I was infected and diagnosed hiv+ in october 2000. I was on Sustiva and Combivir for two years and have been on a treatment interruption since may 2003. My cd4 fluctuate fron 480 to 700 and viral load is now up at 28,000. I would like to start trying to get pregnant in june of this year after I run my first marathon. My husband is hiv- so we will do artifical insemination. I did well on Sustiva and Combivir, undetectable viral loads and cd4 at 900. I know that I can't be on Sustiva when I am pregnant so I will have to start some different meds. My question is, should I start my meds now? I read that it is better to be off you meds the first three months of pregnancy, but at the same time my viral load is high. Should I start my meds now to bring it down for when I start trying to get pregnant in june and hopefully it will be undetectable by then and I can stop my meds for the first trimester? Do I stop them once I know that I am pregnant or once I start trying? Sorry, I know that they are a lot of questions, but they are all sort of related. And finally I have an excellent HIV doctor, but my obgyn eventhough I love her does not have a lot of experience with hiv pregnant women. Are there really any obgyn's who specialize in pregnant women who are hiv+? Thanks a lot for you excellent job!!!

The risk of HIV transmission increases with increasing viral load; HIV transmission is < 1% if moms have undetectable viral loads on treatment. To optimize your health and reduce the risk of transmission to yuor baby, I would recommend that you consider beginning treatment now. Some women feel more comfortable waiting to start therapy until after the first trimester (first 3 months) of pregnancy since the first trimester is when most of the baby's organs are formed. However, many, many women have been treated during their first trimester without apparent ill effect.

You are corect to point out that efavirenz is not generally recommended during pregnancy (particularly during early pregnancy) because of birth defects observed in baby monkeys whose mothers were given efavirenz during pregnancy. There are several other antivirals that could be combined into a good regimen for you. The Recommendations for the Use of Antivirals During Pregnancy (available on this web site under "Treatment Guidelines") have just been updated and have a nice discussion of available antivirals and their use during pregnancy. I would urge you to discuss your options with your HIV care provider. He/she can also likely recommend an OB/GYN who has experience in caring for HIV positive women. Good luck!