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Dolutegravir best option for women of child-bearing age with HIV

Although dolutegravir was linked to a higher risk for neural tube defects among newborns, it prevented many more deaths and HIV transmissions among women than efavirenz, according to findings published in Annals of Internal Medicine.

“Dolutegravir is superior to efavirenz for HIV antiretroviral therapy (ART) but may be associated with an increased risk for neural tube defects (NTDs) in newborns if used by women at conception,” Caitlin M. Dugdale, MD, from Massachusetts General Hospital and Harvard Medical School, and colleagues wrote.

Dugdale and colleagues used a computer model to project the clinical outcomes of ART policies, including maternal and child deaths, sexual and perinatal transmission and neural tube defects, for women with HIV of child-bearing age in South Africa (n = 3.1 million). The model evaluated three treatment strategies, including efavirenz for all women; dolutegravir for all women; and WHO-recommended efavirenz without contraception or dolutegravir with contraception.

Treatment with dolutegravir prevented 13,700 maternal deaths and 57,700 sexual transmissions of HIV, compared with efavirenz. However, dolutegravir was associated with 4,400 more total pediatric deaths due to neural tube defects.

Compared with efavirenz, the WHO approach prevented 4,900 maternal deaths and 20,500 sexual transmissions of HIV, but increased pediatric deaths by 300.

Dolutegravir demonstrated the lowest rate of combined deaths among women and children (n = 358,000), compared with the WHO approach (n = 362,800) and efavirenz (n = 367,300).

“These results argue against a blanket policy of favoring efavirenz over dolutegravir in women of childbearing potential,” Dugdale and colleagues concluded. “Rather, this study supports an open, context-specific discussion about the tradeoffs between the risks for harm and the benefits of these treatment options.”

In an accompanying editorial, Risa M. Hoffman, MD, MPH, from David Geffen School of Medicine at the University of California, Los Angeles, and Lynne M. Mofenson, MD, from the Elizabeth Glaser Pediatric AIDS Foundation, wrote that the study by Dugdale and colleagues underscores the complexity of choosing treatment for pregnant women.

“The Dugdale model may help guide policymakers in critically balancing benefits and risks as they make decisions regarding national ART policy,” they wrote. “Moving forward, context-specific discussions must occur among all stakeholders, including women living with HIV, who have the highest stake in policy decisions.” – by Alaina Tedesco

Disclosures: Dugdale reports grants from National Institute of Allergy and Infectious Diseases and Harvard University Center for AIDS Research. Hoffman reports no relevant financial disclosures. Mofenson reports receiving support from WHO. Please see study for all other authors’ relevant financial disclosures.