Use of antiviral therapy in pregnancy

Question 1

Conceiving on cART

Answer 1

• Women conceiving on an effective cART regimen should continue this even if it contains efavirenz or does not contain zidovudine.
  Exceptions are:
• Protease inhibitor (PI) monotherapy should be intensified to include one or more agents that cross the placenta
• The combination of stavudine and didanosine should not be prescribed in pregnancy

Question 2

Naïve to cART: mother needs ART for herself

Answer 2

• Women requiring ART for their own health should commence treatment as soon as possible
• Although there is most evidence and experience in pregnancy with zidovudine plus lamivudine, tenofovir plus emtricitabine or abacavir plus lamivudine are acceptable nucleoside backbones
• If no contraindications it is recommended that the third agent in cART should be efavirenz or nevirapine (if the CD4 cell count is less than 250 cells/μL) or a boosted PI
• No routine dose alterations are recommended for ARVs
• Consider twice daily darunavir if initiating darunavir-based ART or if known resistance

Question 3

Naïve to cART: mother does not need cART for herself

Answer 3

• All women should have commenced ART by week 24 of pregnancy
• Zidovudine, lamivudine and abacavir can be used if the baseline viral load is 350 cells/μL.
• Women who do not require treatment for themselves should commence temporary cART in the second trimester if the baseline VL is > 30 000 HIV RNA copies/mL ( earlier if VL > 100 000 HIV RNA copies/mL).

Question 4

Late-presenting woman not on treatment

Answer 4

• A woman who presents after 28 weeks should commence cART without delay.
• If the viral load is unknown or > 100 000 HIV RNA copies/mL a three or four drug regimen that includes raltegravir is suggested
• An untreated woman presenting in labour at term should be given a stat dose of nevirapine and commence fixed-dose zidovudine with lamivudine
  and raltegravir
• Intravenous zidovudine be infused for the duration of labour and delivery
• In preterm labour, if the infant is unlikely to be able to absorb oral medications consider the addition of double-dose tenofovir to further load the baby
• Women in labour/with rupture of membranes requiring delivery without a documented HIV result must be recommended to have an urgent HIV test

Question 5

Elite controllers with HIV

Answer 5

Untreated women with a CD4 cell count ≥ 350 cells/μL and a viral load of

Question 6

Stopping ART postpartum

Answer 6

• Antiretroviral therapy should be continued postpartum in women who commenced cART with a history of an AIDS-defining illness or with a CD4 cell count 500 cells/μL unless there is discordance with her partner or co-morbidities