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WHAT COCKTAIL TO BE TAKEN DURING THE COURSE OF PREGNANCY?
Aug 20, 2002

DEAR DR. ABERG, I AM 31 YEARS OLD, HIV POSITIVE AND PLANNING TO GET PREGNANT NEXT YEAR. MY NUMBERS ACCORDING TO MY SPECIALIST ARE GOODS THAT I DON'T HAVE TO TAKE A MEDICATION, YET. MY VL IS 1,975 FROM 1180 AFTER 6 MONTHS AND MY CD4 IS 780 FROM 559 AFTER 6 MONTHS ALSO. NOW MY QUESTION IS IT NORMAL THAT MY CD4 INCREASES WITHOUT AN ANTIRETROVIRALS? MY DOCTOR ADVICES ME THAT I HAVE TO TAKE AN ANTIRETROVIRALS BEFORE I GET PREGNANT TO STABILIZE THE VIRUS TO UNDETECTABLE LEVEL, ALL THROUGHOUT MY PREGNANCY. NOW MY QUESTION IS, ISN'T THAT DANGEROUS FOR THE FETUS AT THE 1ST TRIMESTER TO TAKE A STRONG MEDICATION, WON'T IT AFFECT THE GROWING FETUS, BECAUSE I BELIEVE 1ST TRIMESTER IS THE ORGANOGENESIS STAGE, I DON'T WANT MY BABAY TO COME OUT AS A FREAK. PLEASE HELP ME..LET ME KNOW IF YOU AGREE WITH MY DOCTOR. AND WHAT ARE THE ANTIRETROVIRALS THAT I HAVE TO TAKE ON PREGNANCY? PLEASE HELP ME..THANK YOU SO MUCH..

Response from Dr. Aberg

The current guidelines suggest that women who are on antiretroviral therapy (ART) before they get pregnant stay on their ART during their pregnancy. Women who are not on ART at the time of conception should begin ART around 12-14 weeks.

The rationale behind this is that if a women is already on ART and is virologically suppressed, she should stay on this regimen to keep her HIV controlled during the pregnancy. Obviously if she develops a detectable viral load, a genotype should be obtained and the medications adjusted accordingly. If a women is not already on ART, it makes sense to wait until 12 weeks because the first trimester (12 weeeks) is the most common time during pregnancy when a woman may have morning sickness and miscarriages. Starting new drugs at this time may worsen the morning sickness or it may mask another problem. It would be difficult to know if the woman was having side effects from the new ART or from other causes. There has not been any reports of increased birth defects related to ART in women who received ART during the first trimester so we do believe it is safe to take these drugs during that time period if one needs to. Potential reasons to consider starting a woman on ART immediately would be primary HIV infection or symptomatic HIV warranting therapy. The health of the woman needs to be highest priority.

There are certain medications we avoid during pregnancy. EFV (efavirenz, sustiva) has been associated with birth defects in monkeys. The combination of DDI (didanosine, Videx) and D4T (stavudine, Zerit) has been associated with increased risk of pancreatitis and potential death in pregnant women. Some experts do not prescribe IDV(indinavir, crixivan) because they are concerned that the women may not be able to stay well hydrated and be more prone to kidney stones. There is no data to support this and this would be a personal recommendation by some experts. I have prescribed IDV during pregnancy without problems but I also have seen one women who did develop kidney stones. Also, some experts do not prescribe ABC (abacavir, ziagen) particularly during the first trimester as it may be difficult to distinguish morning sickness from ABC hypersensitivity reaction (an allergic reaction).

Based on your CD4 count and HIV viral load, it is certainly reasonable to wait until after 12 weeks to start therapy. I also usually stop ART after the delivery in someone like yourself who I would not be prescribing ART to if it wasn't for the fact you were pregnant. Depending on other factors (e.g history of premature delivery, HIV viral load, previous ART), I usually start my patients on ART bewteen 12-20 weeks. It is very important to have a genotype done to see if you have resistant virus. This will depend on where you live. For instance, in St Louis, MO where I practice, 17% of pregnant women who never had taken ART before had genotypes showing that their virus was resistant to the class of drugs called non-nucleoside reverse transcriptase inhibitors (NNRTIs) which includes NVP (nevirapine, Viramune). NVP is one of the most common drugs prescribed during pregnancy but this would not be effective in reducing HIV viral loads in women who have such mutations.

As far as your CD4 fluctuating, yes that may happen depending on the time of day your CD4 count is drawn, whether or not you had any other illnesses at the time and variablity of the assay. You should get another one drawn at about the same time of day and tested at the same lab. Also, ask your doctor what the CD4 percent is. The percent does not vary as much.

The particular regimen for you will depend on what your genotype reveals, any underlying problems you may have and what will be the most tolerable. Most of my ART-naive (never been on ART) pregnant patients are on CBV (AZT and 3TC combined in one pill called Combivir) plus NVP. If they have resistance to NNRTI's, then I use Kaletra (Lopinavir combined with ritonavir) or NFV (nelfinavir, Viracept). Occasionally I have used 3 nucleosides such as Trizivir (AZT, 3TC and ABC commbined in one pill). The regimens vary depending on whether the women has been on ART before and her underlying health.

Sorry for such a long answer. This is a very big and important topic. I suggest you take time to talk with a perinatal coordinator or HIV-experienced clinician to discuss all your concerns and needs. Remember the transmission rate to your baby may be as low as less than 1 percent if you maintain an undetectable HIV viral load during the last trimester and through delivery so it is critical that you take your ART as prescribed.

Congratulations. I wish you a successful pregnancy and healthy baby.


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