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AIDS Drugs During delivery
Jul 18, 2000

I am planning a pregnancy and would like your opinion on the best drugs to take during delivery. I was on AZT monotherapy from 92-94 at 300mg. Presently I am successfully taking DDI, D4T and Viramune: VL <25, CD4 300. My pre HAART VL has never gone above 4000. I have not taken any other AIDS medications than those listed above. I may be resistant to AZT because of my monotherapy use (we can't test because I am undetectable) and I should not combine AZT and D4T. What would you suggest would be the best regime for delivery given that standard care is AZT as part of drug regimen and AZT IV during delivery given that it doesn't look like its in my or the baby's interest to take AZT. I am content with staying on my present regimen with no changes/additions as long as I am undetectable.

Additionally, I was wondering what might be the best drug regimen for my newborn given my possible AZT resistance and D4T likely being in the babies blood. I had preferred viramune for the baby but recently saw a study that one dose of viramune would not produce enough blood concentration in newborns whose mothers took viramune prior to delivery.

Thanks for your help.

Response from Dr. Luzuriaga

Since your viral load seems to be well-controlled, I agree with your decision to continue your current regimen. With low viral load, your chances of transmission are much reduced.

For your baby, I would probably recommend AZT and nevirapine or ddI and nevirapine. We know that AZT works to prevent HIV transmission even when moms have received AZT. Your concerns regarding the potential of AZT resistant viruses with your past history of AZT therapy are well-founded. However, you've been off AZT for a while and with low viral load, your chances of passing viruses resistant to AZT are low. You also had concerns about passing stavudine to your infant and then treating your infant with AZT. If your baby is not treated with stavudine, he/she will clear the stavudine. ddI is another alternative, but is a drug with which we have much less experience to prevent HIV transmission.

Given nevirapine's track record in preventing HIV transmission, I would recommend it as part of your baby's regimen. Again, with well-controlled viral load, I think that the chance of you having nevirapine-resistant virus is low. Nevirapine can still be used when moms have received it -- dosing adjustments can be made. Since dosing recommendations for all antiretroviral agents differ for newborns and can vary with some circumstances, I would recommend that your obstetrical and pediatric care providers consult with someone expert in caring for HIV-exposed or infected babies for the exact doses.

You might have noticed that all drugs that I have recommended are reverse transcriptase inhibitors and thus block an early step in replication of the virus. While regimens containing protease inhibitors are recommended to prevent adult HIV infection after certain exposures (health care workers, etc), they act at a later step in the viral cycle and we have very little information on how to dose most protease inhibitors in newborns. So, at this time I'm less enthusiastic about including protease inhibitors in regimens to prevent HIV transmission to babies.

Katherine Luzuriaga, M.D.

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