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 |
||
+ | *Vertical transmission of HIV occurs in 25 to 35% of patients if untreated, but less than 1% if treated |
||
− | === Epidemiology === |
||
+ | *Risk of transmission is proportional to viral load at delivery and goes down with treatment |
||
− | * An increasing problem with the increase in effectiveness of antiretroviral therapy |
||
− | * Decreasing vertical transmission over time |
||
− | == |
+ | ===Epidemiology=== |
− | === Antepartum === |
||
− | * Monitor viral load monthly during pregnancy |
||
− | * Routine HIV management including vaccinations (including TDaP) |
||
+ | *An increasing problem with the increase in effectiveness of antiretroviral therapy |
||
− | === Initial regimens for treatment-naive women === |
||
+ | *Decreasing vertical transmission over time |
||
− | * 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 |
||
+ | ==Management== |
||
− | === Safety in pregnancy === |
||
+ | ===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 |
||
+ | **[[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" |
{| class="wikitable" |
||
− | ! |
+ | !Drug |
− | ! |
+ | !Starting |
− | ! |
+ | !Continuing |
− | ! |
+ | !Restarting |
− | ! |
+ | !Conceiving |
|- |
|- |
||
− | ! colspan=5 | |
+ | ! colspan="5" |NRTIs |
|- |
|- |
||
− | | |
+ | |[[ABC]] |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
|- |
|- |
||
− | | |
+ | |[[FTC]] |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
|- |
|- |
||
− | | |
+ | |[[3TC]] |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
|- |
|- |
||
− | | |
+ | |[[TDF]] |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
|- |
|- |
||
− | | |
+ | |[[ZDV]] |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
|- |
|- |
||
− | | |
+ | |[[TAF]] |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
|- |
|- |
||
− | ! colspan=5 | |
+ | ! colspan="5" |Integrase Inhibitors |
|- |
|- |
||
− | | |
+ | |[[DTG]] |
− | | style="color:goldenrod" | |
+ | | style="color:goldenrod" |Avoid in T1,<br />then preferred |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Avoid in T1 |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Avoid in T1 |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
|- |
|- |
||
− | | |
+ | |[[RAL]] |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
|- |
|- |
||
− | | |
+ | |[[BIC]] |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
|- |
|- |
||
− | | |
+ | |[[EVG-COBI]] |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:goldenrod" | |
+ | | style="color:goldenrod" |Consider switch |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
|- |
|- |
||
− | ! colspan=5 | |
+ | ! colspan="5" |Protease Inhibitors |
|- |
|- |
||
− | | |
+ | |[[ATV/r]] |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
|- |
|- |
||
− | | |
+ | |[[DRV/r]] |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Preferred |
|- |
|- |
||
− | | |
+ | |[[LPV/r]] |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
|- |
|- |
||
− | | |
+ | |[[ATV/COBI]] |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:goldenrod" | |
+ | | style="color:goldenrod" |Consider switch |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
|- |
|- |
||
− | | |
+ | |[[DRV/COBI]] |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:goldenrod" | |
+ | | style="color:goldenrod" |Consider switch |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
|- |
|- |
||
− | ! colspan=5 | |
+ | ! colspan="5" |NNRTIs |
|- |
|- |
||
− | | |
+ | |[[EFV]] |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
|- |
|- |
||
− | | |
+ | |[[RPV]] |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative |
|- |
|- |
||
− | | |
+ | |[[DOR]] |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
|- |
|- |
||
− | | |
+ | |[[ETR]] |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
|- |
|- |
||
− | | |
+ | |[[NVP]] |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
|- |
|- |
||
− | ! colspan=5 | |
+ | ! colspan="5" |Entry Inhibitors & Fusion Inhibitors |
|- |
|- |
||
− | | |
+ | |[[IBA]] |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data |
|- |
|- |
||
− | | |
+ | |[[MVC]] |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
|- |
|- |
||
− | | |
+ | |[[T-20]] |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
|- |
|- |
||
− | ! colspan=5 | |
+ | ! colspan="5" |Fixed Drug Combinations |
|- |
|- |
||
− | | |
+ | |[[ABC]]-[[DTG]]-[[3TC]] |
− | | style="color:goldenrod" | |
+ | | style="color:goldenrod" |Avoid T1 (DTG),<br />then preferred |
− | | style="color:goldenrod" | |
+ | | style="color:goldenrod" |Consider switch if T1 |
− | | style="color:goldenrod" | |
+ | | style="color:goldenrod" |Avoid T1 (DTG),<br />then preferred |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended (DTG) |
|- |
|- |
||
− | | |
+ | |[[EFV]]-[[FTC]]-[[TDF]] |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative (EFV) |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative (EFV) |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative (EFV) |
|- |
|- |
||
− | | |
+ | |[[EFC]]-[[3TC]]-[[TDF]] |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative (EFV) |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative (EFV) |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative (EFV) |
|- |
|- |
||
− | | |
+ | |[[FTC]]-[[RPV]]-[[TDF]] |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative (RPV) |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue (RPV) |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative (RPV) |
− | | style="color:darkblue" | |
+ | | style="color:darkblue" |Alternative (RPV) |
|- |
|- |
||
− | | |
+ | |[[BIC]]-[[FTC]]-[[TAF]] |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data (BIC/TAF) |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data (BIC) |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data (BIC/TAF) |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data (BIC/TAF) |
|- |
|- |
||
− | | |
+ | |[[DOR]]-[[3TC]]-[[TDF]] |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data (DOR) |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data (DOR) |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data (DOR) |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data (DOR) |
|- |
|- |
||
− | | |
+ | |[[FTC]]-[[RPV]]-[[TAF]] |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data (TAF) |
− | | style="color:darkgreen" | |
+ | | style="color:darkgreen" |Continue (RPV/TAF) |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data (TAF) |
− | | style="color:darkgrey" | |
+ | | style="color:darkgrey" |No data (TAF) |
|- |
|- |
||
− | | |
+ | |[[EVG/COBI]]-[[FTC]]-[[TDF]] |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended (EVG/c) |
− | | style="color:goldenrod" | |
+ | | style="color:goldenrod" |Consider switch |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended (EVG/c) |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended (EVG/c) |
|- |
|- |
||
− | | |
+ | |[[EVG/COBI]]-[[FTC]]-[[TAF]] |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended (EVG/c) |
− | | style="color:goldenrod" | |
+ | | style="color:goldenrod" |Consider switch |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended (EVG/c) |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended (EVG/c) |
|- |
|- |
||
− | | |
+ | |[[DRV/COBI]]-[[FTC]]-[[TAF]] |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended (DRV/c) |
− | | style="color:goldenrod" | |
+ | | style="color:goldenrod" |Consider switch |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended (DRV/c) |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended (DRV/c) |
|- |
|- |
||
− | | |
+ | |[[DTG]]-[[RPV]] |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:goldenrod" | |
+ | | style="color:goldenrod" |Consider switch |
− | | style="color:darkred" | |
+ | | style="color:darkred" |Not recommended |
− | | style="color:darkred" | |
+ | | 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 |
− | * |
+ | *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 |
||
+ | |||
+ | {| 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 |
||
− | === Post-partum === |
||
− | * |
+ | **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 |
||
− | * Discuss plans for contraception |
||
+ | **If they won't be breastfeeding, give [[cabergoline]] 1 mg po once within 24 hours of delivery to prevent lactation |
||
− | * Monitor for post-partum depression |
||
+ | *Discuss plans for contraception |
||
− | * Counsel on the risks of prechewing food as a method of transmission (if applicable) |
||
+ | *Monitor for [[post-partum depression]] |
||
+ | *Counsel on the risks of pre-chewing food as a method of transmission (if applicable) |
||
[[Category:HIV]] |
[[Category:HIV]] |
||
+ | [[Category:Obstetrical infections]] |
Latest revision as of 11:33, 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
- 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)