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Updated Guidelines for Pregnant Women with HIV and Preventing Mother-to-Child Transmission

The U.S. Department of Health and Human Services last week released an update to its Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Notable changes include discussion of antiretroviral treatment as prevention and pre-exposure prophylaxis (PrEP) for serodiscordant couples wishing to conceive, and a new section on options for perinatally infected women who are now pregnant themselves.

Key changes to the recommendations are summarized in What's New in the Guidelines, and additions and revisions are highlighted in yellow throughout the text and tables of the online guidelines document.

Changes include:

• Pregnant women with perinatal HIV infection -- while prenatal care and antiretroviral therapy (ART) generally do not differ between pregnant women who were perinatally infected and those infected in other ways, there are some notable challenges such as drug resistance.
• Contraception -- clarification that women withHIV can continue to use all existing hormonal contraceptive methods, but drug interactions with antiretrovirals should be taken into account.
• Reproductive options for discordant couples -- the panel recommends that the HIV-positive partner in a mixed-status couple should receive ART with sustained undetectable viral load, while PrEP for the HIV-negative partner may offer an additional tool to reduce the risk of transmission.
• Risk of birth defects -- additional data from cohort studies and updated Antiretroviral Pregnancy Registry data reaffirm the lack of a clear association between first-trimester exposure to any antiretroviral drug and increased risk of birth defects, though babies exposed to tenofovir (Viread) have lower bone mineral content.
• Recommended antiretroviral drugs:

o   Ritonavir-boosted darunavir (Prezista) has been promoted to a preferred protease inhibitor for treatment-naive pregnant women, boosted atazanavir (Reyataz) remains on the preferred list, but lopinavir/ritonavir (Kaletra) has been demoted to an alternative.

o   Efavirenz remains a preferred NNRTI when initiated after the first 8 weeks of pregnancy, while rilpivirine (Edurant) has been added as an alternative.

o   Raltegravir has been promoted to the first preferred integrase inhibitor for initial treatment of pregnant women.

o   Boosted saquinavir (Invirase) and nevirapine (Viramune) are no longer recommended for initial therapy for treatment-naive pregnant women.

o   There are insufficient data to recommend cobicistat (Tybost) as a booster for pregnant women.

• Immediate ART -- the panel recommends that ART initiation should be considered as soon as HIV is diagnosed during pregnancy, in light of data showing that earlier viral suppression lowers the risk of transmission.
• HIV/hepatitis C coinfection-- the guidelines include a link to the AASLD/IDSA/IAS-USA hepatitis C treatment guidelines, but notes that there is not yet sufficient safety data to recommend new direct-acting antiviral agents during pregnancy.

8/12/15

Reference

U.S. Department of Health and Human Services. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Updated July 6, 2015.