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
- PI regimens
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
- If high risk, then manage as above for HIV-positive women, and repeat serology or get viral PCR
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)
