PI Perspective #39
November 2004 View PDF En
español
Update: Guidelines for Use of
Anti-HIV Drugs during Pregnancy
In June 2004, a supplement was added to the Federal Guidelines
for the use of anti-HIV drugs during pregnancy. These guidelines
focus on mother-to-child transmission of HIV and discuss treatment
strategies that can reduce the risk of an HIV-positive woman transmitting
HIV to her child. The update included information on the use and
potential risks and benefits, to both mother and child, of each
of the approved anti-HIV medications. This article will briefly
highlight the new recommendations. For more information on pregnancy
and HIV, call our hotline at 1-800-822-7422 and ask for Project
Inform’s publication, Pregnancy and HIV.
Anti-HIV medications
The following chart outlines current recommendations for the use
of anti-HIV therapies during pregnancy. (A more detailed table and
additional information is available through Project Inform’s
website and hotline.)
Recommended during pregnancy
zidovudine (AZT/Retrovir)
lamivudine (3TC/Epivir)
nevirapine (Viramune)
nelfinavir (Viracept)
saquinavir (Fortovase)
Alternative options
didanosine (ddI/Videx) *do not use with d4T
emtricitabine (FTC/Emtriva)
stavudine (d4T/Zerit) *do not use with ddI
abacavir (Ziagen)
indinavir (Crixivan)
lopinavir+ritonavir (Kaletra)
ritonavir (Norvir) *use only as a booster
Not recommended or not enough data to recommend
tenofovir (Viread)
zalcitabine (ddC/Hivid)
efavirenz (Sustiva)
delavirdine (Rescriptor)
amprenavir (Agenerase)
fosamprenavir (Lexiva)
atazanavir (Reyataz)
enfuvirtide (Fuzeon)
The use of nevirapine (Viramune)
We have known for some time that the serious side effects
associated with taking nevirapine, specifically a rash and/or liver
toxicity; seem to be experienced more often in women than men. In
general, non-pregnant women with pre-treatment CD4+ cell counts
above 250 who receive continuous nevirapine are at an increased
risk for liver toxicity, including liver failure and death. Men
with pre-treatment CD4+ cell counts of above 400 also have higher
risk for liver toxicity than men with lower CD4+ counts. This suggests
an interaction between sex and immune status, as being risk factors
for rash associated liver toxicity. In other words, something about
being female or male may put you more at risk for liver toxicity
depending on your CD4+ cell count.
The guidelines now include a section on nevirapine and liver and
rash side effects. It recommends that pregnant women who start therapy
for the first time should take nevirapine with caution, specifically
women who have CD4+ cell counts above 250. In addition, pregnancy
itself can mimic some of the early symptoms of liver toxicity, for
example fatigue or nausea. Doctors should monitor liver enzymes,
(i.e., alanine amino transferase), especially in the first 18 weeks
of therapy for women who receive nevirapine during pregnancy.
Mode of delivery
Management of labor and delivery should focus on minimizing
the risk of transmission to the child and complications to the mother.
Up until recently, an elective Cesarean section was the recommended
mode of delivery for HIV-positive pregnant women. Now, given a greater
understanding of the correlation between HIV levels and transmission
risks, elective C-sections are only recommended for women with viral
load above 1,000 near the time of delivery. Whereas women with HIV
levels below 1,000 are counseled on the risks and benefits of elective
C-section and encouraged to make a choice about natural childbirth
or elective C-section.
An elective C-section is normally scheduled at the 37th–38th
week of pregnancy. Unlike an emergency C-section, that happens after
a woman’s water has broken and is oftentimes performed in
high-risk situations, an elective C-section is planned and done
before a woman’s water has broken. The longer an infant is
exposed to the torn membranes and blood, the higher the risk of
transmission at labor and delivery.
Research shows that babies exposed to ruptured membranes for more
than four hours are at significantly higher risk for infection.
An elective C-section can minimize the length of time an infant
is exposed to the membranes, reducing the risk of HIV transmission.
However, like any surgery, an elective C-section comes with potential
complications, such as infections. These complications and associated
healing time can increase if a woman is HIV-positive.
Recent data underscores the importance of lowering a mother’s
HIV levels in order to reduce the risk of transmission. A woman
with a viral load of 1,000 or below close to the time of delivery
has a lower risk of transmitting HIV to her infant. Several studies
show that elective C-section offered little additional benefit in
lowering HIV transmission risk when a women’s viral load is
below 1,000. As a result, current guidelines recommend that women
with a viral load of less than 1,000 be counseled on the risk and
benefits of an elective C-section. This allows a woman more of a
choice in how she would like to have her child.
We’ve come extremely far in terms of preventing mother-to-child
transmission. This is a success in the treatment world that is often
not discussed or honored. Today many women living with HIV with
good medical care and support systems are able to have a healthy
child, not infected with HIV.
NEXT