Antiretroviral therapy (ART) in pregnancy

antiretroviral drug therapy (ART) in pregnancy

Seek expert advice.

Anti retro viral therapy (ART) is indicated for all pregnant women living with HIV, regardless of their HIV viral load or CD4-cell count (1).

• they are beneficial for:
  • the health of the mother
  • prevention of transmission to a partner
  • prevention of vertical transmissionby
    • lowering maternal viral load
    • providing infant pre-exposure prophylaxis using intrapartum antiretroviral therapy that rapidly crosses the placenta in order to achieve adequate systemic drug levels in the infant
    • providing infant post-exposure prophylaxis (2)

In patients who are already on ART

• treatment should not be discontinued during the first trimester for obstetrical reasons.
• assess patient compliance
• assess medication safety profile during pregnancy
• continue ART during pregnancy
• but if the woman is not on therapy and there is no urgent medical indication for combination antiretroviral therapy, it can be delayed until after 14 weeks' gestation (2,3)

In women who are not on ART but require for their own health should commence treatment as soon as possible

• prescribed ART regimen should be continued throughout pregnancy and postpartum.

If a mother does not require HIV treatment for their own health, ART should be commenced by week 24 of pregnancy to prevent mother to child transmission (1).

A woman who presents after 28 weeks should commence ART without delay HIV resistance testing should be performed prior to initiation of treatment

Highly active anti-retroviral therapy (HAART) is now the standard of care for all individuals who are HIV positive requiring antiretroviral therapy for their own health and because of concerns about resistance to single-drug agents, Zidovudine (ZDV) monotherapy is less commonly used in pregnancy (1).

If a pregnant woman has significant nausea of pregnancy, antiretroviral therapy should not be started until her nausea is adequately controlled

If antiretroviral therapy is discontinued for any reason during pregnancy, all drugs should be discontinued at once (unless the woman is on non-nucleoside reverse transcriptase inhibitors; in that case a tail of 2 nucleoside reverse transcriptase inhibitors is recommended for 1 week), and all drugs should be resumed simultaneously to minimize the risk of viral resistance developing during therapy (1).

Women who are HIV positive should be counselled about the increased risk of preterm delivery associated with HAART (2).

Reference:

• (1) Money D et al. Guidelines for the care of pregnant women living with HIV and interventions to reduce perinatal transmission: executive summary. J Obstet Gynaecol Can. 2014;36(8):721-734.
• (2) Royal College of Obstetricians and Gynaecologists (RCOG) 2010. HIV in Pregnancy, Management (Green-top Guideline No. 39)
• (3) Rimawi BH et al. Management of HIV Infection during Pregnancy in the United States: Updated Evidence-Based Recommendations and Future Potential Practices. Infect Dis Obstet Gynecol. 2016;2016:7594306.