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
Preconception Counseling and Care for HIV-Infected Women of Childbearing Age
Overview
(Last updated:9/14/2011)
Panel’s Recommendations:
• Discuss childbearing intentions with all women of childbearing age on an ongoing basis throughout the course of their care (AIII).
• Include information about effective and appropriate contraceptive methods to reduce the likelihood of unintended pregnancy (AI).
• During preconception counseling include information on safer sexual practices and elimination of use of alcohol and illicit drugs, and smoking, which are important for the health of all women as well as for fetal/infant health, should pregnancy occur (AII).
• When evaluating HIV-infected women, include assessment of HIV disease status and need for antiretroviral therapy (ART) for their own health (AII).
• Choose an ART regimen for HIV-infected women of childbearing age based on consideration of effectiveness for treatment of maternal disease, teratogenic potential of the drugs in the regimen should pregnancy occur, and possible adverse outcomes for mother and fetus (AII). |
The Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists, and other national organizations recommend offering all women of childbearing age comprehensive family planning and the opportunity to receive preconception counseling and care as a component of routine primary medical care. The purpose of preconception care is to improve the health of each woman before conception by identifying risk factors for adverse maternal or fetal outcome, providing education and counseling targeted to the patient’s individual needs, and treating or stabilizing medical conditions to optimize maternal and fetal outcomes [1]. Preconception care is not a single clinical visit but rather a process of ongoing care and interventions integrated into primary care to address the needs of women during the different stages of reproductive life. Because more than half of all pregnancies in the United States are unintended [2-5] it is important that comprehensive family planning and preconception care be integrated into routine health visits. Providers should initiate and document a nonjudgmental conversation with all women of reproductive age concerning their reproductive desires because women may be reluctant to bring this up themselves [6]. HIV care providers who routinely care for women of reproductive age play an important role in promoting preconception health and informed reproductive decisions.
The fundamental principles of preconception counseling and care are outlined in the CDC Preconception Care Work Group’s Recommendations to Improve Preconception Health and Health Care. In addition to the general components of preconception counseling and care that are appropriate for all women of reproductive age, HIV-infected women have specific needs that should be addressed [7-8]. Because many women infected with HIV are aware of their HIV status prior to pregnancy, issues that impact pregnancy may be addressed before conception during their routine medical care for HIV disease. In addition to those outlined by the CDC Preconception Care Work Group [9], the following components of preconception counseling and care are specifically recommended for HIV-infected women. Health care providers should:
a. Discuss reproductive options, actively assess women’s pregnancy intentions on an ongoing basis throughout the course of care and, when appropriate, make referrals to experts in HIV and women’s health, including experts in reproductive endocrinology and infertility when necessary [10].
b. Offer all women effective and appropriate contraceptive methods to reduce the likelihood of unintended pregnancy. Providers should be aware of potential interactions between ARV drugs and hormonal contraceptives that could lower contraceptive efficacy (see Table 4).
c. Counsel on safe sexual practices that prevent HIV transmission to sexual partners, protect women from acquiring sexually transmitted infections (STIs), and reduce the potential to acquire more virulent or resistant strains of HIV.
d. Counsel on eliminating alcohol, illicit drug use, and cigarette smoking.
e. Educate and counsel women about risk factors for perinatal transmission of HIV, strategies to reduce those risks, potential effects of HIV or treatment on pregnancy course and outcomes, and the recommendation that HIV-infected women in the United States not breastfeed because of the risk of transmission of HIV and the availability of safe and sustainable infant feeding alternatives.
f. When prescribing ART to women of childbearing age consider the regimen’s effectiveness for treatment of HIV, an individual’s hepatitis B disease status, the drugs’ potential for teratogenicity should pregnancy occur, and possible adverse outcomes for mother and fetus [11-13].
g. Use the preconception period in women who are contemplating pregnancy to adjust ARV regimens to exclude efavirenz or other drugs with teratogenic potential.
h. For women who are on ART for their own health and who want to get pregnant, make a primary treatment goal the attainment of a stable, maximally suppressed maternal viral load prior to conception to decrease the risk of mother-to-child transmission.
i. Evaluate and appropriately manage therapy-associated side effects such as hyperglycemia, anemia, and hepatoxicity that may adversely impact maternal-fetal health outcomes.
j. Evaluate the need for appropriate prophylaxis or treatment for opportunistic infections (OIs), including safety, tolerability, and potential toxicity of specific agents when used in pregnancy.
k. Administer medical immunizations (e.g., influenza, pneumococcal, or hepatitis A and B vaccines) as indicated.
l. Encourage sexual partners to receive HIV testing and, if infected, counseling and appropriate HIV care.
Table 4: Drug Interactions Between Antiretroviral Agents and Hormonal Contraceptives
| Antiretroviral (ARV) Drug | Effect on Drug Levels | Dosing Recommendation/ Clinical Comment |
| Non-nucleoside Reverse Transcriptase Inhibitor (NNRTI) |
| Efavirenz (EFV) | Oral ethinyl estradiol/norgestimate:
No effect on ethinyl estradiol concentrations;
↓ active metabolites of norgestimate (levonorgestrel AUC ↓83%; norelgestromin AUC ↓64%)
Implant: ↓ etonogestrel
Levonorgestrel AUC ↓58% | A reliable method of barrier contraception must be used in addition to hormonal contraceptives. EFV had no effect on ethinyl estradiol concentrations, but progestin levels (norelgestromin and levonorgestrel) were markedly decreased. No effect of ethinyl estradiol/norgestimate on EFV plasma concentrations was observed.
A reliable method of barrier contraception must be used in addition to hormonal contraceptives. The interaction between etonogestrel and EFV has not been studied. Decreased exposure of etonogestrel may be expected. There have been postmarketing reports of contraceptive failure with etonogestrel in EFV-exposed patients.
Effectiveness of emergency postcoital contraception may be diminished. |
| Etravirine (ETR) | Ethinyl estradiol AUC ↑22%
Norethindrone: no significant effect | No dosage adjustment necessary. |
| Nevirapine (NVP) | Ethinyl estradiol AUC ↓20%
Norethindrone AUC ↓19%
DMPA: no significant change | Use alternative or additional methods.
No dosage adjustment needed. |
| Ritonavir (RTV)-boosted Protease Inhibitor (PI) |
| Atazanavir/ritonavir (ATV/r) | ↓ Ethinyl estradiol
↑ Norgestimate | Oral contraceptive should contain at least 35 mcg of ethinyl estradiol. Oral contraceptives containing progestins other than norethindrone or norgestimate have not been studied. |
| Darunavir/ritonavir (DRV/r) | Ethinyl estradiol AUC ↓44%
Norethindrone AUC ↓14% | Use alternative or additional method.
|
| Fosamprenavir/ritonavir (FPV/r) | Ethinyl estradiol AUC ↓37%
Norethindrone AUC ↓34% | Use alternative or additional method. |
| Lopinavir/ritonavir (LPV/r) | Ethinyl estradiol AUC ↓42%
Norethindrone AUC ↓17% | Use alternative or additional method. |
| Saquinavir/ritonavir (SQV/r) | Ethinyl estradiol AUC ↓48%
Norethindrone: no significant change | Use alternative or additional method. |
| Tipranavir/ritonavir (TPV/r) | Ethinyl estradiol AUC ↓48%
Norethindrone: no significant change | Use alternative or additional method. |
| PI without RTV |
| Atazanavir (ATV) | Ethinyl estradiol AUC↑48%
Norethindrone AUC ↑110% | Oral contraceptive should contain no more than 30 mcg of ethinyl estradiol or use alternative method. Oral contraceptives containing less than 25 mcg of ethinyl estradiol or progestins other than norethindrone or norgestimate have not been studied. |
| Fosamprenavir (FPV) | With APV: ↑ Ethinyl estradiol and ↑ norethindrone; ↓APV 20% | Use alternative method. |
| Indinavir (IDV) | Ethinyl estradiol AUC ↑25%
Norethindrone AUC ↑26% | No dose adjustment. |
| Nelfinavir (NFV) | Ethinyl estradiol AUC ↓47%
Norethindrone AUC ↓18% | Use alternative or additional method. |
| CCR5 Antagonist |
| Maraviroc (MVC) | No significant effect on ethinyl estradiol or levonorgestrel | Safe to use in combination. |
Key to Abbreviations: AUC = area under the curve; DMPA = depot medroxyprogesterone acetate
Derived from: Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Department of Health and Human Services. January 10, 2011; pp. 1–166; Tables 15a, 15b, and 15d. Accessed August 31, 2011. Available at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. |
References
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