PregnancyManagementandHIVJudyLevison,MD,MPH

Professor,DepartmentofObstetricsandGynecology

BaylorCollegeofMedicine,Houston,TX

Disclosures:None

•  ListthebasictenetsofmanaginganGretroviraltherapy(ART)inapregnantwoman

•  Stateatleast3topicsprovidersshouldaddresspriortodeliverywithwomenlivingwithHIV

•  Explainyourapproachtoawomanwhoisnotvirallysuppressedby35weeksgestaGon

ObjecGves

§  HIV-infectedwomendeliveringinfantsannually§  ≈8700in20061§  ≈30%increasesince2000

§  HIV-infectedinfantsbornin50states§  1650in1991§  151in20093§  69in20134

1Whitmore,PediatricsJAIDS2011;57:p218;2NHSSSurveillanceReport2013,vol25;

3Taylor,2012CROI,abst103;4TaylorJAMAPediatrics2017

CDC:PerinatallyInfectedInfants

ThenumbersmayseemsmallbuttheyrepresenttheGpoftheiceberg

Withoutdiagnosisandtreatmentduringpregnancy/labor,25%ofwomenwithHIVwilldeliverinfantsinfectedwithHIV.

•  Whatweusedtouse– ELISA(anGbodytest)– Westernblot(anGbodytest)

•  In2018whatistherecommendedapproachtotesGng?

TesGng

TESTING

HIVInfec.onandLaboratoryMarkers

HIV Antibody

11

0 10 20 30 40 50 60 70 80 90 100

HIV p24 Ag

16 1st gen

2nd gen 3rd gen

Acute HIV Infection

HIV RNA (plasma)

IgM IgG 4th gen

Infection Undetectable

Modified after Busch et al. Am J Med. 1997

4th generation HIV-1/2 immunoassay

HIV-1/HIV-2 antibody differentiation immunoassay

(-) (+)

HIV-1 (+)

HIV-2 (-) HIV-1 antibodies

detected

HIV-1 (-) HIV-2 (+)

HIV-2 antibodies detected

HIV-1 (-) or indeterminate

HIV-2 (-)

NAT

NAT (+) Acute HIV-1 infection

NAT (-) Negative for HIV-1

Negative for HIV-1 and HIV-2 antibodies and p24 Ag

HIV-1 (+)

HIV-2 (+)

HIV antibodies detected

•  CDC2006recommended(optout)HIVtesGngatfirstprenatalvisitand,inhighriskjurisdicGons,inthirdtrimester(ideallyat<36weeks).ExpeditedtesGnginLabor&Deliveryifnothirdtrimestertestresultsavailable.

•  HighriskjurisdicGonsareareasinwhichprenatalscreeningidenGfiesatleastoneHIV-infectedpregnantwomanper1,000womenscreened.

•  However,screeningiscosteffecGveifprevalence17per100,000(0.17per1000).

hMps://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

Testing in Pregnancy

ANTEPARTUMCAREFORWOMENWITHHIV

•  GoalofanGretroviraltherapy(ART)istomaintainaviralloadbelowthelimitofdetecGonthroughoutpregnancy

•  Whatifsheisalreadyonaregimen?

•  WhatifsheisARTnaïve?

AntepartumCare—GeneralPrinciples

PerinatalGuidelinesNovember2017www.aidsinfo.nih.gov

Whatweknownow• 8075mother-babypairsfollowed2001-2011• NOperinataltransmissionamongthe2651motherswhostartedARTpriortoconcepGon,conGnuedduringpregnancy,andhadaVL<50atdelivery

Mandelbrotetal.ClinicalInfecTousDiseases2015

•  Gloriaisa32yearoldG3P2diagnosedwithHIVduringherfirstpregnancy7yearsago.Sheisontenofovir/emtricitabine/elvitegravir/cobisistat(brandnameStribild)andhasbeenvirallysuppressedonthisregimenfortwoyears.

•  Whatdoyourecommendshetakeduringpregnancy?

Case1

•  A:ChangehertoaregimencontainingAZT•  B:Keepheronthesameregimen•  C:ChangehertoARTotherthanelvitegravir/cobicistat

•  D:BorC

Poll#1

•  IfonARTandvirallysuppressed,stayonsameregimen(noneofcurrentanGretroviralsareknowntobeteratogenic)

•  Ifonelvitegravir/cobicistat(suchasStribildorGenvoya),monitorviralload(VL)carefullyorconsiderswitchtomoreeffecGveregimen

BestBetal.Elvitegravir/CobicistatPharmacokineTcsinPregnancyandPostpartum.

ConferenceonRetrovirusesandOpportunisTcInfecTons2017;SeaMle,WA.PerinatalGuidelinesNovember2017www.aidsinfo.nih.gov

IfalreadyonART:

•  Sheilaisa23yearoldG1P0diagnosedwithHIVatherfirstprenatalvisitthroughrouGnepregnancyscreening.

•  WhatARTregimendoyoustartheronandwhendoyoustartit?

Case2

•  A:ItdependsonhergestaGonalage•  B:IwouldwaitfortheresultsoftheHIVgenotypetomakesurehervirusisnotresistanttothedrugIamprescribing

•  C:Iwouldplaceheronaregimencontainingtenofoviralafenamidesincethatisthenewestformoftenofovir

•  D:AandB

Poll#2

•  Ini.ateARTassoonasHIVisdiagnosed–  BeginARTwhileawaiGngresultsofHIVgenotypeforresistance(ifthereisresistancetoaprescribeddrug,youcanchangeit)

–  Considerincludinganintegraseinhibitorsuchasraltegravirordolutegravirifhighviralload(VL)lateinpregnancy(expect1-logdecreaseperweek)

•  Includetenofovir/emtricitabine(ortenofovir/lamivudine)ifsheisco-infectedwithhepa..sB(HBV)

BoucoiranIetal.CanJInfectDisMedMicrobiol.2015RahangdaleLetal.AmJObstetGynecol.2016

BrownRSetal.Hepatology.2016

IfshehasnevertakenARTbefore(ARVnaïve):

WhatARVsshouldIprescribe?• “Givewhatshewilltake”*

– Doesshehavetroubleswallowinglargepills?– Wouldsheratherhave2smallpillsoronelargepill?– Mostindividualsadheretoonceadayregimensbemerthantwiceadayregimens

• Theguidelinesareguidelines*DebCohan

Initiating ART in Pregnancy (aka prescribe what they will take)

NRTI/NtRTI NNRTI PI EI/II

Preferred ABC/3TCTDF/F(3)TC

ATV/rDRV/r(BID)

RAL(BID)

AlternaGve ZDV/3TC EFV

RPVLPV/r

DTG(preferredifacuteHIV)

Insufficientdata TAF

aidsinfo.nih.gov DHHS Perinatal Guidelines November 2017 with special thanks to Deb Cohan for her concise graphic summary of the 2017 Perinatal Guidelines

AndifshehasalowCD4count

•  CD4<200:givesulfasoxazole/trimethoprim800mg/160mg(BactrimDS)topreventpneumocysGsjirovecipneumonia(yes,Iknowsheispregnant;benefitsoutweighrisks;makesuresheisonprenatalvitamins—whichcontainfolate)

•  CD4<50:giveazithromycin1200mgweeklytopreventmycobacteriumaviumcomplexpneumonia

WhatnonstandardprenatalbloodtestsdoIneedtoorder?LiverandkidneyfuncGonHepaGGspanelHepaGGsBsurfaceanGbodyHepaGGsAanGbodyHLA5701toruleoutabacavirhypersensiGvityHIVgenotypeforresistance

hMps://www.hiveonline.org/perinatal-providers/

Monitoringinpregnancy

•  CheckVL–  2-4weeksareriniGaGngtreatment–  monthlyunGlundetectable–  every3months–  at34-36weekstoinformdecisionregardingmodeofdeliveryandop'malmanagementofnewborn

•  CheckCD4countevery6monthsinwomenwhoarevirallysuppressedandhaveCD4counts>200

AcuteHIV:whatdowemeanbythisandwhydoesitmamer?

•  RecentdiagnosisofHIV–  Forexample:HIVnegaGveinfirsttrimesterandHIVposiGveinthirdtrimester

•  InfantsborntomothersinfectedwithHIVduringpregnancy(orbreasseeding)areathigherriskthaninfantswhosemothershavehadHIVpriortopregnancy

•  ImperaGvetoreduceviralloadrapidly•  DolutegraviristhepreferredintegraseinhibitorinthissituaGon

•  Melanieisa20yearoldG1P0at35weeksgestaGonwhohasbeenonARTsince18weeks.ShehasanunstablelivingsituaGonandherboyfriendhassomeGmeslockedheroutofherroom,whereshekeepshermedicaGons.Herviralload,whichwasundetectableat26weeks,isnow11,000.

•  Whatdoyoudo?

Case3

•  A:Doagenotypeforresistance•  B:Arrangeforhomehealthcareorhospitaladmissiontogivedirectlyobservedtherapy

•  C:ScheduleherforaCesareanat38weeks•  D:Addanintegraseinhibitorifsheisnotalreadyonone

•  E:A,B,andD

Poll#3

Lackofviralsuppression– Resistancevs.adherence– Addintegraseinhibitorsuchasraltegravirordolutegravir

– Considerdirectlyobservedtherapy– ScheduledCesareanifVL>1000at38weeks

Westling et al. AIDS Patient Care STDS. 2012;26(12):714-7. Nobrega et al.AIDS Res Hum Retroviruses. 2013 Nov;29(11):1451-4.

Rahangdale et al. AJOG. 2016; 214(3):385.e1-7

Don’tforgettodiscuss:

•  RecommendaGonforlifelongtreatmentwithARVs(regardlessofCD4count)

•  Modeofdelivery•  ContracepGonplans:“Whendoyouwanttohaveyournextbaby?”

•  Infantprophylaxis•  Infantfeeding:“IntheU.S.werecommendnotbreasseeding.Howdoyoufeelaboutthat?”

•  Nopre-chewingofinfantfoods

•  Flu•  Tdap•  HepAandHepBifnotimmune

Don’tforgettogivevaccinaGons:

RetenGoninCarearerDelivery

•  NaGonally,womenmoresuccessfullyamendprenatalvisitsthanprimarycareHIVappointmentsarerdelivery

•  TwotofourvisitsperyeararerecommendedtofollowVLandCD4counts

•  Whatcanwedotoimprovelongtermfollow-uparerdelivery?

InnovaGonsinCare

•  AdaptaGonofCenteringPregnancy(groupprenatalcare)

•  Centering:–  10twohoursessionsduringpregnancy–  FocusedacGviGesanddiscussionofissuesinpregnancy,e.g.nutriGon,domesGcviolence,whattoexpectinlabor,changesinrelaGonships,contracepGon,postpartumdepression

– WomenofsimilargestaGonalagesgroupedtogether

Whatwehaveadded•  AcGviGesanddiscussionsofHIV-relatedtopicstoeachsession– HowandwhenwereyoudiagnosedwithHIVandwhatwasthatlike?

–  TowhomhaveyoudisclosedyourHIVdiagnosisandwhomdoyousGllwanttotell?

–  VideosonhowARTworksandhowtakingARTpreventstransmissionofHIVtobaby

– HowcanyouprotectyourpartnerifpartnerdoesnothaveHIV?

– MeettheprimarycareandpediatricdoctorsandaskthemquesGonsaboutfollow-upcare

CollaboraGonwithHoustonFoodBank

•  AnGcipateagreaterreducGoninsenseofsGgmaanddepressionandagreaterincreaseinknowledgeandadherencetomedicaGoninthegroupvs.standardone-on-onecare

•  ExpectmoreregularamendanceatprimaryHIVcareclinicianvisitsintheyeararerdelivery

Hypotheses

Na.onalPerinatalHIVHotline24hoursaday,7daysaweek,365daysayear

(888)448-8765

TheClinicianConsultaGonCenter(CCC)providesfree,confidenGal,andGmelyexpertperinatalHIVandHIV-exposedinfantconsultaGontocliniciansofallexperiencelevelsandtrainingbackgrounds.

AdviceisbasedonFederaltreatmentguidelines,currentmedicalliterature,andclinicalbestpracGces.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1OHA30039-01-00 (AIDS Education and Training Centers National Clinician Consultation Center) awarded to the University of California, San Francisco. (updated 10/24/17)

Thankyou!•  LetmeknowifyouhavequesGons•  jlevison@bcm.edu

Thank you!!To learn more, please visit www.nccc.ucsf.edu!