HIV drugs during pregnancy
Which drugs should I use?
Like all decisions relating to HIV treatment, there are no hard and fast rules.
Your treatment should be individual. It should suit your own health and your own situation.
Using triple combinations
AZT is still the only HIV drug licensed for use in pregnancy. There is also a lot of experience with this drug in pregnant women.
So some doctors recommend it during this time, particularly if a woman is starting treatment in pregnancy.
However, a recent British and European study looked at non-AZT HAART among pregnant women and found no difference in rates of mother-to-child transmission, undetectable viral load at delivery or abnormalities in the babies.
Use of other nucleoside analogues also increased over time – between 2006 and 2009 about 60 percent of women in this study received non-AZT HAART. Over 70 percent were already receiving non-AZT HAART before they became pregnant.
If you do not need to use treatment for your own health, you may decide to use START.
You will receive two nucleosides
This third drug will probably be a protease inhibitor.
The protease inhibitor is most likely to be lopinavir boosted with ritonavir (called Kaletra and in one pill) or atazanavir boosted with ritonavir.
If you plan to stop treatment straight after your baby is born a protease inhibitor has an advantage over an NNRTI. Your body processes protease inhibitors relatively quickly. You can stop all the drugs in your combination at the same time with a low risk of resistance.
If you need to start treatment for your own health and continue, a drug that is often used is an NNRTI called nevirapine. This drug has been widely used in pregnancy.
There is however a caution against starting nevirapine-based HAART for women with CD4 counts above 250 cells/mm3 because of a risk of liver (hepatic) toxicity.
Nevirapine appears to be safe for women with lower CD4 counts (below 250 cells/mm3). There is no concern with people who have used nevirapine successfully in their combination and now have a higher CD4 count on treatment.
You will probably receive nevirapine if you start your treatment with a CD4 count less than 250 cells/mm3.
As we explained above, if your viral load is greater than10,000 copies/mL NNRTI-based HAART, where appropriate, may be more successful in getting your viral load to undetectable before delivery.
If you are already using combination therapy, and all is going well, you are likely to remain on the same combination. It is increasingly common for women to already be receiving HAART before they become pregnant.
If you are using efavirenz, ddI or ddI and d4T together, you may need to stop or switch those drugs.
This will also depend on what other choices are available to you.
If you have side effects, or your viral load is detectable, your doctor will also look for a possible switch in therapy.
Although it is rare, some women have even delivered babies on combinations of five or more anti-HIV drugs (sometimes called mega-HAART).
Finally, if you only find out that you are HIV positive very late into your pregnancy or in labour you will have specific treatment.
You are likely to be offered nevirapine, regardless of your CD4 count, because a single dose appears to be safe, nevirapine is absorbed very rapidly and is the most effective drug for reducing mother-to-child transmission in this situation.
As resistance to nevirapine develops easily, you need to use it with two other drugs. These are often AZT and 3TC (called Combivir, when together in one pill).
It is best to continue with a triple combination until your viral load is below 50 copies/mL. This will reduce the risk of resistance.
If your CD4 count is greater than 250 cells/mm3 you will be given a boosted protease inhibitor, instead of continuing with nevirapine, for at least a week but ideally until your viral load is undetectable.
If your CD4 count is less than 350 cells/mm3 you will be advised to continue HIV treatment.
You should only continue treatment if you are strictly taking every dose as prescribed.
In some circumstances, depending on the drugs you are using and your birth plan, you may also receive AZT directly into a vein (intravenously, IV) during labour.