HIV in Pregnancy: An Update

Obstetricians’ chief role in working with consultants is to ensure that a less-effective drug is not prescribed merely because a patient is pregnant. An effective Class C drug should not be replaced by an ineffective Class B drug solely because an internist does not understand drug use in pregnancy. Obstetricians understand that risks of drugs must be balanced against the risks of untreated diseases.

We sometimes prescribe antiseizure drugs and other category D medications during pregnancy when the benefits outweigh the risks, and preventing HIV transmission from mother to fetus is no different. Suppressing the virus is the primary goal in HIV treatment today, and pregnancy should not preclude the use of therapeutics that can attain that goal.

• New intrapartum approach. Probably the most significant recent change to the NIH guidelines concerns the use of intravenous zidovudine (AZT) during labor in women infected with HIV.

Parenteral AZT had been the standard of care since 1994; however, the 2012 guidelines state that AZT is no longer required during labor for HIV-infected women who are receiving combination antiretroviral regimens and who have an undetectable viral load (HIV RNA less than 400 copies/mL near delivery). Studies have shown that with these two criteria met, the transmission rate is low enough that there is no reason to believe that AZT would provide any additional benefit.

Utilizing the Ob. skill set

The choice of drug regiments for HIV-infected pregnant women should be based on the same principles used to choose regimens for nonpregnant individuals, and it is the obstetrician’s job – not the job of the internist or other expert – to decide whether there are compelling pregnancy-specific reasons that should cause modifications.

When there is concern about an elevated risk of preterm birth, as there is with the use of protease inhibitors in the first trimester, obstetricians can utilize cervical length screening and/or appropriate techniques and approaches for monitoring patients, just as they would monitor other patients with elevated risk.

Obstetricians also can also bring their expertise and knowledge of current obstetrical technologies to the table when it comes to the use of amniocentesis in HIV-infected pregnant women. The risks of amniocentesis are minimal (no perinatal transmissions have been reported after amniocentesis in women without detectable virus and on effective ART), but any small potential or perceived risk can be further reduced by using new tests that allow a determination of the likelihood of chromosomal abnormalities through peripheral blood sampling. If a patient’s peripheral blood status is indicative of lower-than-expected risks of aneuploidy, for instance, the patient may decide she can forego amniocentesis.

Additionally, the field of safe reproduction for HIV-discordant couples is progressing. Data from the NIH-supported HPTN 052 randomized clinical trial show that early initiation of ART in the infected partner significantly reduces HIV transmission to the uninfected partner.

Although not as well studied, periconception administration of antiretroviral pre-exposure prophylaxis (PrEP) for HIV-uninfected partners may offer an additional tool for reducing the risk of sexual transmission. (The NIH guidelines for use of ARV drugs in pregnant HIV-infected women include a section on "Reproductive Options of HIV-Concordant and Serodiscordant Couples.")

Uninfected women should be regularly counseled about consistent condom use, but especially in cases in which couples are opposed to protected intercourse and the use of assisted reproductive techniques (sperm preparation techniques coupled with either intrauterine insemination or in vitro fertilization), the use of antiretroviral medications by uninfected women may provide for safer conception.

Dr. Minkoff serves as chairman of the department of obstetrics and gynecology at Maimonides Medical Center in New York and is a distinguished professor of obstetrics and gynecology at State University of New York–Health Science Center. Hef has published extensively on HIV detection and treatment and has been involved over the years on numerous panels, task forces, and guideline committees dealing with the care of HIV-infected women. He currently serves on the panel for the National Institutes of Health’s guidelines for the use of antiretroviral drugs in pregnant HIV-infected women.

Dr. Minkoff reported that he has no disclosures relevant to this Master Class.