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
Antepartum Care
Special Situations - Failure of of Viral Suppression
(Last updated:9/14/2011)
Panel’s Recommendations:
• If an ultrasensitive HIV RNA assay indicates failure of viral suppression to below detectable levels after an adequate period of treatment:
o Assess resistance and adherence (AII). o Consult an HIV treatment expert (AIII).
• Scheduled cesarean delivery is recommended for HIV-infected pregnant women who have HIV RNA levels >1,000 copies/mL near the time of delivery (AII). |
A three-pronged approach is indicated for management of women on ARV regimens who have suboptimal suppression of HIV RNA (i.e., detectable virus at any time during pregnancy using ultrasensitive assays). They should be: 1) evaluated for resistant virus (if plasma HIV RNA is >500–1,000 copies/mL); 2) assessed for adherence, incorrect dosing, or potential problems with absorption (e.g., with nausea/vomiting or lack of attention to food requirements); and 3) consideration should be given to modifying the ARV regimen. Experts in the care of ARV-experienced adults should be consulted, particularly if a change in drug regimen is necessary. Hospitalization may be considered for directly observed drug administration, adherence education, and treatment of comorbidities such as nausea and vomiting.
HIV RNA levels should be assessed 2–4 weeks after an ARV drug regimen is initiated or changed to provide an initial assessment of effectiveness [1]. Baseline HIV RNA levels have been shown to affect the time to response in both pregnant and nonpregnant individuals [2]. Most patients with an adequate viral response at 24 weeks have had at least a one log10 copies/mL HIV RNA decrease within 1–4 weeks after starting therapy [1]. Treatment-naive individuals should have HIV RNA <400 copies/mL after 24 weeks of treatment and <50 copies/mL after 48 weeks of treatment.
Because maternal antenatal viral load correlates with risk of perinatal transmission of HIV, suppression of HIV RNA to undetectable levels should be achieved as rapidly as possible. Scheduled cesarean delivery is recommended for HIV-infected pregnant women who have HIV RNA levels >1,000 copies/mL near the time of delivery (see Transmission and Mode of Delivery).
References
1. 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. http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf.
2. European Collaborative Study, Patel D, Cortina-Borja M, Thorne C, Newell ML. Time to undetectable viral load after highly active antiretroviral therapy initiation among HIV-infected pregnant women. Clin Infect Dis. Jun 15 2007;44(12):1647-1656.