Journal of Applied Hematology

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 9  |  Issue : 3  |  Page : 95--100

Hematological profile of newborns exposed to maternal human immunodeficiency virus and antiretroviral therapy


Ibrahim Abdulqadir1, Aminu Abba Yusuf2, Muhammad Alhaji Ndakotsu1, Abubakar Umar Musa1, Mujtaba Mashi Isyaku3, Sagir Gumel Ahmed2, Jamilu Tukur4,  
1 Department of Haematology and Blood Transfusion, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Haematology and Blood Transfusion, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Haematology and Blood Transfusion, Federal Medical Center, Katsina, Nigeria
4 Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria

Correspondence Address:
Dr. Ibrahim Abdulqadir
Department of Haematology and Blood Transfusion, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria

Abstract

BACKGROUND: Thousands of pregnant women are infected with human immunodeficiency virus (HIV) and some of them take antiretroviral therapy (ART) either for their own health or as a means of preventing mother-to-child transmission. This entails fetal exposure to drugs with attendant effect on hematological parameters. AIMS: The aim of this study is to determine the effect of maternal HIV and ART on hematological profile of newborns. SETTINGS AND DESIGN: Comparative cross-sectional study involving 70 each of HIV- and ART-exposed and HIV- and ART-unexposed newborns at Aminu Kano Teaching Hospital, Kano, Nigeria. SUBJECTS AND METHODS: Cord blood was collected for hemogram, reticulocyte count, and erythrocyte sedimentation rate. STATISTICAL ANALYSIS USED: Data were analyzed using SPSS version 20 and P < 0.05 was considered statistically significant. RESULTS: The mean hematocrit, platelet, and reticulocyte counts of the HIV-exposed newborns were significantly lower than those of HIV-unexposed (P < 0.05). Among HIV-exposed newborns, newborns of mothers with CD4+ T-cell <350/μl had significantly lower hematological parameters than those of mothers with CD4+ T-cell ≥350/μl (P < 0.05). Furthermore, HIV-exposed newborns of mothers on second-line ART had significantly lower hematological parameters than HIV-exposed newborns of mothers on the first-line ART (P < 0.05). There was positive correlation between maternal CD4+ T-cell count and newborns' hematocrit (r = 0.71), platelet count (r = 0.54), and reticulocyte count (r = 0.63). CONCLUSIONS: Newborns exposed to maternal HIV and ART had lower hematological parameters than HIV-unexposed newborns and maternal CD4+ T-cell count <350/μl and second-line ART were significantly associated with lower hematological parameters.



How to cite this article:
Abdulqadir I, Yusuf AA, Ndakotsu MA, Musa AU, Isyaku MM, Ahmed SG, Tukur J. Hematological profile of newborns exposed to maternal human immunodeficiency virus and antiretroviral therapy.J Appl Hematol 2018;9:95-100


How to cite this URL:
Abdulqadir I, Yusuf AA, Ndakotsu MA, Musa AU, Isyaku MM, Ahmed SG, Tukur J. Hematological profile of newborns exposed to maternal human immunodeficiency virus and antiretroviral therapy. J Appl Hematol [serial online] 2018 [cited 2019 Mar 25 ];9:95-100
Available from: http://www.jahjournal.org/text.asp?2018/9/3/95/244538


Full Text

 Introduction



Human immunodeficiency virus (HIV) constitutes serious health challenge among women with estimated 1.3 million positive pregnancies in Sub-Saharan Africa in the year 2010 and in Nigeria about 26.5% of all HIV-infected pregnancies led to newborn infection in the year 2011.[1],[2] Judicious use of antiretroviral therapy (ART) can reduce the risk of mother-to-child transmission (MTCT) from over 40% to <2%.[3],[4],[5] This made WHO in the year 2013 to recommend the use of triple ART for all pregnant women and breastfeeding mothers who are HIV positive irrespective of their CD4 count or clinical stage.[1] However, in spite of the potential benefit of ART in prevention of MTCT (PMTCT) and the WHO recommendation, only about 11% of these HIV-infected pregnant women have access to ART either for their own health or as a means of PMTCT of HIV in Nigeria.[2],[6] This entails in utero exposure of the fetus to drugs that could affect its hematological profile. Although many studies have established the safety of this intervention, yet it is associated with significant alterations of the hematological profile of newborn.[4],[7],[8],[9] There is no study in this part of the country that has previously evaluated the effect of maternal HIV and ART on the hematological profile of the newborns. Hence, this study aimed to determine the hematological profile of newborns exposed to maternal HIV and ART.

 Subjects and Methods



This was a prospective, comparative, cross-sectional study conducted among 70 each of HIV- and ART-exposed and HIV- and ART-unexposed newborns delivered through spontaneous vaginal delivery with Apgar score ≥8 at 5 min in labor ward of Aminu Kano Teaching Hospital from October 2014 to December 2016. The number of participants enrolled into this study was calculated from a prevalence rate of HIV among pregnant women delivered in the same labor ward between 2003 and 2005.[10] Excluded from the study were newborns delivered by women with sickle cell disease, hypertension and liver, renal or endocrine diseases, and newborn of mothers tested positive to Hepatitis B and C viruses. Furthermore, excluded from this study were newborns delivered by HIV-positive women who were not on ART for at least 3 months as well as newborns delivered with obvious congenital deformity. Exposed newborns that have positive HIV DNA polymerase chain reaction test at 6 weeks of life were also excluded from the study.

Clinical data (evidence of sickle cell disease, hypertension, diabetes, liver and renal disease, ART usage and type, most recent CD4+ T-cell count, and routine antenatal care drugs such as hematinics and intermittent prevention therapy for malaria) of the pregnant women were extracted from their case folders. The umbilical cord of the newborns was double clamped in the standard way and the area in between the clamps was clean with 70% ethanol swabs followed by betadine swabs. Four milliliters of blood were collected each from the umbilical cord of the newborns and antecubital veins of the pregnant women into K2-ethylenediaminetetraacetic acid and plain bottles. Samples were processed within 4 h of collection. Informed written consent was obtained from each mother and the study was approved by the Research Ethics Committee of the Hospital.

In this study, exposed newborns refer to newborns delivered by HIV-positive women on triple antiretroviral drugs for at least 3 months before delivery, while unexposed newborns refer to newborns delivered by HIV-negative women and thus not on ART. Exposed newborns were categorized according to maternal CD4+ T-cell count (born by mothers with CD4+ count <350/ml and CD4+ count ≥350/ml) and type of ART (born by mothers on first-line regimen and second-line regimen).

Full blood count was conducted with Swelab Alfa 3-part differentials Coulter (Boule Medical Diagnostics, Sweden) while reticulocyte count and erythrocyte sedimentation rate (ESR) were determined manually. Serologic tests for HIV and Hepatitis B and C of the maternal serum were conducted with Determine™ HIV-1/2 Ag/Ab Combo, Ascon, and Healgen, respectively. DNA PCR analysis of the dry blood spot of exposed newborns was performed by COBAS-TagMan 48 (Roche Diagnostics, USA).

Data analysis was performed using Statistical Package for the Social Sciences version 20 (IBM Corp. Armonk, NY) and result presented as mean (± standard deviation). Independent sample t-test was used to compare means of hematological parameters while Pearson parametric correlation and partial correlation analyses were used to test for association as appropriate and P < 0.05 was considered statistically significant.

 Results



The data set was tested for normality using Shapiro–Wilk test (P > 0.05) and homogeneity of variances using Levene's test for homogeneity of variances (P > 0.05) and all other underlying assumptions of each statistical test were satisfied before the analysis was carried out.

There was no significant difference between the two groups of newborns in term of mean birth weight (P = 0.43) and sex (χ2 = 2.391, df = 4, P = 0.87).

The mean hematocrit, platelet count, and reticulocyte count of the exposed newborns were significantly lower than that of their unexposed counterparts (P < 0.05). Other hematological parameters and results of comparison between these parameters for the two groups of newborns were as depicted in [Table 1]. The results of comparison between hematological parameters of exposed newborns according to maternal CD4+ T-cell count are depicted in [Table 2] and shows that, newborns of mothers with CD4+ T-cell <350/μl had significantly lower hematocrit, platelet count, and reticulocyte count than those of mothers with CD4+ T-cell ≥350/μl (P < 0.05). In addition, exposed newborns of mothers on the second-line ART had significantly lower hematocrit, platelet count, and reticulocyte count than exposed newborns of mothers on the first-line ART (P < 0.05) as depicted in [Table 3]. There was positive correlation between maternal CD4+ T-cell count and exposed newborns' hematocrit (r = 0.71), platelet count (r = 0.54), and reticulocyte count (r = 0.63) and this same correlation persisted after controlling for the corresponding maternal parameters using partial correlation analysis. The results of association between hematological parameters of exposed newborns and maternal CD4+ T-cell count is depicted in [Table 4], while the scatter plots of maternal CD4+ T-cell count and newborns' hematological parameters are depicted in the [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].{Table 1}{Table 2}{Table 3}{Table 4}{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}

 Discussion



All exposed newborns in this study did not receive any intervention (such as nevirapine) for PMTCT before cord blood sample collection. We report lower values of hemoglobin, reticulocyte count, and platelets count among exposed newborns in relation to their unexposed counterparts. However, we did not find any significant difference between the two groups of newborns in term of mean corpuscular volume, red cell distribution width, total white blood cell count, and its differentials as well as ESR. Although Schramm et al. did not find any difference in terms of hematological parameters between exposed and unexposed newborns, our findings were similar to those reported by other studies.[9],[11],[12],[13]

These findings could be due to in utero exposure of the newborn to maternal cytokines and/or antiretroviral drugs leading to either decreased production or increased destruction of the affected cells. However, the finding of low reticulocyte count together with low cell counts may suggest decreased production rather than increased destruction. Decreased cells production can arise from generalized suppression of hemopoiesis or specific inhibition of erythropoiesis and megakaryopoiesis. The inhibitory cytokines and myelosuppressive drugs in the maternal circulation may be capable of crossing the placenta to suppress fetal hemopoiesis as well. This assumption is corroborated by the detection of high concentration of hemopoietic inhibitory cytokines such as tumor necrosis factor-α and interferon-α, β, and γ in cord blood of HIV-exposed newborns.[11],[14] The cord blood mononuclear cells of HIV-exposed newborns have also been shown to have increased production of these hematopoietic inhibitory cytokines.[11],[14] Furthermore, many antiretroviral drugs including both NRTI, nonnucleoside reverse transcriptase inhibitor, protease inhibitor, and integrase inhibitors have been shown to the cross placenta at a rate sufficient enough to reach cord blood concentration similar to or even higher than maternal blood concentration in some cases.[15],[16],[17] However, why the white blood cells are spared from the suppressive effects of inhibitory cytokines and antiretroviral drugs is unknown. It is likely white cells are able to withstand the suppressive effect better and/or recover from it early. This can be speculated from the physiology of white cells such as additional primary site of lymphopoiesis, lymphocytes maturation site outside the bone marrow, longer lifespan of lymphocytes, and high turnover of neutrophils.[18],[19],[20]

We report significant positive correlation between maternal CD4 count and hematological parameters of exposed newborns. Similar association between maternal CD4 count and hemoglobin and platelets count of HIV-exposed newborns was earlier reported by Pacheco et al.[21] This probably arose because CD4 count is an important determinant of disease severity. As such women with low CD4+ T-cell count will likely have low hematological parameters on their own, higher concentration of hemopoietic inhibitory cytokines, and increased risk of transmitting HIV to their newborn infants.

Although we are not aware of any study that previously determined the association between type of ART (i.e., first and second line) and hematological parameters of exposed newborns, this study reports significant lower hematological parameters among newborns of mother on the second-line ART and this is irrespective of the composition of second-line ART. Furthermore, this finding can be interpreted in the same line of disease severity as women who failed the first-line regimen are assumed to have more advanced disease.

This study could not differentiate neonatal hematological parameter due to exposure to maternal HIV alone from those due to ART exposure and/or combination of the two, as all the HIV-positive pregnant women enrolled into our study were already commenced on ART.

 Conclusions



In conclusion, newborns exposed to maternal HIV and antiretroviral drugs had low hematological parameters than their HIV-unexposed counterparts and even among HIV-exposed newborns maternal CD4+ T-cell count <350/μl and the second-line ART were significantly associated with low hematological parameters. This will serve as a guide for the care of growing population of HIV-exposed infant in the era of PMTCT.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1WHO Consolidated Guidelines on the use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach; 2013. Available from: http://www.who.int/hiv/pub/guidelines/en/. [Last accessed on 2014 Jan 20].
2Global AIDS Response Country Progress Report. Nigeria. Abuja: GARPR; 2012. Available from: http://www.unaids.org/./knowyourresponse/countryprogressreports/2012coun. [Last accessed on 2014 Jan 20].
3National Guidelines for Prevention of Mother to Child Transmission of HIV in Nigeria. Abuja: Federal Ministry of Health; 2010. Available from: http://www.emtct-iatt.org/wp./Nigeria_National-PMTCT-Guidelines_2010.pd. [Last accessed on 2014 Mar 03].
4Leroy V, Karon JM, Alioum A, Ekpini ER, Meda N, Greenberg AE, et al. Twenty-four month efficacy of a maternal short-course zidovudine regimen to prevent mother-to-child transmission of HIV-1 in West Africa. AIDS 2002;16:631-41.
5McIntyre J. Maternal health and HIV. Reprod Health Matters 2005;13:129-35.
6Nkwo P. Prevention of mother to child transmission of human immunodeficiency virus: The Nigerian perspective. Ann Med Health Sci Res 2012;2:56-65.
7Prevention of Mother to Child Transmission of HIV: Expert Panel Report and Recommendations to the U.S. Congress and U.S. Global AIDS Coordinator; 2010. Available from: http://www.pepfar.gov/documents/organization/135465.pdf. [Last accessed on 2014 Jan 11].
8Kesho Bora Study Group, de Vincenzi I. Triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV-1 (Kesho Bora study): A randomised controlled trial. Lancet Infect Dis 2011;11:171-80.
9Bunders MJ, Bekker V, Scherpbier HJ, Boer K, Godfried M, Kuijpers TW, et al. Haematological parameters of HIV-1-uninfected infants born to HIV-1-infected mothers. Acta Paediatr 2005;94:1571-7.
10Tukur J, Galadanci H, Adeleke SI, Mukhtar-Yola M. Outcome of delivery among HIV positive mothers at Aminu Kano teaching hospital, Kano. Niger J Med 2007;16:34-7.
11Borges-Almeida E, Milanez HM, Vilela MM, Cunha FG, Abramczuk BM, Reis-Alves SC, et al. The impact of maternal HIV infection on cord blood lymphocyte subsets and cytokine profile in exposed non-infected newborns. BMC Infect Dis 2011;11:38.
12Schramm DB, Anthony F, Mathebula B, Sherman G, Coovadia A, Gray GE, et al. Effect of maternal HIV-1 status and antiretroviral drugs on haematological profiles of South African infants in early life. Open AIDS J 2010;4:156-65.
13Bae WH, Wester C, Smeaton LM, Shapiro RL, Lockman S, Onyait K, et al. Hematologic and hepatic toxicities associated with antenatal and postnatal exposure to maternal highly active antiretroviral therapy among infants. AIDS 2008;22:1633-40.
14Afran L, Garcia Knight M, Nduati E, Urban BC, Heyderman RS, Rowland-Jones SL, et al. HIV-exposed uninfected children: A growing population with a vulnerable immune system? Clin Exp Immunol 2014;176:11-22.
15McCormack SA, Best BM. Protecting the fetus against HIV infection: A systematic review of placental transfer of antiretrovirals. Clin Pharmacokinet 2014;53:989-1004.
16Else LJ, Taylor S, Back DJ, Khoo SH. Pharmacokinetics of antiretroviral drugs in anatomical sanctuary sites: The fetal compartment (placenta and amniotic fluid). Antivir Ther 2011;16:1139-47.
17Cespedes MS, Castor D, Ford SL, Lee D, Lou Y, Pakes GE, et al. Steady-state pharmacokinetics, cord blood concentrations, and safety of ritonavir-boosted fosamprenavir in pregnancy. J Acquir Immune Defic Syndr 2013;62:550-4.
18Summers C, Rankin SM, Condliffe AM, Singh N, Peters AM, Chilvers ER, et al. Neutrophil kinetics in health and disease. Trends Immunol 2010;31:318-24.
19McCracken JM, Allen LA. Regulation of human neutrophil apoptosis and lifespan in health and disease. J Cell Death 2014;7:15-23.
20Tough DF, Sprent J. Lifespan of lymphocytes. Immunol Res 1995;14:1-12.
21Pacheco SE, McIntosh K, Lu M, Mofenson LM, Diaz C, Foca M, et al. Effect of perinatal antiretroviral drug exposure on hematologic values in HIV-uninfected children: An analysis of the women and infants transmission study. J Infect Dis 2006;194:1089-97.