed including immune dysfunction,
congenital and cardiac abnormalities, and cancer risk. All instances were associated with
increased incidences in HEU infants, but the authors also stressed the fact that these needed
further looking into with regards to its probable cause and effect relationship with ART. Long term
complications would need to be documented as well.

Reflection

Until October 2020, there has already been 81,169 HIV and AIDS cases in the Philippines
from the beginning of 1984. This is according to the DOH HIV/AIDS and ART registry. In 2019
alone, about 90 pregnant women were diagnosed to be HIV positive while bearing their child. This
from around 70 cases in 2018.

HIV infection sees no slowing down. Thankfully diagnosis and treatment seem to be
catching up. ART in pregnant women saw a dramatic and considerable decrease in maternal to
child transmission.

The aggressiveness of the therapy, although favorable in suppressing the virus, is meant
to have other possible complications in infants born to mothers who were under the treatment
program. Antiretrovirals were naturally designed to suppress the virus, hence expected to have
an implication on fetal development on the cellular level.

It is imperative that this study would be continued using cohort design to be able to
determine a definitive causative relationship between the ART agents and the seen complications
mentioned in this paper. This way, the therapy can be modified and the agents that would be
proven to be more harmful than beneficial would be discontinued. This would pave a way for
innovative new treatment strategies and regimen.

Application to profession

Physicians are always faced with the dilemma of balancing benefits with harm especially
with agents that were specifically used to target cellular mechanisms such as anti-retroviral
therapy for HIV. Patients need to be screened and monitored diligently to be able to alter their
regimen accordingly and prevent untoward complications.

This is especially true with immunosuppressed individuals, not only with HIV infected
patients, but also those receiving chemotherapy and, as was brought to focus on this paper,
pregnant women.

You have to take care and assess two patients in pregnant mothers, one is the patient
themselves, the other is the patient inside their womb. As if treatment with immunosuppressive
drugs were not difficult and tedious in itself for patients with depressed immune system, we also
have to consider very important factors such as placental transmission and fetal well-being.

Most of the time compromise needs to be made.

The paper attempted to put incidence and prevalence numbers on these cases, however,
since pregnancy is really a complicated and multifactorial process, current data without enough
cohort studies would prove to be lacking and unsubstantial.

It however hopes to spark inspiration for succeeding research and hopefully would be the
basis for therapies with better long-term effects and broader safety profile than what we have and
utilize now. |