|Iniitating antiretrovirals in pregnancy
Dec 17, 2002
I am a Clinical Immunologist seeking your opinion for the initiation of antiretroviral therapy for a gynecologist who tested HIV positive during the first trimester of pregnancy. Most probably, she aquired the infection occupationally as her husband has tested negative and she denies any extramarital sexual contact. Her hemogram, urine and other routine labs are normal. She is negative for Hepatitis B and C. Her CD4 count is 215. Viral loads are not very reliable and cannot be done. Since she is approaching the 16th week of pregancy we wish to initiate antiretroviral for her. Since the use of antiretrovirals is uncommon in India, the source patient is unlikely to have been on any antiretrovirals. Our choice of medication for her is Zidovudine and Lamividine, to be combined either with Nevirapine or Nelfinavir. The problem with the latter is the high cost here and long term toxicity and also the large number of pills that might make the busy gynecologist noncompliant. Nevirapine too is toxic but in our use in more than 80 patients we have had to discontinue it in only one patient due to skin toxicity. A recent review in NEJM suggests that it could be part of therapy in pregnancy even though there are no studies to support its use throught pregnancy (as opposed to one time use). As a pragmatic compromise we plan to give her AZT+3TC with Nevirapine and change the latter to Efavirenz once she delivers. Do you agree that this is a reasonable choice or would you like to suggest something else. Thanks.
Response from Dr. Luzuriaga
In settings where combination therapy is possible, a combination of ZDV chemoprophylaxis with additional antiretroviral medications to optimize maternal health is recommended for infected women whose clinical, immunologic, or virologic status requires treatment or whose HIV-1 RNA is >1,000 copies/mL regardless of their clinical or immunologic status. Women in the first trimester of pregnancy may consider delaying the initiation of therapy until after 10--12 weeks' gestation.
With a CD4 count of 215, your patient meets most experts' criteria for initiation of therapy to optimize her health. Either of the regimens that you recommend sounds reasonable, given the low likely prevalence of resistance mutations in your setting. However, you might wish to consider the nelfinavir regimen since that would leave nevirapine for perinatal prophylaxis if maternal viral load does not fall to less than 1000 copies/ml. You mention that RNA testing is difficult, but if at all possible, I would recommend that you test at 36 weeks and use nevirapine prophylaxis if RNA is over 1000 copies/ml. If you and your patient feel that this approach is too costly or demanding, then ZDV/3TC/nevirapine throughout pregnancy is a reasonable alternative. I would also recommend follow-up for toxicities (CBC, LFT's for both regimens, glucose intolerance with PI use).
A new set of guidelines for the use of antiretrovirals during pregnancy has just been released and is available on this web site (see Treatment Guidelines) or through www.hivatis.org -- it has updated information regarding the safety of antiretrovirals during pregnancy.
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