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Reinitiating ART in Late Pregnancy
Optimal ART During Late Pregnancy After a Break in Therapy

Released: April 20, 2017

Expiration: April 19, 2018

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In this HIV cases series, we highlight common patient case scenarios and the critical decision making that goes into selecting optimal patient management strategies. This case features an HIV-infected, pregnant woman in her third trimester. What follows is a discussion of which factors may influence a clinician’s choice of DHHS-recommended ART.

Case Details
A 27-year-old pregnant woman presents to an inpatient acute detox unit at 30 weeks’ gestation. She was previously admitted to rehab for IV drug use on multiple occasions and has recently been actively injecting heroin. She expresses the desire to stop, given her pregnancy.

She is HIV positive with an extensive but unknown ARV history and variable compliance. She discontinued ART 12 weeks ago. Her current lab results include a CD4+ cell count of 480 cells/mm3, HIV-1 RNA of 85,000 copies/mL, a white blood cell count of 5.3 x 109/L, hemoglobin of 10.5 g/dL, and serum creatinine of 0.5 mg/dL. She is HLA-B*5701 negative.

Key Considerations
Outside of an elevated HIV-1 RNA, the patient’s lab results do not warrant much concern. For instance, her slight anemia is not abnormal in late pregnancy, and her CD4+ cell count is high enough to mitigate worry of opportunistic infections.

The primary imperatives here, then, are to preserve her long-term well-being and to protect her developing fetus throughout the remainder of pregnancy and during birth. Because she presents in her third trimester, a rapid reduction in HIV-1 RNA is needed not only to reduce the risk of mother-to-child transmission but also to avoid a scheduled cesarean delivery, which is recommended should her HIV-1 RNA not fall below 1000 copies/mL by 38 weeks’ gestation.

To achieve this reduction in 8 weeks, which regimen would be optimal? Although resistance testing can guide treatment selection, ART initiation should not be delayed while waiting for results in this patient. Furthermore, the predominant species after a 12-week break in ART will likely be wild type.

Preferred Treatment Options
To optimize maternal health and to reduce the risk of perinatal transmission of HIV, the DHHS recommends that pregnant women initiate combination ART regardless of CD4+ cell count. By class, the following are preferred drugs.

  • Boosted PI: atazanavir (ATV)/ritonavir (RTV), darunavir (DRV)/RTV
  • INSTI: raltegravir (RAL)
  • NNRTI: None
  • NRTI: abacavir/lamivudine (3TC), tenofovir DF (TDF)/emtricitabine (FTC), or TDF + 3TC

Boosted PIs such as DRV/RTV or ATV/RTV are among the recommended options for initiating ART during pregnancy and are also recommended in settings where treatment must be initiated before the results of drug resistance testing are available owing to a high barrier to genetic resistance. Despite the resistance advantage, boosted PIs in general reduce HIV-1 RNA levels more slowly than INSTIs. Because insufficient data are available for dolutegravir or elvitegravir use during pregnancy, any regimen containing these drugs is not currently recommended. By contrast, RAL has been studied longer and there are sufficient data establishing its safety in pregnancy. However, RAL has a lower genetic barrier to resistance than boosted PIs and, therefore, would not be the best choice in a previous treatment setting where underlying drug resistance may be present. Several small case series have shown that addition of RAL to a standard ART regimen late in pregnancy results in a rapid decline in HIV-1 RNA. Thus, the combination of DRV/RTV + TDF/FTC + RAL would be a reasonable approach in this case, providing the patient with both a high barrier to resistance and rapid HIV-1 RNA reduction to reduce the risk of HIV transmission to her child.

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Which of the following ART regimens do you use in patients who present late in pregnancy with a high HIV-1 RNA and a history previous ART with variable adherence?
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