In utero exposure to protease inhibitor-based antiretroviral regimens delays growth and developmental milestones in mice

PLoS One. 2020 Nov 19;15(11):e0242513. doi: 10.1371/journal.pone.0242513. eCollection 2020.


Antiretroviral therapy (ART) in pregnancy has dramatically reduced HIV vertical transmission rates. Consequently, there is a growing number of children that are HIV exposed uninfected (CHEUs). Studies suggest that CHEUs exposed in utero to ART may experience developmental delays compared to their peers. We investigated the effects of in utero ART exposure on perinatal neurodevelopment in mice, through assessment of developmental milestones. Developmental milestone tests (parallel to reflex testing in human infants) are reflective of brain maturity and useful in predicting later behavioral outcomes. We hypothesized that ART in pregnancy alters the in utero environment and thereby alters developmental milestone outcomes in pups. Throughout pregnancy, dams were treated with boosted-atazanavir combined with either abacavir/lamivudine (ATV/r/ABC/3TC), or tenofovir/emtricitabine (ATV/r/TDF/FTC), or water as control. Pups were assessed daily for general somatic growth and on a battery of tests for primitive reflexes including surface-righting, negative-geotaxis, cliff-aversion, rooting, ear-twitch, auditory-reflex, forelimb-grasp, air-righting, behaviors in the neonatal open field, and olfactory test. In utero exposure to either ART regimen delayed somatic growth in offspring and evoked significant delays in the development of negative geotaxis, cliff-aversion, and ear-twitch reflexes. Exposure to ATV/r/ABC/3TC was also associated with olfactory deficits in male and forelimb grasp deficits in female pups. To explore whether delays persisted into adulthood we assessed performance in the open field test. We observed no significant differences between treatment arm for males. In females, ATV/r/TDF/FTC exposure was associated with lower total distance travelled and less ambulatory time in the centre, while ATV/r/ABC/3TC exposure was associated with higher resting times compared to controls. In utero PI-based ART exposure delays the appearance of primitive reflexes that involve vestibular and sensory-motor pathways in a mouse model. Our findings suggest that ART could be disrupting the normal progress/maturation of the underlying neurocircuits and encourage further investigation for underlying mechanisms.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Animals
  • Anti-HIV Agents / administration & dosage
  • Atazanavir Sulfate / administration & dosage
  • Atazanavir Sulfate / toxicity*
  • Developmental Disabilities / chemically induced*
  • Dideoxynucleosides / administration & dosage
  • Dideoxynucleosides / toxicity
  • Emtricitabine / administration & dosage
  • Emtricitabine / toxicity
  • Exploratory Behavior / drug effects*
  • Female
  • Fetal Growth Retardation / chemically induced
  • Growth Disorders / chemically induced*
  • HIV Protease Inhibitors / administration & dosage
  • HIV Protease Inhibitors / toxicity*
  • Hand Strength
  • Homing Behavior / drug effects
  • Lamivudine / administration & dosage
  • Lamivudine / toxicity
  • Male
  • Mice
  • Mice, Inbred C57BL
  • Pregnancy
  • Prenatal Exposure Delayed Effects*
  • Random Allocation
  • Reflex, Abnormal
  • Reflex, Righting / drug effects
  • Sensation Disorders / chemically induced
  • Taxis Response / drug effects
  • Tenofovir / administration & dosage
  • Tenofovir / toxicity


  • Anti-HIV Agents
  • Dideoxynucleosides
  • HIV Protease Inhibitors
  • Lamivudine
  • Atazanavir Sulfate
  • Tenofovir
  • Emtricitabine
  • abacavir

Grants and funding