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Individualising HIV Treatment – Considerations for Women of Child-bearing Age
are unchanged in pregnancy, but there is a risk that this drug can cross Summary and Conclusions
the placenta, giving rise to increased bilirubin levels in the baby. Despite the fact that roughly 50% of HIV-positive individuals are
women, there is a lack of good-quality randomised controlled trials
Guidelines that are sufficiently powered to look at gender differences in response
The risk of many of the antiretroviral drugs in pregnancy is unknown. to antiretroviral therapy. While disease progression appears to be
Nevertheless, the consideration is that the risk of transmission to the similar in women and men, toxicity profiles and responses to treatment
foetus outweighs the risk for most agents. The European AIDS Clinical show some differences.
Society (EACS) guidelines state that HIV-positive women wishing to
become pregnant should be advised to do so under the “best possible
conditions: undetectable viral load, high CD4 cell count, no other
While low, the risk of vertical
infection, no use of drugs which are prohibited during pregnancy...”,
adding that there are no differences in the guidelines for initiation of
mother-to-child transmission
ART between pregnant and non-pregnant women.
33
Nevertheless, ART
does exist and appropriate
during pregnancy has the additional aim of preventing mother-to-child
treatment choices need to be
transmission over and above the aim of protecting the woman.
made to prevent transmission.
The US Food and Drug Administration (FDA) has specific pregnancy
categories for each antiretroviral drug, assigned based on the risk to
the foetus (see Table 1).
34
There is no equivalent system currently In addition, the longer life-expectancy of HIV sufferers means that
operating in Europe. Those treatments preferable for use in pregnant more HIV-positive women are having children. While low, the risk of
women are listed in Table 1. Most fall into the B and C categories. vertical mother-to-child transmission does exist and appropriate
Thus, the only NNRTI recommended for HIV-positive pregnant women treatment choices need to be made to prevent transmission while
is nevirapine, which was upgraded to category B in April 2007. In ensuring the continuing health of the mother. HAART has significantly
contrast, efavirenz was downgraded to category D by the FDA in 2006 decreased the risk of vertical transmission. This all affects the choice of
based on documented teratogenicity in animals, and is also not ART given to women, as well as the timing of treatment initiation.
recommended by the WHO
35
or EACS;
33
however, it is the most Thus, it is important that physicians are up to date with the latest
popularly prescribed NNRTI, emphasising the fact that adherence to guidelines, and that women receive effective counselling regarding
treatment guidelines is generally low. their options. ■
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EUROPEAN INFECTIOUS DISEASE 2007 57
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