The Body Covers: The 7th Conference on Retroviruses and Opportunistic Infections
State of the Art Lecture: Management of the HIV-Infected Pregnant Woman
Mary Jo O'Sullivan
University of Miami Sch. of Med., Florida
January 31, 2000
Click Here to Listen to the Original Lecture
The prevention of neonatal HIV infection has been one of the true triumphs of antiretroviral therapy. Dr. O'Sullivan reviewed the state of the art of caring for the HIV-infected pregnant patient.
All pregnant women should be offered screening for HIV infection. At some sites, this is voluntary and at others, routine. The acceptance rate for voluntary screening is as high as 96% and the perception of provider attitude toward testing is the main determinant of whether testing is accepted.
Evaluation of Disease Status
In addition to routine prenatal labs, laboratory work-up should include toxoplasma gondii IgG and IgM, and CMV IgG and IgM. Both toxoplasma and CMV can reactivate in patients with impaired immunity. Prophylaxis is available for toxoplasma for patients with advanced disease. A baseline CD4+ and RNA are needed to determine the status of the patient's immune system and the need for antiretroviral therapy and prophylaxis. All patients should have a PPD skin test, and two controls should be used if CD4+ count is <500 cells/µl. A positive PPD should be evaluated and treated as usual, while a negative PPD with positive controls requires no further evaluation. A positive PPD with negative controls should be followed by a chest X-ray.
For patients with more advanced disease, PCP or MAC prophylaxis should be instituted. Varicella prophylaxis with acyclovir 800 mg TID for ten days is appropriate if exposure is suspected.
Role of Antiretroviral Therapy
Women should receive adequate antiretroviral therapy regardless of pregnancy status. Viral load correlates with transmission rate. Other factors associated with transmission include rupture of membranes over four hours, birth weight <2,500 grams, and lack of AZT use. Unfortunately there is inadequate information about some antiretroviral drugs in the setting of pregnancy. Tables were presented summarizing what is known about current AR drugs regarding placental transfer, animal safety, and human studies.
Adherence is a major issue for pregnant women, both during and after pregnancy. Adherence has been shown to decrease to levels of 60% post-partum, illustrating the importance of offering education and support during this critical period when a woman will be concerned about many factors other than her own health.
Role of Cesarean Section
Most of the data on cesarean section pre-date current potent triple drug antiretroviral regimens and some pre-date viral load testing. While elective C-section has been shown to decrease transmission, complications are higher than with vaginal delivery. It is unclear how much benefit cesarean section adds when viral load is below quantification. Cesarean section is recommended when viral load is detectable, prenatal care is late (>38 weeks), AZT is not used, or the patient requests the procedure.
Rapid HIV Testing
Several rapid HIV tests are now available or in development. These tests may be helpful in the setting of late presentation as a way to evaluate the need for antiretroviral therapy. Studies are in progress to assess the use of the test in this setting. If rapid testing is used, a confirmatory test should be done and the patient should be advised of the risk of a false positive result for the rapid test.
It is recommended that breast -feeding not occur and that antiretrovirals be continued with attention to good adherence. Contraception should be discussed and caution regarding disposal of sanitary pads should be stressed. Viral load and CD4 count should be repeated at six weeks post-partum. The baby should receive pediatric follow-up for medications and PCR testing. For both baby and mother, linkage to long term care is critical. Enrollment in the Antiretroviral Pregnancy Registry is encouraged.
Amniocentesis has been largely discarded in the care of HIV+ pregnant women because of the risk of transmission of infection. This is being reassessed in the era of HAART. Likewise, the optimal regimen for antiretroviral treatment is not yet known, and long term follow-up of babies exposed to HIV medications in utero and post-partum is ongoing.
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