hiv treatment in pregnant women


new recommendations were released on HIV care in pregnant women, and interventions to reduce perinatal HIV transmission (see hiv prenatal recs 2019 in dropbox, or https://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf . the following is a brief description of those recommendations more useful in primary care, from this 366-page document.

Note: this is not fundamentally different from the 2018 guidelines on HIV therapy: http://gmodestmedblogs.blogspot.com/2018/07/new-hiv-treatment-guidelines.html . please see this blog/document for more general HIV info

Summary of main points:
--partners of pregnant women should be tested for HIV. in women trying to get pregnant and have an HIV-positive partner who has a sustained negative HIV viral load, best to have condomless sex limited to 2-3 days before and the day of ovulation, which has "effectively no risk of sexual HIV transmission to the partner without HIV"
--early HIV testing in pregnant women; retest in 3rd trimester if higher risk, including women who live in facilities with >1 case/1000 pregnant women/yr or are incarcerated, and those residing in areas of high HIV incidence
--in women not on antiretrovirals, begin therapy as soon as possible, independent of the CD4 count
--check HIV viral load at approx 34-36 weeks gestation to inform method of delivery
--not use dolutegravir in women trying to conceive, at the time of conception, or in first trimester; one study found potentially higher risk of neural tube defects with dolutegravir, though larger studies to come out soon. dolutegravir is still the preferred INSTI in pregnant women after the first trimester.  
    --BUT, in women on dolutegravir who become pregnant, it is unclear what to do since: neural tube defects may have already occurred;  depending on the time in the first trimester, the added risk of neural tube defects may be quite small; neural tube defects do happen anyway; and, changes in ART, even in the first trimester, can lead to viral rebound and increased perinatal transmission
--their Table 7 goes through the HIV meds for pregnant women. in general:
    --NRTIs are okay, though AZT is considered an alternative, and TAF does not have sufficient data
    --INSTIs: raltegravir is preferred. others not recommended or insufficient data. avoid all combos with cobicistat. Dolutegravir is  the preferred INSTI after the first trimester
    --PIs: atavanavir/ritonavir and darunavir/ritonavir are preferred. lopinavir/ritonavir is alternative. others not recommended
    --NNRTIs: only efavirenz and rilpivirine are okay, others are considered alternatives
    --fixed combos: ABC/DTG/3TC is not recommended in first trimester but is preferred thereafter; EFV/FTC/TDF or EFV/3TC/TDF  and FTC/RPV/TDF are considered alternatives
--their TABLE 3 has drug interactions between HIV meds and hormonal contraceptives

--lots more in the document, including treatment of co-infected women (hep B and C, etc), acute HIV infection, intrapartum management, newborn management, diagnosis in infants and children.

so, some important new recommendations for us in primary care. especially since we may well be treating HIV-positive women of reproductive age who either desire being pregnant or are not on consistent contraception to avoid pregnancy.  at this point, best to avoid dolutegravir in them, pending an upcoming larger study

geoff

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