Association of nucleoside reverse transcriptase inhibitors with adverse perinatal outcomes in pregnant women living with HIV: systematic review and meta-analysis

Abstract

Background

The WHO recommends antiretroviral therapy (ART) containing two nucleoside reverse transcriptase inhibitors (NRTIs) as backbone. WHO recommends tenofovir disoproxil fumarate combined with lamivudine or emtricitabine as first line in pregnancy, and zidovudine, abacavir or tenofovir alafenamide, combined with lamivudine or emtricitabine, as alternatives.

Objectives

This study aims to evaluate the risk of adverse perinatal outcomes in pregnant women living with HIV (WLHIV) receiving different NRTIs.

Methods

Data sources included Medline, CINAHL, Global Health, and Embase.

Study eligibility criteria

Cohort studies.

Participants

Pregnant WLHIV.

Interventions

ART regimens containing different NRTI drugs.

Assessment of risk of bias

Newcastle-Ottawa Scale and Grading of Recommendations Assessment, Development and Evaluation.

Methods of data synthesis

Random-effects meta-analysis.

Results

In total, 22 cohort studies including 124,478 pregnant WLHIV met the eligibility criteria. ART containing tenofovir disoproxil fumarate was associated with lower risk of preterm birth (risk ratio, 0.89; 95% CI, 0.81–0.97), very preterm birth (0.58; 0.40–0.86), small for gestational age (0.76; 0.59–0.98), very small for gestational age (0.60; 0.48–0.73), stillbirth (0.49; 0.31–0.78), and neonatal death (0.61; 0.40–0.93), compared with ART not containing tenofovir disoproxil fumarate. ART containing zidovudine was associated with an increased risk of very preterm birth (1.59; 1.01–2.49), small for gestational age (1.33; 1.03–1.70), very small for gestational age (1.63; 1.25–2.13), stillbirth (2.23; 1.10–4.55), and neonatal death (1.65; 1.08–2.52), compared with ART not containing zidovudine. For ART regimens also containing either lamivudine or emtricitabine, zidovudine was associated with an increased risk of very preterm birth (1.62; 1.04–2.52), small for gestational age (1.52; 1.28–1.82), very small for gestational age (1.68; 1.36–2.06), stillbirth (2.19; 1.03–4.67), and neonatal death (1.65; 1.08–2.52), compared with ART containing tenofovir disoproxil fumarate. Abacavir was not associated with adverse perinatal outcomes. Tenofovir alafenamide was not associated with low birthweight compared with tenofovir disoproxil fumarate.

Conclusions

Tenofovir disoproxil fumarate is associated with a lower risk of adverse perinatal outcomes, whereas zidovudine is associated with an increased risk of perinatal outcomes. Abacavir is not associated with adverse perinatal outcomes. Our findings support current WHO guidelines.