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HIV infection during pregnancy

Management: - pregnant women with HIV should be started on antiretroviral treatment regardless or CD4 count or not they have clinical symptoms. - all patients should have access to CD4 testing & routine viral load monitoring. - antiretroviral prophylaxis during pregnancy can reduce the risk of transmission to the infant [3] - see acquired immunodeficiency syndrome for antiretroviral regimens a) zidovudine, lamivudine & lopinavir/ritonavir may be the preferred combination during pregnancy b) nucleoside reverse transcriptase inhibitor options - tenofovir, abacavir, zidovudine [6] - tenofovir disoproxil fumarate safe - tenofovir alafenamide not recommended [4] c) antiretroviral protease inhibitor options - lopinavir/ritonavir, atazanavir/saquinavir, atazanavir/darunavir [6] d) efavirenz - not teratogenic [4] - may be continued in women who become pregnant [6] e) nevirapine - may be continued in pregant women doing well - should not be initiated in pregnant women with CD4 counts >250 cells/mm3 or liver disease [6] f) too little experience with etravirine or rilpivirine g) raltegravir may be considered as an alternative agent h) dolutegravir, elvitegravir, enfuvirtide & maraviroc, bictegravir, & tenofovir alafenamide are not recommended because of a lack of safety data [4,6] - avoid dolutegravir in 1st 8 weeks [4] i) tenofovir-emtricitabine should not be a 1st treatment choice [9] - coinfection with hepatitis B may be indication for tenofovir-emtricitabine [9] j) zidovudine + lamivudine [9] - zidovudine (AZT) should be administered to women near delivery if viral load exceeds >1000 copies/mL or is unknown [6] - HIV-exposed neonates should receive AZT for 4-6 weeks, with nevirapine added in the first few days of life if maternal infection is uncontrolled [6] Notes: - postpartum maternal viral suppression in women diagnosed with HIV1 infection during pregnancy is < 50% [7] - 13% do not receive HIV-related care until after delivery - 40% have <=1 viral load test within 1 year of delivery [7]

Related

perinatal transmission of HIV

General

infection in pregnant patients human immunodeficiency virus-1 (HIV-1)

References

  1. AIDS info: US Department of Health and Human Services AIDSinfo: http://aidsinfo.nih.gov
  2. Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States July 6, 2006 http://aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf (corresponding NGC guideline withdrawn March 2016)
  3. Use of antiretroviral drugs for treating pregnant women and preventing HIV Infection in infants World Health Organization Nov. 2009 http://www.who.int/hiv/pub/mtct/rapid_advice_mtct.pdf corresponding NGC guideline withdrawn Feb 2016
  4. Medical Knowledge Self Assessment Program (MKSAP) 16, 18, 19. American College of Physicians, Philadelphia 2012, 2018, 2021.
  5. Thompson MA et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society - USA panel. JAMA 2012 Jul 25 ; 308:387. PMID: 22820792 http://jama.jamanetwork.com/article.aspx?articleid=1221704
  6. Zuger A Use of Antiretroviral Drugs in Pregnancy. Physician's First Watch, April 22, 2014 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. 2014. AIDSinfo. Clinical Guidelines Portal. March 28, 2014. http://aidsinfo.nih.gov/Guidelines/HTML/3/perinatal-guidelines/0 (corresponding NGC guideline withdrawn March 2016)
  7. Swain CA, Smith LC, Nash D et al. Postpartum human immunodeficiency virus care among women diagnosed during pregnancy. Obstet Gynecol 2016 Jul; 128:44 PMID: 27275796
  8. AIDSinfo: Maternal-Child Transmission http://aidsinfo.nih.gov/guidelines/default_db2.asp?id=66 - Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. http://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf (corresponding NGC guideline withdrawn March 2016)
  9. Young K, Fairchild DG, Hefner JE New Guidelines Issued on HIV Treatment During Pregnancy. Physician's First Watch, Sept 12,2017 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org