Ask the Expert: HIV Treatment and Pregnancy

Continuing the series of “Ask the Expert”, Dr. James Cutrell, Assistant Professor in the Department of Medicine Infectious Disease Division, comments on treatment of HIV patients who are pregnant. A topic that is definitely high-yield in preparation for internal medicine boards. Below are Dr. Cutrell’s comments:

“Here is a link to the most recent guidelines on HIV and pregnancy published in March of this year.  This is the summary of the major changes with links to the full guidelines and different sections.

http://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0/

The following are the key take home points for the residents:

  • All HIV-infected women should be virally suppressed on ART if contemplating pregnancy.
  • All HIV-infected women, either known or newly diagnosed, should be started on ART regardless of CD4 count to achieve maximal viral suppression prior to delivery and to reduce perinatal transmission of HIV.
  • IV zidovudine (AZT) is only administered intrapartum to mothers with a detectable VL > 1,000 copies/mL at time of delivery or if rapid HIV Ab screen is positive and confirmatory testing is pending.
  • Due to increased experience and longitudinal safety data, several additional ART drugs have been added to the preferred regimens in pregnancy in addition to the traditional combination of zidovudine-lamivudine and lopinavir-ritonavir.
    • NRTI: Tenofovir plus emtricitabine or Abacavir plus lamivudine
    • PI: Ritonavir-boosted atazanavir
    • NNRTI: Efavirenz only after first 8 weeks of pregnancy
  • Historically, efavirenz use has been discouraged in women of child-bearing age due to potential teratogenicity.  Although current data does not suggest a significant increase in birth defects, an increase in neural tube defects from 1st trimester exposure could not be completely excluded due to small numbers.   The US Guidelines state that women of childbearing age should have a pregnancy test and be counseled to use contraception and avoid pregnancy prior to starting efavirenz based regimens.  Women who are pursuing pregnancy should be treated with alternative regimens if possible.  However, the period of risk for the fetus is only in the first 6-8 weeks (1st trimester) which usually has past before a pregnancy is recognized; therefore, a woman who is beyond the 8 week period can be started on an efavirenz-based regimen if ART-naïve or can continue it if she is already on efavirenz and virologically suppressed and has become pregnant.
  • The UK and WHO guidelines do not recommend restrictions on the use of efavirenz in pregnancy or women desiring to have children.