HIV in pregnancy

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

• NRTI backbones
  • ABC/3TC
  • TDF/FTC or TDF/3TC
• INSTI 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

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

Post-partum

• If they won't be breastfeeding, give cabergoline 1 mg po once, given within 24 hours of delivery to prevent lactation
• Discuss plans for contraception
• Monitor for post-partum depression