BHIVA challenges BMJ recommendations on ART during pregnancy: tenofovir still strongly recommend
Simon Collins, HIV i-Base
On 21 September, the British HIV Association (BHIVA) took the unusual step of issuing a statement (reproduced below) to publicly challenge a recent paper from the British Medical Journal (BMJ). The statement also challenged the linked BMJ recommendations, especially over choice of ART during pregnancy.
The controversial BMJ study, published two weeks earlier, used a meta-analysis of serious outcomes related to NRTI component of ART, and concluded that zidovudine should be used in preference to tenofovir DF (TDF) or abacavir.
The methodological problems with the BMJ paper are covered in an i-Base review earlier in this issue of HIV Treatment Bulletin.
British HIV Association (BHIVA) response to BMJ article ‘Antiretroviral therapy in pregnant women living with HIV: a clinical practice guideline’  published 11 September 2017.
- BHIVA does not support recommendations of “ART in pregnant women living with HIV: a clinical practice guideline” (BMJ, 11/9/17).
- Other systematic reviews and numerous observational studies show TDF to be safe in HIV in pregnancy.
- BHIVA does agree any decision regarding ARVs should always be discussed in full with every woman.
- BHIVA’s recommendation remains to continue or to start TDF or abacavir with emtricitabine or lamivudine as a nucleoside backbone.
- We do not think this data should influence use TDF/emtricitabine for pre-exposure prophylaxis in women of child-bearing potential.
This BMJ systematic review has “strongly recommended” that pregnant women living with HIV should not be treated with the combination TDF/emtricitabine/lopinavir/ritonavir due to higher rates of early neonatal death reported in the PROMISE randomised clinical trial. 
The PROMISE trial compared the efficacy of zidovudine/single-dose nevirapine with combination protease inhibitor-based (lopinavir-ritonavir) ART using zidovudine/lamivudine or tenofovir/emtricitabine backbone to prevent mother-to-child transmission in women with CD4 cell count >350 cells/mm3.
BHIVA does not recommend the use of lopinavir/ritonavir for the treatment of HIV in adults, including in pregnant women, and certainly not at the 50% higher dose used in the third trimester in the PROMISE trial. In addition PROMISE investigated outcomes in women initiating therapy. Most women in UK will conceive on ART, most commonly with TDF/FTC backbone and this study does not address that cohort.
The systematic review also made a “weak recommendation” that zidovudine/lamivudine should be used preferentially over TDF/emtricitabine as the nucleoside backbone in pregnant women because of the lower number of stillbirths and early neonatal deaths in this arm of the PROMISE study. As both arms received lopinavir/ritonavir the BMJ panel postulates that TDF/emtricitabine is the cause of the difference. Despite the BMJ panel’s assertion that pharmacokinetic interactions between tenofovir and lopinavir/ritonavir are not relevant there are data reporting increased levels of both drugs when co-administered at standard doses.
Three previous systematic reviews [3–5] reported no increase of birth adverse events or safety events (and no increased risk of congenital anomalies) in infants exposed to tenofovir compared to non-TDF-containing regimens in HIV-exposed infants, although data remain limited and studies evaluating neonatal mortality, infant anthropometry and bone growth are required. WHO used these systematic reviews to inform their guidelines on HIV and pregnancy, which include the use of TDF-containing regimens.
In addition to these systematic reviews, there are numerous observational studies showing TDF/emtricitabine to be safe in pregnancy. For example, Zash et al  published a birth surveillance study of 47,027 pregnant women in Botswana, including 11,932 women with HIV, where preterm birth, very preterm birth, small and very small size for gestational age, stillbirth, and neonatal death were evaluated. In this very large cohort, the risk for any adverse or severe adverse birth outcome was lowest among infants exposed to a combined regimen of TDF, emtricitabine and efavirenz but all TDF/emtricitabine-based regimens were found to be safer than those with zidovudine/lamivudine as a backbone and the highest risk of adverse outcomes with observed in those women receiving lopinavir-based regimes.
The writing group agree that any decision regarding ARVs should always be discussed in full with every woman. Currently, our recommendation remains to continue or to start tenofovir or abacavir with emtricitabine or lamivudine as the nucleoside backbone (Grading: 2C). The third agent should be one of the following: efavirenz, raltegravir, rilpivirine, ritonavir-boosted darunavir or ritonavir-boosted atazanavir, as per national BHIVA Adult treatment guidelines . In addition the group does not think this data should influence decisions to use tenofovir/emtricitabine for pre-exposure prophylaxis in women of child-bearing potential.
The BHIVA guidelines on the management of HIV in pregnancy will be published for consultation later this year.
BHIVA writing group. British HIV Association (BHIVA) response to BMJ article ‘Antiretroviral therapy in pregnant women living with HIV: a clinical practice guideline’  published 11 September 2017. (21 September 2017).
- Siemieniuk RAC et al. Antiretroviral therapy in pregnant women living with HIV: a clinical practice guideline. BMJ 2017; 358: j3961.
- Fowler MG et al; IMPAACT 1077BF/1077FF PROMISE Study Team. Benefits and risks of antiretroviral therapy for perinatal HIV prevention. N Engl J Med 2016; 375: 1726–1737.
- Nachega JB et al. Safety of tenofovir disoproxil fumarate–based antiretroviral therapy regimens in pregnancy for HIV-infected women and their infants: a systematic review and meta-analysis. J AIDS: 2017; 76: 1–12.
- Wang L et al. Safety of tenofovir during pregnancy for the mother and fetus: a systematic review. Clin Infect Dis 2013; 57: 1773–1781.
- Mofenson LM et al. Tenofovir disoproxil fumarate safety for women and their infants during pregnancy and breastfeeding. AIDS 2017; 31: 213–232.
- Zash R et al. Comparative safety of antiretroviral treatment regimens in pregnancy. JAMA Pediatr 2017; Epub ahead of print.