Case study of multi-drug resistant woman receiving newer antiretroviral drugs in pregnancy

A poster from Furco and coworkers from Northwick Park Hospital, Harrow, St Mary’s Hospital, London and Chelsea and Westminster Hospital, London reported a case study of a multi-drug resistant HIV-positive pregnant woman receiving a combination of newer antiretroviral drugs.

This patient was a 38-year-old African woman, pregnant with twins, who presented with a viral load of 4,660 copies/mL and CD4 count 471 cells/mm³) in early trimester.

She had previously been treated with different combinations of NRTIs (5), NNRTIs (2) and protease inhibitors (2). Genotypic sequencing showed the following mutations – RT: D67N, V118I/V, M184V, Y188L, L210W, T215Y; protease: L10I, I13V, G16E, K20I, M36I, M46I, I47V, F53L, I54V, D60E, D63T, H69K, I84V, L89M. A confirmatory phenotypic test showed high-level antiretroviral resistance.

At 25 weeks gestation, she received a combination of tenofovir/emtricitabine, darunavir/ritonavir, etravirine and enfuvirtide. After 4 weeks her viral load was undetectable (<50 copies/mL).

PK studies for enfuvirtide, etravirine and darunavir were performed and all drug concentrations were within the expected therapeutic ranges.

At 34 weeks, her viral load was still undetectable and she delivered two HIV negative infants by caesarean section.

The infants received ARV prophylaxis with enfuvirtide, nevirapine and ddI. The investigators noted that enfurvirtide was undetectable and darunavir/ritonavir and etravirine were detectable in cord blood. The infants’ adverse events included injection site reactions, hypertriglyceridaemia, anaemia, transient hypereosinophilia and raised alanine transferase.

Furco A, Gosrani B, Nicholas S et al. Use of newer antiretroviral (ARV) drugs (darunavir, etravirine and enfuvirtide) in HIV-positive pregnant woman with pan-class resistance failure. 14th Annual BHIVA Conference, Dublin, 2008. HIV Medicine, 9 Suppl. 1. P60.