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Antiretroviral Drugs in Pregnant Women with HIV Infection

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welcome to this week's Mountain West ADC

echo my name is Brian wood medical

director and I will turn it over to

today's speaker hi everybody

I'm gonna give a rapid-fire update just

more to let you know what has been

changed and then you can delve a little

bit deeper if you need most of the

changes and the perinatal guidelines

which we were just released last Friday

December 7th which is an update from the

November 2017 guidelines are pretty

minor and they are available here so I

just wanted to put in a slide to remind

us why we care about this so much and

this is the estimated incidence of

perinatal HIV infection for a hundred

thousand live births in the US since

1978 to 2013 and you can see you know

there was quite a peak at the beginning

of the epidemic and then they put in the

milestones of a lot of important things

that happened that helped decrease

perinatal transmission but thankfully it

has just continued to be a trend

downwards and at this point we think

about 5,000 women with HIV who give

birth in the United States every year in

2013 only 69 were born with HIV and the

incidence was 1.8 out of 100,000 births

the CDC has a goal of less than one out

of a hundred thousand live births and I

will just say that Brian and I sit here

and we give advice but we are not the

people who are taking care of these

women with HIV who are pregnant you are

and I really want to credit all of you

for helping with these numbers and so

many of you are taking care of these

pregnant women so I applaud you I'm

gonna go through just the changes and

again not the prettiest transitions but

we will just fly through so there was a

new section about women who desire to

breastfeed in the US and that was

actually added in March 27th March 27th

of 2018 but that was really only added

to formally to the guidelines now

breastfeeding is still not recommended

in the US when women with HIV do choose

to breastfeed

despite counseling they should be

counseled and they have a really nice

list of how to counsel these women to

minimize

the risk of transmission they recommend

saying to all pregnant women in the

United States we recommend

formula-feeding to avoid the risk of HIV

transmission to your baby through breast

milk do you have any questions or

concerns about that and we point out

that that's just a really nice

non-judgmental way to open this

conversation and we had a great eco talk

from Judy Levinson from Baylor on

November 2nd 2017 and I put a link to

that they also have made some changes in

the HIV testing section and one thing

they really stress for the first time is

making sure that partners of women with

or without HIV partners of any pregnant

women should be encouraged to be HIV

tested and that really hasn't been an

emphasis before and that's to make sure

that even if your patient doesn't have

HIV that they are not at ongoing risk

during their pregnancy of HIV if their

partner has HIV getting them linked to

care they also risk recommend a risk

assessment of all women considering

pregnancy and all pregnant women even if

they were previously tested negative and

I think that is because some people

think well they were pregnant a year ago

and they were HIV negative we don't need

to retest but it is really important to

retest and counsel every pregnancy

because things change and if women are

high-risk really talk about prevention

counseling and considering prep they

also stress retesting certain

individuals in the third trimester and

they stress before 36 weeks if possible

and they added this time women who are

incarcerated or who reside in states

that require third trimester testing I

searched long and hard to find which

states those were in the 2006 CDC

testing recommendations they have a list

I don't know if it's been updated since

then but that is what they actually

reference in these current perinatal

guidelines most of the states were in

the northeast and southeast and Texas

none included really the states that

most of us live in in women at high risk

even if they're not in a state that

mandates it we should think about their

trimester testing and certainly any

woman with signs or symptoms of acute

HIV in terms of changes in preconception

counseling they stress again it's very

important to discuss reproductive

desires with all women of child

aged on an ongoing basis throughout

their course of care and really

emphasize the primary treatment goal in

pregnancy is a sustained viral load

suppression for the health of the woman

baby and her partner and then of course

new counseling about diet a go Baron you

may all feel like we have hashed this

out and I sort of do too

so we're gonna go through quickly

through what they finally harmonized the

recommendations with the perinatal

guidelines and the ARV guidelines and

that is actually a kind of a theme in

these updates for the first time they

really try to make it so their

guidelines are harmonized or

synchronized with the antiretroviral

guidelines which is wonderful by their

own admission they change the guidelines

about diet egg Revere and that they are

very conservative and that was their

word and they said they will likely or

may change in 2019 while we have

additional data from this study that was

discontinued

so to summarize it as quickly as

possible

women who are starting to taper here

should have a pregnancy test women who

are pregnant and less than 14 weeks

since their last menstrual period or 12

weeks since conception or trying to

conceive or unable to consistently use

contraception should ideally not beyond

diet aggravator but after 14 weeks diet

egg Rivera is considered a preferred in

stay during pregnancy and if diet a

career is used at the time of delivery

or after delivery again discuss

contraception in these women how about

women who come to you are already on

dial you take Rivera but are in their

first trimester so to continue or not to

continue the counseling messages they

give us which I have to say are not real

convincing for changing is that neural

tube defects may have already occurred

depending on the current gestational age

the additional risk of these defects

developing during the remaining time in

the first trimester is probably small

everyone has a background risk of neural

tube defects regardless of whether they

have HIV or are on medications and that

changes in therapy even in the first

trimester are often associated with

viral rebound

increase the risk of perinatal HIV

transmission I think if you had that

conversation with your patient they

wouldn't be very likely to change but

it's important to have the conversation

so they're aware of risks and benefits

they also added some new information in

the reproductive options for Co

discordant couples which I found really

exciting and heartening because even in

the last guidelines they were still

quite tepid about you equals you

messaging but there really was more

emphasis on you equals you messaging

undetectable equals untranslated

suppressed and basically said if if the

HIV part of the partner living with HIV

has a suppressed viral load that they

can be engaging in condomless sexual

intercourse ideally around the time of

trying to conceive they also really

stress prep if the viral load is not

suppressed and the infected partner

there was significantly less emphasis on

assisted reproductive technologies which

previously were made to sound like the

most ideal options and they've really

de-emphasized them they mention them as

options but they don't emphasize them

they also added some clarity about

infertility workups for couples

attempting to conceive via condomless

sexual intercourse and they say if

conception doesn't occur within six

months these patients should have

infertility workup including semen

analysis and then finally if the male

partner does not have HIV they say it's

important to use condoms we're not

trying to conceive educate the male

partner about the importance of the

partners adherence to meds which is kind

of interesting I think trying to add

additional support I can see situations

if there's intimate partner violence

we're putting the partner in control of

nagging or encouraging adherence could

be a difficult situation but I think it

is important that everyone is aware of

the importance of the pregnant person

with HIV taking their AR T and then they

recommended HIV testing every three

months while attempting conception

without condoms in terms of general

principles regarding use of

antiretroviral

drugs during pregnancy I'm a little

surprised that this is something new and

I wonder if it's just the wording change

but they said it was new to screen for

depression and anxiety as part of their

assessment for supportive care provide

counseling about what to expect during

L&D and the postnatal period I feel like

we and the echo family have really

mastered this we've really realized how

important it is to talk to women before

they go into the delivery room as to

what to expect what to do about infant

feeding and how to handle those

situations if they're not going to

breastfeed they also talked about

coordinating services with a

multidisciplinary team which we are

doing I think great job in terms of

antiretroviral therapy and pregnancy

they have different categories and

they've actually added one preferred

alternative insufficient data to

recommend usually that's for initiation

in pregnancy and then they added not

recommended except in special

circumstances and that includes

situations in which treatment

experienced pregnant women may need to

initiate or continue drugs with limited

safety and efficacy data or specific

safety concerns and then there's a not

recommended section and then they added

a new table for situation specific

recommendations for a-artie and pregnant

women and those trying to conceive and

that is an amazing table I can highly

recommend it they basically go through

every single drug and have a

recommendation for every situation

whether they're initiating a RT whether

they've been on a RT before whether

they're failing their current regimen

all kinds of things so it's it's quite a

table and I borrowed this from Brian

when he gave his talk this summer about

what he thought was the optimal regimen

prior to this guideline update and the

big change is here are that these are

the preferred regimens for treatment

naive naive pregnant women the NRTI

backbones that they recommend are to

Nava beer with FTC or 3tc thing or a

back of their 3tc again with the same

restrictions that we always talk about

with

back here in terms of in STIs RAL tegra

beer or dial you take a beer after the

first trimester or considered preferred

and then pee is add as a nevere and

Ratana beer or boosted aruna beer with

her tone of air but that must be used be

ID I've highlighted the changes in red

here I think I might have forgotten to

highlight big tag review alternative

regimens are combivir AZT 3tc a Fabrice

or real pain with again the usual

restrictions and then in terms of P is

you can use LaPenta via Ratana beer

Brian and I were noting before this that

now the only single tablet regimen

that's even considered alternative are

fabrics in the form of a triplet or real

marina in the form of complainer so

that's a little bit disheartening and

now if a bronze has been given really

full rein to be used there's

insufficient data and basically all of

our newer medicines and not recommended

you can see that column and the key

change here is Cove assist at SoCo be

stat Kobus is step boost at regimens and

pregnancy there is significant concern

based on data about decreased plasma

levels in the second and third

trimesters and so if someone is on a

Cobie containing regimen they say

consider switching to another regimen

that is recommended for use in pregnancy

and if you must continue a Cobie

containing regimen absorption should be

optimized and viral load should be

monitored frequently so what if after

all your best efforts a patient has a

detectable viral load or via logic

failure well this section was updated to

include that you should really talk

about food requirements and possible

drug interactions and again this is

something we talk about here all the

time consider in ste resistance testing

if someone's previously been on on insti

they have a sex partner within ste

history or they're starting or changing

to an in steel eight in pregnancy and

then viral load testing is currently

recommended at 34 to 36 weeks gestation

for delivery planning providers may

consider repeat testing even after that

and select women who are at high

for viral rebound the cd4 cell count

monitoring recommendations were just

changed to say in most women if they

have consistently greater than 300 cd4

cells and they've been on a RT for

greater than two years that they do not

need to have a cd4 count checked after

the initial test at their first

antenatal visit and so again harmonizing

really with the ARV guidelines they

talked about women who have HIV and Hep

C and pregnancy and there's been data to

show that there's really low uptake of

Hep C testing and Hep C exposed infants

in general we think there's about a six

percent transmission risk of Hep C from

a mother to baby in women with HIV

that's probably double then we think

about 10 to 20 percent risk and so they

really want to stress that these babies

should be tested for hep c and they give

specific recommendations Hep C antibody

tests after 18 months Hep C RNA testing

is not recommended in the neonatal

period and definitely not before 2

months and they basically say also if

you have a negative Hep C RNA early on

it means nothing because my Aranea can

be intermittent in terms of acute HIV

and pregnancy it depends on when the

diagnosis is made in the first trimester

they recommend a boosted PIB used

because again concerns about diet at

Revere and they think raw egg Revere has

too low of a barrier to resistance in

the second trimester they want us to use

diet tagged Revere and they also point

out if you diagnosed someone with acute

HIV in the postpartum period make sure

they stop breastfeeding those infants of

women who develop acute HIV during their

pregnancy should be treated like a

high-risk infant for HIV exposure

because of the potential for high viral

very Mia they also point out that women

may be extremely susceptible to HIV

infection during pregnancy and

breastfeeding and so women who are at

high risk really need counseling and

discussion of prep delayed cord clamping

was addressed in

most recent guidelines and there was a

recent study of 64 hiv-positive mother

and infant pairs where the mother was

living with HIV and they compared these

are split down the middle delayed

clamping which was 120 seconds after

birth or early clamping cord clamping 30

seconds after birth and the mean

hemoglobin levels at 24 hours and one

month after birth were significantly

higher with delayed cord clamping and

there were no HIV transmissions

increased risk of jaundice or

polycythemia in 18 months with delayed

cord clamping again that's only 32

infants that had delayed cord clamping

they don't make a recommendation they

just put that data out there but they do

say in women without HIV ACOG recommends

delayed clamping in vigorous term and

preterm infants so I think we don't have

totally specific recommendations but we

have some nice early data to suggest

that delayed cord clamping may be safe

in this population I'm going to just

speed through this last few slides

postpartum follow-up of women with HIV

ACOG has changed their recommendations

to say that all women should have

contact with their obstetric care

provider within the first three weeks of

the postpartum period and that is

earlier than and I think it has always

been done women with HIV are recommended

to have a follow appointment with the

healthcare provider who manages their

HIV care whether that's their obstetric

provider or their HIV care provider

within two to four weeks after hospital

discharge and I think this is to really

stress retention and care and then make

sure that they're on the right a RT they

also really stress it's okay to change

AR T after delivery because in certain

point certain women you're gonna be able

to simplify their regimen because we

just talked about there's not a lot of

single tablet regimens AR T management

of newborns with perinatal HIV exposure

or perinatal HIV they just changed some

of the recommendations and I'm not going

to go through at length but there are

very minor changes they did stress that

in all cases where a newborn is

considered higher risk of HIV

acquisition AZT should be continued for

six weeks there's some debate about

whether other medications need to be

continued and then they also pointed out

that for women who have non bee

type HIV or group Oh HIV that there are

now tests available and those should be

used in those babies of those women and

finally we've been talking about

updating our echo birth plan I was

telling Brian I don't love the

expression birth plan because it gives

the idea that you can plan anything

about birth but we're going to update

this

now that the perinatal guidelines have

come out so that everyone can have

access to it thank you for watching this

edition of the Mountain West HIV project

echo didactic series if you're

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echo until next week's edition the

spring load medical director signing off

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