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Should therapy be considered?
Nov 9, 2002

Should I go on a combo therapy while I am pregnant? And if so what regime should it be? My viral load is -50 and my CD-4 counts are 1200. In 5 years since diagnosis I have not taken any HIV drugs. what do you think?

Response from Dr. Aberg

This is a great question and unfortunately one that does not have a known answer. In the past year, I have had 4 women who are pregnant with high CD4+ T-cell counts (>500) and undetectable vital loads. A couple of these women did have low level viremia at some point but not all during pregnancy.

The rationale of taking antiretroviral therapy during pregnancy is to decrease the risk of transmitting HIV to the baby. So, one could argue that in a woman such as yourself with undetectable virus already that there may be no additional benefit in taking antiretrovirals. However, I would argue in favor of taking therapy anyway. We do know from some studies that there may be differences in the amount of virus in different compartments. All we can actually say is that at the time you had your blood drawn, the blood compartment had an undetectable viral load. It doesn't tell us how much virus may be in your genital tract. Also, we do know that the amount of virus in the blood can alter with acute infections and possibly severe stress. So, I don't know if during your pregnancy you may have small increases in your virus or if you would become detectable during delivery.

So, the way I look at things is in risks and benefits. Studies suggest that a pregnant woman on combination therapy achieving an undetectable viral load by time of delivery has a <1% chance of transmitting virus. That is in the setting of therapy controlling the virus. In the setting of not taking therapy, it may be higher. One then has to weigh the pros and cons of taking therapy against the risk of the virus being transmitted to the infant. My position is that if in fact, it may prevent a baby from getting HIV than the risks from taking the therapy is worth it. So, I personally advise all my patients with low level virus or undetectable virus during pregnancy to take therapy. I also advise them to stop therapy after they deliver as they do not need to continue taking them for themsleves; however I do advise them to give the baby HIV therapy as recommended by the pediatricians.

The next question is : What therapy? This is where I think you will get a different opinion among experts. Some would say that AZT monotherapy may be enough followed by IV AZT during labor. It would be unlikely to develop AZT resistance during a short time period but it potentially could occur. Because of the lack of clinical data, I agree with the experts who would recommend combination therapy. Again, I base this only on the off-chance that there is detectable virus in the genital compartment or that at some time during the pregnancy , you are having low level virus circulating. I want to do everything we can to assure the baby is HIV negative.

So, which combination? The choice of therapy is dependent on a few factors. Do you know the person who you contracted HIV from? If so, what do you know about that person's virus? Did s/he have a resistant virus at the time you acquired it? Also, do you have any other illnesses or symptoms? We try to choose a regimen that we expect will be effective in controlling the virus as well as have the least amount of side effects and drug interactions based on your medical history and physical. All I have is the information you have given me so actually having comlete information may change my recommendation. I personally prescribe AZT/3TC and nevirapine most often in women with HIV who are pregnant. In my community, there is a prevalence of around 20% resistance to the non-nucleosides such as nevirapine so in those cases, I prescibe a protease inhibitor instead of nevirapine. Unless there are other reasons that this would not be a good choice, I would recommend that you take AZT/3TC and nevirapine. The other question you may ask is when? Again I do not know because we usually start around 12-16 weeks in order to achieve an undetectable virus. I believe in your case, you could start later, maybe around 24 weeks. My 4 patients chose to go on therapy as per the current guidleines and started bewteen 12-16 weeks.

All I can do is give you my opinion. As I said , others may have different opinions. This is no right answer and you will have decide along with your providers what is right for you. I wish you a successful pregnancy and healthy baby!

Testing and timing (or therapy and teleology)

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