HIV in pregnancy: Difference between revisions

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==Background==
= HIV in pregnancy =


*Vertical transmission of HIV occurs in 25 to 35% of patients if untreated, but less than 1% if treated
== Management ==
*Risk of transmission is proportional to viral load at delivery and goes down with treatment


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


*An increasing problem with the increase in effectiveness of antiretroviral therapy
* NRTI backbones
*Decreasing vertical transmission over time
** ABC/3TC
** TDF/FTC or TDF/3TC
* INSTI regimens
** DTG/ABC/3TC
** DTG and an NRTI backbone
* PI regimens
** ATV/r and an NRTI backbone
** DRV/r and an NRTI backbone


==Management==
=== Safety in pregnancy ===
===Antepartum Management===


*Start a pregnancy-safe antiretroviral regimen (discussed below)
{|
*Monitor viral load monthly during pregnancy
! Drug
*Routine HIV management including vaccinations (including TDaP)
! Starting

! Continuing
====Regimens for Treatment-Naive Women====
! Restarting

! Conceiving
*NRTI backbones
**[[ABC]]/[[3TC]]
**[[TDF]]/[[FTC]] or [[TDF]]/[[3TC]]
*INSTI-based regimens
**'''[[RAL]] + [[TDF]]/[[3TC]]''' (current most common choice)
**[[DTG]]/[[ABC]]/[[3TC]]
**[[DTG]] and an NRTI backbone
**Note: there are some concerns for [[DTG]] causing neural tube defects if used within the first trimester
*PI regimens
**[[ATV/r]] and an NRTI backbone
**[[DRV/r]] and an NRTI backbone

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


* Starting = ART for Pregnant Women Who Have Never Received ARV Drugs and Who Are Initiating ART for the First Time
*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
*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
*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
*Conceiving = ART for Nonpregnant Women Who Are Trying to Conceive

=== Intrapartum Management ===

* HIV-positive women are managed with standard antiretrovirals (discussed above), intravenous [[zidovudine]] during labour, and consideration of [[Cesarean section]], followed by management of the neonate
** If viral load is unknown, get a STAT viral load
** Dose of intrapartum [[zidovudine]] is 2 mg/kg IV given over 1 hour, followed by 1 mg/kg/hour infusion until delivery
** They oral antiretrovirals should be continued during labour

{| class="wikitable"
! rowspan="2" |Viral Load
! colspan="3" |Management of Mother
! rowspan="2" |Management of Infant
|-
![[HIV treatment|ART]]
![[Zidovudine]]
![[Cesarean section|C-section]]
|-
|<40
|yes
|yes
|no
|[[zidovudine]] for 4 to 6 weeks
|-
|40-999
|yes
|yes
|consider
|combination ART, or [[zidovudine]] monotherapy for 4-6 weeks
|-
|≥1000
|yes
|yes
|yes
|combination ART
|-
|unknown
|yes
|yes
|yes
|combination ART, adjusted based on results of maternal viral load
|}

* If serostatus is unknown but they are at risk, then get STAT serology
** If positive, manage as above for HIV-positive women
** If negative, then assess risk that they are in the window period
*** If high risk, then manage as above for HIV-positive women, and repeat serology or get viral PCR
**** High risk includes ongoing commercial sex work or intravenous drug use
*** If not high risk, then no further management required

===Postpartum Management===

*Generally recommend against breastfeeding for HIV-positive mothers in Canada, even if HIV is well-controlled
**Transmission is 10-20% risk if breastfeeding and uncontrolled; less than 1% if fully and reliably suppressed
**As well as risk of HIV transmission, it could theoretically expose child's HIV to low-level antivirals which could induce resistance
**If they won't be breastfeeding, give [[cabergoline]] 1 mg po once within 24 hours of delivery to prevent lactation
*Discuss plans for contraception
*Monitor for [[post-partum depression]]
*Counsel on the risks of pre-chewing food as a method of transmission (if applicable)

[[Category:HIV]]
[[Category:Obstetrical infections]]

Latest revision as of 15:33, 18 September 2020

Background

  • Vertical transmission of HIV occurs in 25 to 35% 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

Antepartum Management

  • Start a pregnancy-safe antiretroviral regimen (discussed below)
  • Monitor viral load monthly during pregnancy
  • Routine HIV management including vaccinations (including TDaP)

Regimens for Treatment-Naive Women

  • NRTI backbones
  • INSTI-based regimens
    • RAL + TDF/3TC (current most common choice)
    • DTG/ABC/3TC
    • DTG and an NRTI backbone
    • Note: there are some concerns for DTG causing neural tube defects if used within the first trimester
  • PI regimens
    • ATV/r and an NRTI backbone
    • DRV/r and an NRTI backbone

Antiretroviral 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

Intrapartum Management

  • HIV-positive women are managed with standard antiretrovirals (discussed above), intravenous zidovudine during labour, and consideration of Cesarean section, followed by management of the neonate
    • If viral load is unknown, get a STAT viral load
    • Dose of intrapartum zidovudine is 2 mg/kg IV given over 1 hour, followed by 1 mg/kg/hour infusion until delivery
    • They oral antiretrovirals should be continued during labour
Viral Load Management of Mother Management of Infant
ART Zidovudine C-section
<40 yes yes no zidovudine for 4 to 6 weeks
40-999 yes yes consider combination ART, or zidovudine monotherapy for 4-6 weeks
≥1000 yes yes yes combination ART
unknown yes yes yes combination ART, adjusted based on results of maternal viral load
  • If serostatus is unknown but they are at risk, then get STAT serology
    • If positive, manage as above for HIV-positive women
    • If negative, then assess risk that they are in the window period
      • If high risk, then manage as above for HIV-positive women, and repeat serology or get viral PCR
        • High risk includes ongoing commercial sex work or intravenous drug use
      • If not high risk, then no further management required

Postpartum Management

  • Generally recommend against breastfeeding for HIV-positive mothers in Canada, even if HIV is well-controlled
    • Transmission is 10-20% risk if breastfeeding and uncontrolled; less than 1% if fully and reliably suppressed
    • As well as risk of HIV transmission, it could theoretically expose child's HIV to low-level antivirals which could induce resistance
    • If they won't be breastfeeding, give cabergoline 1 mg po once within 24 hours of delivery to prevent lactation
  • Discuss plans for contraception
  • Monitor for post-partum depression
  • Counsel on the risks of pre-chewing food as a method of transmission (if applicable)
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