Cases of prenatal exposure should be reported to the Antiretroviral Pregnancy Registry. This registry collects anonymous observational data. The Registry can be contacted at:
Antiretroviral Pregnancy Registry 115 N. Third St., Suite 28401 Wilmington, NC 28401 Tel: 800-258-4263 FAX: 800-800-1052
KEY POINTS
All HIV-positive women of childbearing age should receive information about the impact of HIV on the course and outcome of pregnancy, the impact of pregnancy on HIV progression, and appropriate contraception to prevent unintended pregnancy.
To assure early identification of pregnancy in women with HIV who are sexually active, pregnancy tests should be done whenever they have late or missed menses or other signs of possible pregnancy. Women with the potential of becoming pregnant should be tested before starting potentially teratogenic therapies such as efavirenz (EFV). Patients should be alerted on potential teratogenic effects on the fetus, and suitable contraception should be prescribed.
Contraceptive methods recommended for women with HIV include condoms, which also protect against STDs and prevent HIV transmission to their partners, and hormonal methods. The drug interactions between oral contraceptives and many drugs used in HIV disease make an
additional means of contraception advisable in many cases. Spermicides and intrauterine devices are not recommended for use by HIV-infected women.
HIV testing should be a routine part of prenatal care for all women. HIV testing should be voluntary using the “opt out” method (the HIV test is part of routine bloodwork and the woman may opt to refuse the test). Pre- and post-test HIV counseling should be provided.
All pregnant women infected with HIV should receive antiretroviral therapy.
Zidovudine monotherapy can be provided to untreated pregnant women with a baseline viral load of <1,000 c/mL, but a 3-part ART regimen including zidovudine should always be offered and discussed. Pregnant women should be offered the currently recommended treatment regimens for HIV- infected adults, except that efavirenz (EFV) is contraindicated in the first trimester.
Medical problems associated with ART during pregnancy include hyperglycemia and diabetic ketoacidosis, lactic acidosis, and hyperemesis gravidarum.
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SUGGESTED RESOURCES
Al-Kahn A, Colon J, Palta V, Bardeguez A. Assisted reproductive technology for men and women infected with human immunodeficiency virus type1. Clin Infect Dis. 2003;36:195-200.
Anderson J. HIV and reproduction. In Anderson J, ed. A Guide to the Clinical Care of Women with HIV. Rockville MD: Health Resources and Services Administration, 2001:212-221. Available at http://www.hab.hrsa.gov.
Bartlett J. Recommendations for
antiretroviral therapy in pregnancy. 2003 Medical Management of HIV Infection. Baltimore MD: Johns Hopkins University School of Medicine. 2003:96-105. Available at http://www.hopkins-aids.edu/.
Pham P, Barditch-Crovo P. Pharmacologic Considerations in HIV-Infected Pregnant Patients. In Anderson J, ed. A Guide to the Clinical Care of Women with HIV. Available at http://www.hab.hrsa.gov.
Public Health Service Task Force. Guidelines for the Use of Antiretroviral Agents in HIV- Infected Adults and Adolescents. Available at http://www.aidsinfo.nih.gov.
Public Health Service Task Force.
Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. Available at http:// www.aidsinfo.nih.gov.
Wang C, Celum C. Prevention of HIV. In Anderson J, ed. A Guide to the Clinical Care of Women with HIV. Available at http: //www.hab.hrsa.gov.
World Health Organization. (2001) Global Strategy for Infant and Young Child Feeding. Document A54/7.
REFERENCES
American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 5th Ed. Elkgrove, IL: American Academy of Pediatrics; 2002.
American College of Obstetricians and Gynecologists. Ethics in Obstetrics and Gynecology, 2nd Ed. Washington, DC: American College of Obstetricians and Gynecologists; 2004. Available at http://www.acog.org/from%5Fhome/ publications/ethics Accessed 2/04. American College of Obstetricians and Gynecologists. Human immunodeficiency virus screening. Joint statement of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Pediatrics. 1999;104:128. American College of Obstetricians and Gynecologists. Technical Bulletin Number 205: Preconceptional Care. Washington, DC: American College of Obstetricians and Gynecologists; 1995.
Centers for Disease Control and Prevention. Advancing HIV Prevention: New Strategies for a Changing Epidemic – United States, 2003. MMWR. 2003;52:329-332.
Centers for Disease Control and Prevention. Revised Recommendations for HIV
Screening of Pregnant Women. MMWR. 2001;50(RR19):59-86. Available at http: //www.cdc.gov/mmwr/PDF/rr/rr5019.pdf. Accessed 1/04.
Centers for Disease Control and Prevention. Recommendations of the U.S. Public Health Service Task Force on the Use of Zidovudine to Reduce Perinatal Transmission of
Human Immunodeficiency Virus. MMWR. 1995;43(RR11):1-20.
Cooper ER, Charurat M, Mofenson L, et al. Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission. J Acquir Immune Defic Syndr. 2002;29:484-494.
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Dominguez KL, Lindergren ML, D’Almada PJ, et al. Increasing trend of cesarean deliveries in HIV-infected women in the United States from 1994 to 2000. J Acquir Immune Defic Syndr. 2003;33:232-238.
Eastman PS, Shapiro DE, Coombs RW, et al. Maternal viral genotypic zidovudine resistance and infrequent failure of zidovudine therapy to prevent perinatal transmission of human immunodeficiency virus type 1 in pediatric AIDS Clinical Trials Group Protocol 076. J Infect Dis. 1998;177:557-564.
Garcia PM, Kalish LA, Pitt J, et al. Maternal levels of plasma human immunodeficiency virus type 1 RNA and the risk of perinatal transmission. N Engl J Med. 1999;341:394-402. Ioannidis JP, Abrams EJ, Ammann A,
et al. Perinatal transmission of human immunodeficiency virus type 1 by pregnant women with RNA virus loads <1000 copies/ ml. J Infect Dis. 2001;183:539-545.
Kim LU, Johnson MR, Barton S, et al. Evaluation of sperm washing as a potential method of reducing HIV transmission in HIV- discordant couples wishing to have children. AIDS. 1999;13:645-651.
Public Health Service Task Force (2002). Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1 Infected women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. Available at http://www.aidsinfo.nih.gov.org. Shapiro DE, Sperling RS, Coombs RW. Effect of zidovudine on perinatal HIV- 1 transmission and maternal viral load. Lancet.1999;354:156-158.
Sperling RS, Shapiro DE, Coombs RW, et al. Maternal viral load, zidovudine treatment, and the risk of transmission of human immunodeficiency virus type 1 from mother to infant. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med. 1996;335:1621-1629.
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