HIV in Pregnancy: An Update
Some state laws do not allow opt-out testing and still require affirmative consent, however, so it is important to know your state’s laws. Regardless of your state’s situation, however, failing to test because you deem a patient unlikely to be infected is no longer acceptable.
Testing should be approached just as a blood pressure check is approached – as part of a routine battery of tests that is performed unless the patient declines.
Although the adverse consequences of being identified as HIV positive remain to some extent, it is by no means as severe as it was in the 1980s, when women with positive test results were stigmatized and discriminated against. As primary care providers, we should be reassuring in this regard and much more assertive in making sure patients understand the benefits of testing.
In a related move this year, the U.S. Preventive Services Task Force is recommending that all patients aged 15-65 years should be screened for HIV, regardless of their risk level.
Treating infection
Strategies for preventing perinatal transmission and managing HIV disease in pregnancy are evolving so rapidly that it is often best for obstetricians who see only a few HIV-infected patients a year to work in consultation with an obstetrician with expertise in HIV in pregnancy, an infectious disease specialist or HIV specialty care provider, or an internist with expert knowledge of the antiretroviral drugs. The National Institutes of Health’s guidelines for the use of antiretroviral (ARV) drugs in pregnant HIV-infected women, last updated in July 2012, can be a useful reference.
The latest generation of ARV drugs are not only more effective, but also many require only once-a-day dosing schedules, which can improve patient adherence. On the flip side, there are dozens of choices for individualizing treatment, making treatment decisions much more complex than a decade ago.
Among the important trends and changes for ob.gyns to be aware of are the following:
• A "test and treat" paradigm. We are entering a "test and treat" era in the treatment of HIV infection overall, with the paradigm shifting to a much more liberal and immediate recourse to therapy for HIV-infected adults.
Previously, regular monitoring of virologic status would help guide the timing of therapy initiation. For example, CD4 T-lymphocyte counts of less than 350 mm3 or plasma HIV RNA levels that exceeded certain thresholds were the recommended triggers for initiation of ARV therapy. Although there remains some disagreement among experts who support treating a patient when CD4 counts reach 550 mm3 and experts who support treating a patient regardless of CD4 or viral load, I believe the scale is tipping toward treating almost everyone upon diagnosis. Waiting until patients have become more immunocompromised and reached a chronic infection–induced inflammatory state can drive the development of cardiovascular disease and other long-term health care problems.
While some debate persists as to whether all HIV-infected individuals should begin treatment regardless of CD4 count, there is no question as to the appropriate approach for the pregnant woman.
For HIV-infected pregnant women, it is currently recommended that a combination ARV drug regimen be implemented as early as possible antepartum to prevent perinatal transmission, regardless of HIV RNA copy number or CD4 T-lymphocyte count. Evidence that transmission may be lowered with earlier initiation of ART, combined with growing evidence regarding the safety of ARV drugs, has shifted the mindset from a paradigm of avoiding therapy in the first trimester unless absolutely necessary, to a slightly more aggressive approach with earlier initiation of ARV drugs.
Women who enter pregnancy on an effective ARV regimen should continue this regimen without disruption, as drugs changes during pregnancy may be associated with loss of viral control and increased risk of perinatal transmission.
• Lessening concern about risks. Certainly, the known benefits of ARV drugs for a pregnant woman must be weighed against the potential risks of adverse events to the woman, fetus, and newborn. The NIH clinical guidelines categorize various antiretroviral agents for use in pregnancy as preferred, alternative, or for "use in special circumstances."
In general, however, we have acquired more information on the safety of many of these drugs in pregnancy. As data have accumulated, concerns about potential teratogenic effects and other adverse effects of ARV drugs on fetuses and newborns have lessened.
For example, long-standing concerns about tenofovir decreasing fetal bone porosity and potentially causing other anomalies have lessened with recent studies suggesting that adverse events from tenofovir occur infrequently. The use of other drugs, such as efavirenz, also has been liberalized with recent evidence showing that the risk of adverse events is much lower than once believed; recent guidelines now advise that efavirenz rarely needs to be discontinued among women who were receiving it prior to pregnancy.
