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Antiretroviral therapy for pregnant women living with HIV or hepatitis B: What's the evidence?

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Health Evidence™ hosted a 90 minute webinar examining the effect of antiretroviral therapy for pregnant women living with HIV or hepatitis B. Click here for access to the audio recording for this webinar: https://youtu.be/91moFmIoI3w

Dr. Reed A.C. Siemieniuk, MD, PhD(c), Department of Medicine, University of Toronto, Department of Health Research Methods, Evidence, and Impact, McMaster University led the session and presented findings from their recent systematic review:

Siemieniuk R, Foroutan F, Mirza R, Mah Ming J, Alexander PE, Agarwal A, et al. (2017). Antiretroviral therapy for pregnant women living with HIV or hepatitis B: A systematic review and meta-analysis. BMJ Open, 7(9), e019022.

This review assesses the impact of various antiretroviral/antiviral regimens in pregnant women living with HIV or hepatitis B virus (HBV). Forty-three studies were included in the review. The most common comparison was tenofovir and emtricitabine versus zidovudine and lamivudine. There was no apparent difference between tenofovir-based regimens and alternatives in maternal outcomes, including serious laboratory adverse events and serious clinical adverse events. There was no difference between NRTIs in vertical transmission of HIV or vertical transmission of HBV. We found moderate certainty evidence that tenofovir/emtricitabine increases the risk of stillbirths and early neonatal mortality and the risk of early premature delivery at less than 34 weeks. Tenofovir/emtricitabine is likely to increase stillbirth/early neonatal death and early premature delivery compared with zidovudine/lamivudine, but certainty is low when they are not coprescribed with lopinavir/ritonavir. Other outcomes are likely similar between antiretrovirals.

Lyuba Lytvyn, MSc, PhD(c), Department of Health Research Methods, Evidence, and Impact, McMaster University also briefly presented the findings from their linked systematic review on values and preferences of pregnant women with HIV:

Lytvyn L, Siemieniuk R, Dilmitis S, Ion A, Chang Y, Bala M, et al. (2017). Values and preferences of women living with HIV who are pregnant, postpartum or considering pregnancy on choice of antiretroviral therapy during pregnancy. BMJ Open, 7(9), e019023.

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Antiretroviral therapy for pregnant women living with HIV or hepatitis B: What's the evidence?

  1. 1. Welcome! Antiretroviral therapy for pregnant women living with HIV or hepatitis B: What's the evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
  2. 2. Poll Questions: Consent • Participation in the webinar poll questions is voluntary • Names are not recorded and persons will not be identified in any way • Participation in the anonymous polling questions is accepted as an indication of your consent to participate Benefits: • Results inform improvement of the current and future webinars • Enable engagement; stimulate discussion. This session is intended for professional development. Some data may be used for program evaluation and research purposes (e.g., exploring opinion change) • Results may also be used to inform the production of systematic reviews and overviews Risks: None beyond day-to-day living
  3. 3. After Today • The PowerPoint presentation and audio recording will be made available • These resources are available at: – PowerPoint: http://www.slideshare.net/HealthEvidence – Audio Recording: https://www.youtube.com/user/healthevidence /videos 3
  4. 4. What’s the evidence? Siemieniuk R, Foroutan F, Mirza R, Mah Ming J, Alexander PE, Agarwal A, et al. (2017). Antiretroviral therapy for pregnant women living with HIV or hepatitis B: A systematic review and meta-analysis. BMJ Open, 7(9), e019022. https://healthevidence.org/view- article.aspx?a=antiretroviral-therapy- pregnant-women-living-hiv-hepatitis- systematic-review-33013
  5. 5. What’s the evidence? Lytvyn L, Siemieniuk R, Dilmitis S, Ion A, Chang Y, Bala M, et al. (2017). Values and preferences of women living with HIV who are pregnant, postpartum or considering pregnancy on choice of antiretroviral therapy during pregnancy. BMJ Open, 7(9), e019023. https://www.ncbi.nlm.nih.gov/pubmed/28893 759
  6. 6. • Use CHAT to post comments / questions during the webinar – ‘Send’ questions to All (not privately to ‘Host’) • Connection issues – Recommend using a wired Internet connection (vs. wireless) • WebEx 24/7 help line – 1-866-229-3239 Participant Side Panel in WebEx Housekeeping
  7. 7. Housekeeping (cont’d) • Audio – Listen through your speakers – Go to ‘Communicate > Audio Broadcast’ • WebEx 24/7 help line – 1-866-229-3239
  8. 8. Poll Question #1 How many people are watching today’s session with you? A. Just me B. 2-3 C. 4-5 D. 6-10 E. >10
  9. 9. Students: Sarah Neil-Sztramko (Postdoctoral fellow) Emily Belita (PhD candidate) Patricia Burnett (PhD candidate) Grace Thomas Research Assistant Rawan Farran Research Assistant Kristin Read Research Coordinator Heather Husson Administrative Director The Health Evidence™ Team Maureen Dobbins Scientific Director Olivia Marquez Research Coordinator Maureen Dobbins Scientific Director Claire Howarth Research Coordinator Liz Kamler Research Assistant Emily Sully Research Assistant
  10. 10. What is www.healthevidence.org? Evidence Decision Making inform
  11. 11. Why use www.healthevidence.org? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
  12. 12. A Model for Evidence- Informed Decision Making National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
  13. 13. Stages in the process of Evidence-Informed Public Health National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]
  14. 14. Poll Question #2 Have you heard of PICO(S) before? A. Yes B. No
  15. 15. Searchable Questions Think “PICOS” 1.Population (situation) 2.Intervention (exposure) 3.Comparison (other group) 4.Outcomes 5.Setting
  16. 16. How often do you use systematic reviews to inform a program/services? A. Always B. Often C. Sometimes D. Never E. I don’t know what a systematic review is Poll Question #3
  17. 17. Dr. Reed A.C. Siemieniuk MD, PhD(c), Department of Medicine, University of Toronto, Department of Health Research Methods, Evidence, and Impact, McMaster University
  18. 18. Lyuba Lytvyn MSc, PhD(c), Department of Health Research Methods, Evidence, and Impact, McMaster University
  19. 19. HIV and women http://www.unaids.org/en/resources/infographics/girls-and-women-living-with-HIV*Most are childbearing age
  20. 20. Pregnancy • >1.4 million women living with HIV become pregnant every year1 • Without any intervention, vertical transmission occurs in approximately 1/3 1. World Health Organization. Number of women living with HIV. Geneva, Switzerland: World Health Organization, 2017.
  21. 21. Vertical transmission • ART is the most effective way to reduce vertical transmission 300/1000  5/1000
  22. 22. The Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive “The road to zero new transmissions”
  23. 23. Secondary benefits Focus on reducing vertical transmission: • Fewer HIV complications in women • Building up healthcare systems • Engaging women in care for non-HIV issues • Healthier children • Few undesirable consequences
  24. 24. ART in pregnancy: woman-centered options
  25. 25. ART in pregnancy • Many options – AZT alone (the preferred option until recently) – Combination ART
  26. 26. Recommendations:
  27. 27. PROMISE
  28. 28. PROMISE
  29. 29. PROMISE
  30. 30. Should the WHO continue to recommend tenofovir as first line for pregnant women? A. Continue to recommend tenofovir B. Recommend an alternative (eg AZT) C. No recommendation Poll Question #4
  31. 31. BMJ Rapid Recommendations • https://youtu.be/KnF0AOqZD3E
  32. 32. Recommendations • Patient • Family • Healthcare provider • Society • Payer
  33. 33. Recommendations • Patient • Family • Healthcare provider • Society • Payer
  34. 34. Values and preferences – Collaborating with women living with HIV • Three women living with HIV were co-authors: Rhonda Marama Mullen (New Zealand), Teresia Otenio (United States/Kenya), and Florence Anam (Kenya) • Women-centred perspective – Two had children, one was considering having children in the future – Involved in not-for-profit advocacy work related to women living with HIV
  35. 35. Values and preferences – Collaborating with women living with HIV 1. Informed outcomes most important to women – Main concern was child’s health, not pill burden 2. Led discussion of values and preferences during teleconference 3. Helped interpret and provide context for evidence
  36. 36. Values and preferences – Systematic review of published literature
  37. 37. • 15 qualitative studies • 6 themes: reduction of vertical transmission, child’s health, side effects to child, own health, side effects to oneself, pill burden • No study weighed the relative importance of outcomes directly, but pill burden appeared to be lower priority Overall: Panel considerations aligned with empirical evidence on what mattered for most women Values and preferences – Systematic review of published literature
  38. 38. Systematic review
  39. 39. Woman 1. RCTs pregnant women 2. RCTs non-pregnant adults 3. Observational studies pregnant women Child 1. RCTs pregnant women 1. Living w/ HIV 2. Pre-exposure prophylaxis, HBV 2. RCTs non-pregnant adults 3. Observational studies pregnant women
  40. 40. Included studies
  41. 41. Woman: Acceptability
  42. 42. Woman: Mortality
  43. 43. Woman: Adverse effects
  44. 44. Child: stillbirth or early neonatal mortality
  45. 45. Premature delivery <34 weeks
  46. 46. Poll Question #5 As a pregnant woman living with HIV, do you choose: A. Tenofovir/emtricitabine B. AZT/lamivudine C. Neither
  47. 47. Additional public health considerations • “Ensuring optimal drug availability and lower costs facilitates harmonization of regimens across countries and populations. The recommendation by Siemieniuk et al would fragment the ART market across populations in low and middle income countries, thereby likely increasing risk of stock outs, raising prices and complicating supply chains. These operational realities are critical to consider when making ART recommendations that affect low- and middle-income countries, but, unfortunately, appear to not be adequately considered by the authors.” – Jennifer Cohn, Anja Giphart, Nick Hellman, Elizabeth Glaser Pediatric AIDS Foundation
  48. 48. Public Health Consideration: Different recommendations for pregnant women will complicate provision of care
  49. 49. Poll Question #6 As a public health official, do you recommend: A. Tenofovir/emtricitabine B. AZT/lamivudine C. Neither
  50. 50. Summary • TDF/FTC might increase the risk of stillbirth and neonatal mortality – Certainty is LOW • Most women place a high value on giving their child the best chance of surviving • Public health officials might sometimes place a higher value on improving access to ART
  51. 51. Poll Question #7 The information presented today was helpful A. Strongly agree B. Agree C. Neutral D. Disagree E. Strongly disagree
  52. 52. What can I do now? Visit the website; a repository of over 5,000+ quality-rated systematic reviews related to the effectiveness of public health interventions. Health Evidence™ is FREE to use. Register to receive monthly tailored registry updates AND monthly newsletter to keep you up to date on upcoming events and public health news. Tell your colleagues about Health Evidence™: helping you use best evidence to inform public health practice, program planning, and policy decisions! Follow us @HealthEvidence on Twitter and receive daily public health review- related Tweets, receive information about our monthly webinars, as well as announcements and events relevant to public health. Encourage your organization to use Health Evidence™ to search for and apply quality-rated review level evidence to inform program planning and policy decisions. Contact us to suggest topics or provide feedback. info@healthevidence.org
  53. 53. Poll Question #8 What are your next steps? [Check all that apply] A. Access the full text systematic review B. Access the quality assessment for the review on www.healthevidence.org C. Consider using the evidence D. Tell a colleague about the evidence
  54. 54. Your Feedback is Important Please take a few minutes to share your thoughts on today’s webinar. Your comments and suggestions help to improve the resources we offer and plan future webinars. The short survey is available at: https://surveys.mcmaster.ca/limesurvey/index.p hp/715768?lang=en
  55. 55. Thank you! Contact us: info@healthevidence.org For a copy of the presentation please visit: http://www.healthevidence.org/webinars.aspx

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