6 HIV and pregnancy

6.5 ARVs in pregnancy: when to treat

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• Most guidelines now recommend treating adults with ARVs at a CD4 count of 200 cells/mm³.
• Pregnancy is one situation where ARVs are used differently to the way they are used in treatment of other HIV-positive adults.
• This is because there is a risk of transmission, even with mothers who have low viral loads that are less than 1,000 copies/mL before they start treatment.
• Transmission drops from almost 10% in untreated women to less than 1% in women treated with anti HIV drugs.

Recommendations vary depending on the mother's situation and her own treatment needs when she becomes pregnant.

If a woman is pregnant and does not need HIV treatment for her own health

A woman will be offered:

• a short course of combination therapy after the second trimester (6 months into pregnancy) at 24 to 28 weeks

or:

• AZT monotherapy for mother and baby and have an elective Caesarean section (C-section).

She will need to carefully consider these two options.

• Using 3 drugs will be more likely to reduce her viral load to undetectable levels. This has shown the lowest transmission risk to date.
• Using 3 drugs will also protect her from the possibility of developing resistance. This will protect her options for future treatment.
• C-sections are major surgery. They can carry risks for the mother.
• The baby will be exposed to a more drugs with combination therapy.
• The risk of the mother developing resistance is higher using AZT alone than combination therapy.

If a woman is HIV-positive and needs treatment for her own HIV

If someone is diagnosed during pregnancy and needs ARVs for her own HIV she can be prescribed appropriate combination therapy.

If she is diagnosed early on in her pregnancy, she may wish to delay starting treatment until the end of the first trimester. This is the first 12 to 14 weeks from her last missed period. She may also want to wait if she already knows her HIV status but has not yet started treatment.

There are two main reasons for delaying treatment:

• The baby’s main organs develop in the first 12 weeks in the womb. This is called organogenesis. The baby may therefore be vulnerable to any effects the medicines could have during this time.
• Nausea or 'morning sickness' in the early stage of pregnancy is normal, but symptoms of morning sickness are very similar to the nausea that can occur when starting HIV treatment.

If an HIV-positive pregnant woman wants to begin treatment immediately or urgently needs to start because she has a low CD4 count, this should be recommended by her doctor.

If a woman discovers she is HIV-positive late in pregnancy

There is still a benefit to using ARVs ate in pregnancy. Using combination therapy for 1 week will reduce viral load by a large amount.

Even after 36 weeks, combination therapy will reduce the mother's viral load to very low levels.

If a woman is already using HIV treatment when she becomes pregnant

She should remain on her treatment except in very particular circumstances .

Many women decide to have a baby when they are already using HIV treatment.