Optimizing Outcomes in HIV Treatment - Episode 8

Pregnancy and Transmission of HIV

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The HCPLive Peer Exchange: Optimizing Outcomes in HIV Treatment features insight and opinion on the latest developments in HIV research, diagnosis, and management from leading physician specialists.

This Peer Exchange is moderated by Paul Doghramji, MD, who is a family physician at Collegeville Family Practice in Collegeville, PA, and Medical Director of Health Services at Ursinus College, also in Collegeville, PA.

The panelists are:

  • Alfred A. DeLuca, MD, Infectious Disease Specialist at CentraState Healthcare System in Manalapan, NJ
  • Ian Frank, MD, Director of Anti-Retroviral Clinical Research and Director of Clinical Core at Penn Center for AIDS Research, and Professor of Medicine at the Hospital of the University of Pennsylvania in Philadelphia, PA
  • Paul Sax, MD, Associate Professor of Medicine at Harvard Medical School and Clinical Director of the Division of Infectious Diseases and the HIV Program at Brigham and Women's Hospital, in Boston, MA

Also participating via video is Amir Qaseem, MD, Director of Clinical Policy for the American College of Physicians, based in Philadelphia, PA.

In this segment, the panelists discuss pregnancy and strategies for preventing transmission of HIV from the mother to the baby, calling it “one of the great success stories in HIV research.”

Paul Sax, MD, refers to a study that was done in the 1990s in which pregnant women with HIV were randomized to receive either antiviral therapy with zidovudine or placebo. He says that “just that single drug reduced transmission by over half, like 30 percent risk. It went from 30 percent risk to 8 percent risk, and now with our better therapies, when the moms are treated during pregnancy, the risk of transmission to the newborn is zero. It’s really remarkable.”

Ian Frank, MD, notes that “this is another instance where pre-exposure prophylaxis is sometimes used. Even though the guy in the relationship may have an undetectable viral load, some providers will prescribe pre-exposure prophylaxis to women during periods when the couple is having unprotected sex to see if the women will conceive. And then if she conceives, then the couples will go back to using condoms again. It’s a little bit of an extra insurance.”

Sax says that although pregnant women with HIV can develop resistance to these antiviral drugs, they should be managed in the same way as women with HIV who are not pregnant — by maximizing the likelihood of virologic suppression, because that’s best for both the mother’s outcome and the outcome for the newborn.

To improve treatment adherence in women who are pregnant but not taking their medication (usually for drug use issues or psychosocial issues), Sax says his hospital will recommend hospitalization “during the latter parts of their pregnancy to make sure they get directed observed therapy because the stakes are so high for prevention of transmission.

Alfred DeLuca, MD, recommends baseline resistance testing for pregnant women with HIV. The panelists all agree that all pregnant women should be screened for HIV, with Frank noting that “some experts recommend repeat screening during the third trimester because one of the risks for transmitting the infection is acute HIV infection during pregnancy.”