HIV in pregnancy: Difference between revisions

Revision as of 15:27, 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

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

@@ Line 73: / Line 73: @@
 |-
 | [[DTG]]
-| style="color:darkred" | Avoid in T1,<br />then preferred
+| style="color:goldenrod" | Avoid in T1,<br />then preferred
 | style="color:darkred" | Avoid in T1
 | style="color:darkred" | Avoid in T1
@@ Line 92: / Line 92: @@
 | [[EVG-COBI]]
 | style="color:darkred" | Not recommended
-| style="color:darkred" | Consider switch
+| style="color:goldenrod" | Consider switch
 | style="color:darkred" | Not recommended
 | style="color:darkred" | Not recommended
@@ Line 118: / Line 118: @@
 | [[ATV/COBI]]
 | style="color:darkred" | Not recommended
-| style="color:darkred" | Consider switch
+| style="color:goldenrod" | Consider switch
 | style="color:darkred" | Not recommended
 | style="color:darkred" | Not recommended
@@ Line 124: / Line 124: @@
 | [[DRV/COBI]]
 | style="color:darkred" | Not recommended
-| style="color:darkred" | Consider switch
+| style="color:goldenrod" | Consider switch
 | style="color:darkred" | Not recommended
 | style="color:darkred" | Not recommended
@@ Line 183: / Line 183: @@
 |-
 | [[ABC]]-[[DTG]]-[[3TC]]
-| style="color:darkred" | Avoid T1 (DTG),<br />then preferred
+| style="color:goldenrod" | Avoid T1 (DTG),<br />then preferred
-| style="color:darkred" | Consider switch if T1
+| style="color:goldenrod" | Consider switch if T1
-| style="color:darkred" | Avoid T1 (DTG),<br />then preferred
+| style="color:goldenrod" | Avoid T1 (DTG),<br />then preferred
 | style="color:darkred" | Not recommended (DTG)
 |-
@@ Line 226: / Line 226: @@
 | [[EVG/COBI]]-[[FTC]]-[[TDF]]
 | style="color:darkred" | Not recommended (EVG/c)
-| style="color:darkred" | Consider switch
+| style="color:goldenrod" | Consider switch
 | style="color:darkred" | Not recommended (EVG/c)
 | style="color:darkred" | Not recommended (EVG/c)
@@ Line 232: / Line 232: @@
 | [[EVG/COBI]]-[[FTC]]-[[TAF]]
 | style="color:darkred" | Not recommended (EVG/c)
-| style="color:darkred" | Consider switch
+| style="color:goldenrod" | Consider switch
 | style="color:darkred" | Not recommended (EVG/c)
 | style="color:darkred" | Not recommended (EVG/c)
@@ Line 238: / Line 238: @@
 | [[DRV/COBI]]-[[FTC]]-[[TAF]]
 | style="color:darkred" | Not recommended (DRV/c)
-| style="color:darkred" | Consider switch
+| style="color:goldenrod" | Consider switch
 | style="color:darkred" | Not recommended (DRV/c)
 | style="color:darkred" | Not recommended (DRV/c)
@@ Line 244: / Line 244: @@
 | [[DTG]]-[[RPV]]
 | style="color:darkred" | Not recommended
-| style="color:darkred" | Consider switch
+| style="color:goldenrod" | Consider switch
 | style="color:darkred" | Not recommended
 | style="color:darkred" | Not recommended