HIV in pregnancy: Difference between revisions

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== Background ==
* Vertical transmission of HIV occurs in 1/3 of patients if untreated, but less than 1% if treated
* Risk of transmission is proportional to viral load at delivery and goes down with treatment

=== Epidemiology ===
* An increasing problem with the increase in effectiveness of antiretroviral therapy
* Decreasing vertical transmission over time

== Management ==
== Management ==
* Monitor viral load monthly during pregnancy
* Routine HIV management including vaccinations (including TDaP)


=== Initial regimens for treatment-naive women ===
=== Initial regimens for treatment-naive women ===

* NRTI backbones
* NRTI backbones
** ABC/3TC
** [[ABC]]/[[3TC]]
** TDF/FTC or TDF/3TC
** [[TDF]]/[[FTC]] or [[TDF]]/[[3TC]]
* INSTI regimens
* INSTI regimens
** DTG/ABC/3TC
** [[DTG]]/[[ABC]]/[[3TC]]
** DTG and an NRTI backbone
** [[DTG]] and an NRTI backbone
* PI regimens
* PI regimens
** ATV/r and an NRTI backbone
** [[ATV/r]] and an NRTI backbone
** DRV/r and an NRTI backbone
** [[DRV/r]] and an NRTI backbone
* Common choice: [[RAL]] + [[TDF]]/[[3TC]]


=== Safety in pregnancy ===
=== Safety in pregnancy ===

{| class="wikitable"
{| class="wikitable"
! Drug
! Drug
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! colspan=5 | NRTIs
! colspan=5 | NRTIs
|-
|-
| ABC
| [[ABC]]
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
|-
|-
| FTC
| [[FTC]]
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
|-
|-
| 3TC
| [[3TC]]
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
|-
|-
| TDF
| [[TDF]]
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
|-
|-
| ZDV
| [[ZDV]]
| style="color:darkblue" | Alternative
| style="color:darkblue" | Alternative
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkblue" | Alternative
| style="color:darkblue" | Alternative
|-
|-
| TAF
| [[TAF]]
| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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! colspan=5 | Integrase Inhibitors
! colspan=5 | Integrase Inhibitors
|-
|-
| DTG
| [[DTG]]
| style="color:darkred" | Avoid in T1,<br />then preferred
| style="color:darkred" | Avoid in T1,<br />then preferred
| style="color:darkred" | Avoid in T1
| style="color:darkred" | Avoid in T1
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| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
|-
|-
| RAL
| [[RAL]]
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
|-
|-
| BIC
| [[BIC]]
| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
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| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
|-
|-
| EVG/COBI
| [[EVG-COBI]]
| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
| style="color:darkred" | Consider switch
| style="color:darkred" | Consider switch
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! colspan=5 | Protease Inhibitors
! colspan=5 | Protease Inhibitors
|-
|-
| ATV/r
| [[ATV/r]]
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
|-
|-
| DRV/r
| [[DRV/r]]
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkgreen" | Preferred
| style="color:darkgreen" | Preferred
|-
|-
| LPV/r
| [[LPV/r]]
| style="color:darkblue" | Alternative
| style="color:darkblue" | Alternative
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkblue" | Alternative
| style="color:darkblue" | Alternative
|-
|-
| ATV/COBI
| [[ATV/COBI]]
| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
| style="color:darkred" | Consider switch
| style="color:darkred" | Consider switch
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| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
|-
|-
| DRV/COBI
| [[DRV/COBI]]
| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
| style="color:darkred" | Consider switch
| style="color:darkred" | Consider switch
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! colspan=5 | NNRTIs
! colspan=5 | NNRTIs
|-
|-
| EFV
| [[EFV]]
| style="color:darkblue" | Alternative
| style="color:darkblue" | Alternative
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkblue" | Alternative
| style="color:darkblue" | Alternative
|-
|-
| RPV
| [[RPV]]
| style="color:darkblue" | Alternative
| style="color:darkblue" | Alternative
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkblue" | Alternative
| style="color:darkblue" | Alternative
|-
|-
| DOR
| [[DOR]]
| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
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| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
|-
|-
| ETR
| [[ETR]]
| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
|-
|-
| NVP
| [[NVP]]
| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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! colspan=5 | Entry Inhibitors &amp; Fusion Inhibitors
! colspan=5 | Entry Inhibitors &amp; Fusion Inhibitors
|-
|-
| IBA
| [[IBA]]
| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
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| style="color:darkgrey" | No data
| style="color:darkgrey" | No data
|-
|-
| MVC
| [[MVC]]
| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
|-
|-
| T-20
| [[T-20]]
| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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! colspan=5 | Fixed Drug Combinations
! colspan=5 | Fixed Drug Combinations
|-
|-
| ABC/DTG/3TC
| [[ABC]]-[[DTG]]-[[3TC]]
| style="color:darkred" | Avoid T1 (DTG),<br />then preferred
| style="color:darkred" | Avoid T1 (DTG),<br />then preferred
| style="color:darkred" | Consider switch if T1
| style="color:darkred" | Consider switch if T1
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| style="color:darkred" | Not recommended (DTG)
| style="color:darkred" | Not recommended (DTG)
|-
|-
| EFV/FTC/TDF
| [[EFV]]-[[FTC]]-[[TDF]]
| style="color:darkblue" | Alternative (EFV)
| style="color:darkblue" | Alternative (EFV)
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkblue" | Alternative (EFV)
| style="color:darkblue" | Alternative (EFV)
|-
|-
| EFC/3TC/TDF
| [[EFC]]-[[3TC]]-[[TDF]]
| style="color:darkblue" | Alternative (EFV)
| style="color:darkblue" | Alternative (EFV)
| style="color:darkgreen" | Continue
| style="color:darkgreen" | Continue
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| style="color:darkblue" | Alternative (EFV)
| style="color:darkblue" | Alternative (EFV)
|-
|-
| FTC/RPV/TDF
| [[FTC]]-[[RPV]]-[[TDF]]
| style="color:darkblue" | Alternative (RPV)
| style="color:darkblue" | Alternative (RPV)
| style="color:darkgreen" | Continue (RPV)
| style="color:darkgreen" | Continue (RPV)
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| style="color:darkblue" | Alternative (RPV)
| style="color:darkblue" | Alternative (RPV)
|-
|-
| BIC/FTC/TAF
| [[BIC]]-[[FTC]]-[[TAF]]
| style="color:darkgrey" | No data (BIC/TAF)
| style="color:darkgrey" | No data (BIC/TAF)
| style="color:darkgrey" | No data (BIC)
| style="color:darkgrey" | No data (BIC)
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| style="color:darkgrey" | No data (BIC/TAF)
| style="color:darkgrey" | No data (BIC/TAF)
|-
|-
| DOR/3TC/TDF
| [[DOR]]-[[3TC]]-[[TDF]]
| style="color:darkgrey" | No data (DOR)
| style="color:darkgrey" | No data (DOR)
| style="color:darkgrey" | No data (DOR)
| style="color:darkgrey" | No data (DOR)
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| style="color:darkgrey" | No data (DOR)
| style="color:darkgrey" | No data (DOR)
|-
|-
| FTC/RPV/TAF
| [[FTC]]-[[RPV]]-[[TAF]]
| style="color:darkgrey" | No data (TAF)
| style="color:darkgrey" | No data (TAF)
| style="color:darkgreen" | Continue (RPV/TAF)
| style="color:darkgreen" | Continue (RPV/TAF)
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| style="color:darkgrey" | No data (TAF)
| style="color:darkgrey" | No data (TAF)
|-
|-
| EVG/c/FTC/TDF
| [[EVG/COBI]]-[[FTC]]-[[TDF]]
| style="color:darkred" | Not recommended (EVG/c)
| style="color:darkred" | Not recommended (EVG/c)
| style="color:darkred" | Consider switch
| style="color:darkred" | Consider switch
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| style="color:darkred" | Not recommended (EVG/c)
| style="color:darkred" | Not recommended (EVG/c)
|-
|-
| EVG/c/FTC/TAF
| [[EVG/COBI]]-[[FTC]]-[[TAF]]
| style="color:darkred" | Not recommended (EVG/c)
| style="color:darkred" | Not recommended (EVG/c)
| style="color:darkred" | Consider switch
| style="color:darkred" | Consider switch
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| style="color:darkred" | Not recommended (EVG/c)
| style="color:darkred" | Not recommended (EVG/c)
|-
|-
| DRV/c/FTC/TAF
| [[DRV/COBI]]-[[FTC]]-[[TAF]]
| style="color:darkred" | Not recommended (DRV/c)
| style="color:darkred" | Not recommended (DRV/c)
| style="color:darkred" | Consider switch
| style="color:darkred" | Consider switch
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| style="color:darkred" | Not recommended (DRV/c)
| style="color:darkred" | Not recommended (DRV/c)
|-
|-
| DTG/RPV
| [[DTG]]-[[RPV]]
| style="color:darkred" | Not recommended
| style="color:darkred" | Not recommended
| style="color:darkred" | Consider switch
| style="color:darkred" | Consider switch

Revision as of 19:23, 4 December 2019

Background

  • Vertical transmission of HIV occurs in 1/3 of patients if untreated, but less than 1% if treated
  • Risk of transmission is proportional to viral load at delivery and goes down with treatment

Epidemiology

  • An increasing problem with the increase in effectiveness of antiretroviral therapy
  • Decreasing vertical transmission over time

Management

  • Monitor viral load monthly during pregnancy
  • Routine HIV management including vaccinations (including TDaP)

Initial regimens for treatment-naive women

Safety in pregnancy

Drug Starting Continuing Restarting Conceiving
NRTIs
ABC Preferred Continue Preferred Preferred
FTC Preferred Continue Preferred Preferred
3TC Preferred Continue Preferred Preferred
TDF Preferred Continue Preferred Preferred
ZDV Alternative Continue Alternative Alternative
TAF No data Continue No data No data
Integrase Inhibitors
DTG Avoid in T1,
then preferred 		Avoid in T1 Avoid in T1 Not recommended
RAL Preferred Continue Preferred Preferred
BIC No data No data No data No data
EVG-COBI Not recommended Consider switch Not recommended Not recommended
Protease Inhibitors
ATV/r Preferred Continue Preferred Preferred
DRV/r Preferred Continue Preferred Preferred
LPV/r Alternative Continue Alternative Alternative
ATV/COBI Not recommended Consider switch Not recommended Not recommended
DRV/COBI Not recommended Consider switch Not recommended Not recommended
NNRTIs
EFV Alternative Continue Alternative Alternative
RPV Alternative Continue Alternative Alternative
DOR No data No data No data No data
ETR Not recommended Continue Not recommended Not recommended
NVP Not recommended Continue Not recommended Not recommended
Entry Inhibitors & Fusion Inhibitors
IBA No data No data No data No data
MVC Not recommended Continue Not recommended Not recommended
T-20 Not recommended Continue Not recommended Not recommended
Fixed Drug Combinations
ABC-DTG-3TC Avoid T1 (DTG),
then preferred 		Consider switch if T1 Avoid T1 (DTG),
then preferred 		Not recommended (DTG)
EFV-FTC-TDF Alternative (EFV) Continue Alternative (EFV) Alternative (EFV)
EFC-3TC-TDF Alternative (EFV) Continue Alternative (EFV) Alternative (EFV)
FTC-RPV-TDF Alternative (RPV) Continue (RPV) Alternative (RPV) Alternative (RPV)
BIC-FTC-TAF No data (BIC/TAF) No data (BIC) No data (BIC/TAF) No data (BIC/TAF)
DOR-3TC-TDF No data (DOR) No data (DOR) No data (DOR) No data (DOR)
FTC-RPV-TAF No data (TAF) Continue (RPV/TAF) No data (TAF) No data (TAF)
EVG/COBI-FTC-TDF Not recommended (EVG/c) Consider switch Not recommended (EVG/c) Not recommended (EVG/c)
EVG/COBI-FTC-TAF Not recommended (EVG/c) Consider switch Not recommended (EVG/c) Not recommended (EVG/c)
DRV/COBI-FTC-TAF Not recommended (DRV/c) Consider switch Not recommended (DRV/c) Not recommended (DRV/c)
DTG-RPV Not recommended Consider switch Not recommended Not recommended
  • Starting = ART for Pregnant Women Who Have Never Received ARV Drugs and Who Are Initiating ART for the First Time
  • Continuing = Continuing ART for Women Who Become Pregnant on an ART Regimen that has been Well Tolerated and Virologically Suppressive
  • Restarting = ART for Pregnant Women Who Have Received ARV Drugs in the Past and Who Are Restarting ART
  • Conceiving = ART for Nonpregnant Women Who Are Trying to Conceive
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