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Updated February 3, 2011

Case 3: Perinatal HIV Transmission and Route of Delivery

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A 15-year-old with perinatally acquired HIV infection is found at a follow-up clinic visit to be 17 weeks pregnant. She has failed several antiretroviral regimens in the past due to poor adherence, with several episodes of discontinuation of therapy and failure to keep clinic appointments. She has taken regimens that included zidovudine (Retrovir), lamivudine (Epivir), stavudine (Zerit), nelfinavir (Virzacept), and lopinavir-ritonavir (Kaletra). A HIV genotype performed 1 year earlier (while taking zidovudine plus lamividine plus lopinavir-ritonavir) showed several reverse transcriptase mutations (M184V and K219Q), but no significant protease mutations. Her more recent viral loads have ranged from 13,374 to 29,510 copies/ml and CD4 counts have ranged from 236 to 405 cells/mm3. Her social history is complicated by runaway behavior, alcohol abuse, and unprotected sex with multiple partners. Despite intense counseling, she has declined treatment with antiretroviral therapy during her pregnancy, but states she will take any recommended medications during labor and delivery. At 35 completed weeks of gestation, she returns for a visit but continues to refuse antiretroviral therapy. A viral load test is drawn; the following week it is found to be 22,450 copies/ml.

What is the most appropriate course of action to recommend?

A Perform an emergent amniocentesis to determine fetal lung maturity, followed by induction of labor if the results are positive.
B Advise that vaginal delivery would be appropriate after 38 completed weeks of gestation, since cesarean section does not reduce the risk of HIV transmission if the maternal HIV RNA level is less than 50,000 copies/ml.
C Continue to counsel her about the efficacy of HAART in reducing mother-to-child HIV transmission, arrange for an elective cesarean section delivery at 38 completed weeks of gestation, and give intravenous zidovudine starting 3 hours prior to the cesarean section.
D Continue to counsel her about the efficacy of HAART in reducing mother-to-child HIV transmission, schedule a cesarean section delivery at 40 completed weeks of gestation, and give intravenous zidovudine starting 3 hours prior to the cesarean section.