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SPECIAL CONSIDERATIONS

SPECIAL CONSIDERATIONS. August 2012. Acute HIV Infection (1). Primary or acute HIV infection in pregnancy or during breast-feeding is associated with increased risk of transmission. Counsel all pregnant or breast-feeding women about prevention of HIV. Reinforce importance of using condoms.

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SPECIAL CONSIDERATIONS

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  1. www.aidsetc.org SPECIAL CONSIDERATIONS August 2012

  2. Acute HIV Infection (1) • Primary or acute HIV infection in pregnancy or during breast-feeding is associated with increased risk of transmission. • Counsel all pregnant or breast-feeding women about prevention of HIV. Reinforce importance of using condoms. • Maintain a high level of suspicion for acute HIV in women who have a compatible clinical syndrome, even if high-risk behaviors are not reported. 2 August 2012 www.aidsetc.org

  3. www.aidsetc.org Acute HIV Infection (2) • When acute HIV is suspected, obtain a plasma RNA and an HIV antibody test. (AII) • Repeat antibody testing in 3rd trimester for all women with an initial negative antibody: • Who are known to be at risk of HIV, and • Who are receiving care where incidence in pregnant women is at least 1 per 1,000 per year; and for • Women who are incarcerated or reside in jurisdictions with elevated HIV incidence (AII) 3 August 2012

  4. www.aidsetc.org Acute HIV Infection (3) • All pregnant women with acute or recent HIV infection should start an ARV drug regimen as soon as possible, with the goal of complete suppression of VL. (AI) • Use an RTV-based PI regimen. (AIII) • Perform baseline genotyping; adjust regimen if necessary to optimize response. (AIII) 4 August 2012

  5. www.aidsetc.org Hepatitis B and HIV Coinfection (1) • Screen all HIV-infected pregnant women who have not been screened in the current pregnancy for hepatitis A, B, and C. (AII) • Administer HBV vaccine series to pregnant women who screen negative for HBV. (AII) • Consult with an expert in HIV and HBV for management of coinfection during pregnancy. (AIII) August 2012

  6. www.aidsetc.org Hepatitis B and HIV Coinfection (2) • Screen pregnant women with chronic HBV infection for antibodies to HAV; if negative, administer HAV vaccine series. (AII) • Interferon is not recommended in pregnancy. (AIII) August 2012 6

  7. Hepatitis B and HIV Coinfection (3) • ART is recommended for all. • ART should include a dual-NRTI/NtRTI backbone with 2 drugs active against both HIV and HBV. (AII) • TDF + 3TC or FTC preferred (A1) • Initiation of an ARV regimen that does not include anti-HBV drugs may be associated with reactivation of HBV and development of IRIS • Counsel on signs and symptoms of liver toxicity and assess LFTs 1 month after initiation of treatment then every 3 months at least. (BIII) August 2012 www.aidsetc.org

  8. Hepatitis B and HIV Coinfection (4) • If ART is discontinued postpartum, monitor LFTs frequently and reinitiate treatment for HIV and HBV if a flare is suspected. (BIII) • Give HBV immune globulin and the 1st dose of HBV vaccine series to infants within 12 hours of birth. Give 2nd and 3rd doses at ages 1 month and 6 months. (AI) www.aidsetc.org

  9. www.aidsetc.org Hepatitis C and HIV Coinfection (1) • Screen for HCV in all pregnant women who have not been screened during the current pregnancy. (AIII) • Recommendations for ARV use during pregnancy are the same as those for pregnant women without HCV. (BIII) • Interferon is not recommended; ribavirin is contraindicated for use during pregnancy. (AIII)

  10. www.aidsetc.org Hepatitis C and HIV Coinfection (2) • Screen women with HCV for HAV and HBV. • If negative for HAV IgG, give HAV vaccine series. (AIII) • If not infected with HBV, give HBV vaccine series. (AIII) • Counsel women about symptoms of liver toxicity; check LFTs 1 month after initiation of ART, then at least every 3 months thereafter. (BIII) • Make decisions about mode of delivery based on standard OB and HIV-related indications alone. (BIII) August 2012

  11. www.aidsetc.org HIV-2 Infection and Pregnancy (1) • In the United States, 166 cases met CDC criteria for HIV-2 diagnosis between 1998 and 2010. • HIV-2 is endemic in West African countries and occurs in France and Portugal. 11 August 2012

  12. www.aidsetc.org HIV-2 Infection and Pregnancy (2) • Most HIV screening tests detect HIV-2 but do not distinguish between HIV-1 and HIV-2. • Bio-Rad Laboratories Multispot HIV-1/HIV-2 test is the exception and should be used if HIV-2 is suspected. • Available HIV-2 supplemental tests are not FDA approved. • Available HIV-2 VL assays are not FDA approved. • State or local health departments can arrange for additional testing by the CDC. 12 August 2012

  13. www.aidsetc.org HIV-2 Infection and Pregnancy (3) Recommendations: • Suspect HIV-2 in pregnant women who are from or have partners from countries where HIV-2 is endemic, who are HIV positive on initial ELISA and who have repeatedly indeterminate results on HIV WB along with VL at or below the limit of detection. (BII)

  14. www.aidsetc.org HIV-2 Infection and Pregnancy (4) • Treat women who require treatment for their own health with 2 NNRTIs and a boosted PI. (AIII) • ZDV/3TC + LPV/r preferred (AIII). TDF + 3TC or FTC plus LPV/r can be an alternative. (BIII) • Optimal perinatal prophylaxis not defined. Experts recommend: • Boosted PI regimen (2 NRTIs plus LPV/r, with drugs stopped postpartum (BIII); or • ZDV prophylaxis alone during pregnancy and intrapartum (BIII) 14

  15. www.aidsetc.org HIV-2 Infection and Pregnancy (5) • NNRTIs and enfuvirtide are not active against HIV-2 and should not be used. (AIII) • Give HIV-2-exposed infants the standard 6-week ZDV prophylactic regimen. (BIII) • Breast-feeding is not recommended. (AIII) August 2012

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