The indications for ART in nonpregnant patients are a CD4+ count of 350 or less and a detectable viral load; however, these requirements are relaxed in pregnancy. “Thus antiretrovirals are given to many pregnant women with HIV who would not otherwise receive them [if they were not pregnant],” she said. Aggressive treatment with potent combination therapies has been shown to reduce the perinatal transmission rate to 1%, compared with a 21% transmission rate when no ART is used (J. Acquir. Immune Defic. Syndr. 2002;29:484–94), she said.
But to maximize its effectiveness, this aggressive therapy must be maintained throughout the pregnancy and the delivery. “The goal should be to minimize the maternal viral load at delivery and maximize fetal intracellular antiretroviral levels, as well as to provide postexposure prophylaxis to infants,” she said.
On the safety of ART, pregnancy outcome studies do not suggest an increase in spontaneous abortion, stillbirth, LBW, or low Apgar scores in association with these medications—and so there is no need to stop these drugs, she said. In fact, if any medication needs to be stopped because of hyperemesis, she recommends all medications be eliminated together to avoid the risk of developing resistance.
The only exception to this is efavirenz (Sustiva, Bristol-Myers Squibb), which is the only HIV medication now classified as category D because it has been linked to an increase in neural tube defects, she said. This drug should ideally be stopped before conception. “Acknowledge that HIV-infected women are choosing to get pregnant; give them preconception counseling, and get them off this drug before they conceive,” she advised. In addition, there is some suggestion of an association between nucleoside reverse transcriptase inhibitors (NRTIs) and neonatal mitochondrial toxicity syndrome.
Maternal toxicities associated with ART can include gastrointestinal problems, anemia, and/or hepatic steatosis/lactic acidosis (NRTIs); hyperglycemia (protease inhibitors); and hepatitis (nevirapine and others).
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