by Carolyn Chu, MD, MSc, AAHIVS, AAHIVM Chief Medical Officer

March 12, 2024

Featured Literature:

Dadabhai S, Chou VB, Pinilla M, et al.; for the IMPAACT PROMISE 1077BF/FF team.  Effects of preterm birth, maternal ART and breastfeeding on 24-month infant HIV-free survival in a randomized trial.  AIDS.  2024 Mar 4.  doi: 10.1097/QAD.0000000000003878.  PMID: 38427596.

This was a planned secondary analysis of PROMISE/1077 study data to assess the impact of preterm and very preterm, antenatal ARVs, and infant feeding type on 24-month overall and HIV-free survival outcomes.  Maternal regimens included three arms: (a) oral zidovudine (ZDV) during pregnancy followed by a single dose of nevirapine (NVP) and double dose of tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) at labor onset, followed by a one-week TDF/FTC “tail”; (b) antepartum zidovudine/lamivudine/boosted lopinavir continued through the first week post-delivery; and (c) antepartum TDF/FTC/boosted lopinavir through the first week post-delivery.  All infants received NVP prophylaxis for six weeks; qualifying breastfeeding dyads underwent further randomization to either continued daily infant NVP or maternal TDF-based ART through breastfeeding cessation.  3535 infants born to mothers enrolled between 2011 and 2015 were included in analyses.  Median GA at delivery was 39 weeks; 83% were born full-term and 17% preterm (14% born ≥34 to <37 weeks and 3% born <34 weeks).  Preterm birth <37 weeks was associated with decreased 24-month HIV-free survival compared to full-term birth.  Infants with antenatal TDF-based ART exposure had greater risk of HIV infection or death by 24 months compared to ZDV-based ART, when adjusted for breastfeeding.  Breastfeeding was protective against risk of HIV infection or death when adjusted for maternal antenatal ART arm.

Author’s Commentary:

This analysis reinforces the importance of preventing preterm delivery and monitoring of pregnancy outcomes for women with HIV (and their exposed infants), especially with the almost universal adoption of second generation INSTIs as first-line ART.  Further work is needed to explore the mechanisms linking specific ARVs to preterm delivery, as these are still somewhat unclear.  Importantly, these findings highlight the health and survival benefits of early breastfeeding—given the benefits of breastmilk particularly for preterm infants, ongoing attention to identifying optimal approaches to the care of premature HIV-exposed infants is especially critical.  

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