I am a hiv+ woman, my husband is hiv-. We are thinking about having a baby and my doctor, a very experienced HIV doctor at the university of MN, insists that I wait to start therapy until my eleventh week of pregnancy. My viral load is approx. 30,000 and my cd4 are at a stable 500s. I have been hiv+ since 2000 when I started on Sustiva and Combivir. I was one of the few unfortunates to suffer from mild lipodistrophy on that regimen. I had responded so well and was so healthy otherwise that my doctor suggested a treatment interruption. I have been off my meds for two years now feeling healthier than ever in my life, training for a full marathon. My doctor believes that I should become pregnant first and not start my meds until my eleventh week of pregnancy to avoid toxicity and to avoid resistency in case the nausea has me vomiting my meds. He trusts I will do well on my new regimen due to my healthy lifestyle and due to how I made sure to take my meds so religiously before. He believes that even with my labs the way they are now I will succesfully lower my VL to undetectable before I give birth to my baby. I am confused because nobody seems to agree with my doctor. Please let me know what you think about his reasoning.

Antiretroviral therapy would not generally be recommended for a woman with a viral load of 30,000 and a CD4 count in the 500's. However, most experts would recommend therapy if you were pregnant to optimize your health and minimize the risk of transmitting the virus to your baby. As you point out, you have a couple of options regarding when to start therapy. Some experts recommend waiting until after the first trimester (first 12 weeks of pregnancy), in order to minimize the baby's exposure to the antivirals when the baby's organs are forming. Others recommend starting meds and driving viral load to undetectable before a woman gets pregnant. Since accumulating evidence suggests that most antivirals (with the exception of Sustiva) are safe for administration during pregnancy, I would favor the latter approach. However, I would urge you to read as much as you can and discuss this again with your doctor. The "Guidelines for the use of antiretroviral agents during pregnancy" (available on this web site under the "Treatment Guidelines" section) has a lot of good information on the use of antivirals during pregnancy, including dosing, potential side effects, recommended regimens, etc.).