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Pregnancy and HIV

Antiretroviral treatment during pregnancy significantly reduces risk of transmission to the fetus. National guidelines to reduce perinatal transmission of HIV were last updated in April 2009 and can be viewed at:
http://www.aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?GuidelineID=9

Though not specifically targeting HIV pregnant women, the DHHS adult and adolescent treatment guidelines were last updated in December 2009.  These guidelines review data from recent studies suggesting better outcomes with earlier initiation of highly actively antiretroviral therapy (HAART) and the initiation of HAART in the context of pregnancy.  Moreover, these guidelines designate newer ARVs as first-line therapy that may represent feasible options in the setting of pregnancy.

Summary of Guidelines and Madison Clinic Policy:

Providers should counsel their female patients about pregnancy and avoid EFV in women of childbearing age who wish to conceive.

Providers should strongly encourage a second contraceptive method (beyond condoms) for those women of childbearing age who are on EFV and provide information about emergency contraception for women on EFV who rely on condoms alone for contraception.

In the event of pregnancy, providers should first discuss whether the patient plans to continue the pregnancy. For women who desire to terminate their pregnancy - referral to family planning services (HMC Women’s and Children’s clinic or UWMC OB/Gyn) should be made.

For women who plan to carry the pregnancy to term – referral for routine ultrasound and prenatal care should be performed (see details below).

  • Refer patients to Perinatalogy at UWMC (MICC) with an effort to have at least one email or phone conversation with the OB provider, prior to the patient’s first visit at UWMC.
    • UWMC MICC Contact: Chris Murphy, RN at 598-3514
    • Jane Hitti, MD
  • If feasible, prior to referral to UW of newly pregnant patients, providers should ensure recent laboratory testing that includes:
    • HIV viral load, T cell subset and genotype testing if viral load is detectable
    • comprehensive metabolic profile, CBC with differential
  • The following laboratory studies are helpful, but not necessary to obtain before referral:
    • standard prenatal labs (prenatal blood type and antibody screen, rubella, RPR, Hepatitis serologies, CMV, Toxoplasmosis, HSV1/2, VZV, urinalysis)
    • current cervical or urine NAAT testing for N. gonorrhoea and C. trachomatis
    • Pap smear if not current in the past year
    • HbA1C in the past six months in those with diabetes mellitus

General Principles of HIV Care in the Context of Pregnancy

  • Patients already on effective ARVs with suppressed viral loads should continue their current regimens (unless on EFV and in the first trimester)
  • Changes to ART regimens made during pregnancy by the perinatology provider will be discussed with the patient’s primary HIV provider
  • Patients will be seen at the UW MICC for a 6-week postpartum visit including HIV labs, and will be advised to return for follow-up at Madison Clinic within 2-3 months after this visit for ongoing HIV primary care
  • Breastfeeding is not recommended in the post-partum setting in the United States regardless of HIV medications, viral load or CD4 count

Counseling on the initiation of HAART, ideally utilizing a team based approach (HIV counselor, clinical RN, HIV pharmacist, HIV clinician) is recommended for patients who are not on ARVs at the time of diagnosis of pregnancy or are diagnosed with HIV during pregnancy:

  • For women who meet criteria for treatment, HAART should be initiated based on standard adult and adolescent treatment guidelines, including during 1st trimester.  However, the timing of initiation will depend also on maternal symptoms (nausea/vomiting) and the relative clinical urgency for starting ARV therapy.  In many cases, initiation can be safely deferred until after 12-14 weeks gestation.
  • Women who do not meet criteria for treatment, should start HAART for prophylaxis of perinatal transmission (can be delayed until after 1st trimester but ideally started well before gestational week 28)
  •   Agents to avoid during pregnancy:          
    1. EFV at conception and during early pregnancy
    2. Nevirapine for women with CD4 counts > 250 cells/uL
    3. ddI or d4T particularly later in pregnancy

Preconception Counseling

[See expanded Guidelines]

HIV-infected women

  • Avoid EFV
  • Regular HIV testing of the HIV-negative partner
  • Consider referral for preliminary fertility counseling and discussion of safer conception  methods such as intravaginal insemination at home
  • Providing ARVs for use by HIV-negative male partners before intercourse (Pre-Exposure Prophylaxis or PREP) is not recommended at this time.

HIV-uninfected women with HIV+ partners

  • HIV testing of female partners prenatally at diagnosis of pregnancy and again during 3rd trimester, before 36 weeks gestation
  • No standard recommendations exist regarding safe conception practices to reduce transmission from HIV-positive men to HIV-negative women, however, European studies have evaluated sperm washing and intrauterine insemination as a possible options.  A UW study investigating these methods in serodiscordant couples is ongoing.

Fertility Services:
Roosevelt Women’s Clinic: 598-5600
Seattle Reproductive Medicine: 877-777-6002

  • Providing ARVs for use by HIV-negative female partners before intercourse (PREP) is not recommended at this time.

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