Pregnancy Management and HIV - Southeast AIDS Education ... · Pregnancy Management and HIV Judy...
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Pregnancy Management and HIV Judy Levison, MD, MPH Professor, Department of Obstetrics and Gynecology Baylor College of Medicine, Houston, TX
Transcript of Pregnancy Management and HIV - Southeast AIDS Education ... · Pregnancy Management and HIV Judy...
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• [email protected]
Thank you!!To learn more, please visit www.nccc.ucsf.edu!
