1. What’s New in the Perinatal Guidelines
Updates from July 31, 2012

2. Lesson Learned from Clinical Trials
Breast-feeding and Nutrition (BAN) study
Postpartum maternal triple-drug prophylaxis vs infant NVP in women with CD4 cell counts ≥250 cells/µL
Arm 1 (control):
Maternal ZDV/3TC for 1 week; infant sdNVP + ZDV/3TC for 1 week
Arm 2: Control as above, then
Maternal ZDV/3TC/LPV/r for 6 months
Arm 3: Control as above, then
Infant NVP for 6 months
Results
No significant difference between maternal triple-drug prophylaxis (Arm 2) and infant NVP (Arm 3) at 28 and 48 weeks
August 2012

3. Preconception Counseling (1)
Contraception
Updated information on hormonal contraceptive interactions with ARVs
Reproductive options for serodiscordant couples
Use of ART is recommended for the HIV-infected partner, with maximal viral suppression achieved prior to attempting conception
For CD4 counts ≤550 cells/µL (AI)
For CD4 counts >550 cells/µL (BIII)
August 2012

4. Preconception Counseling (2)
Preexposure prophylaxis (PrEP)
Recommendations
Periconception administration of ARV PrEP may offer an additional tool to reduce the risk of sexual transmission. (CIII)
The utility of PrEP of the uninfected partner when the infected partner is receiving ART has not been studied.
Discussion on PrEP includes information on:
Studies
Counseling
Laboratory testing
Monitoring individuals on PrEP
August 2012

5. Antepartum Care
Initial assessment of HIV-infected pregnant women should include:
Screening for hepatitis C and tuberculosis infection
A history of side effects or toxicities from prior ARV regimens
Use of effective ART to reduce transmission to uninfected partners
Discussion of HPTN 052 trial
August 2012

6. Antiretroviral Drugs during Pregnancy
Modified drug categories:
Preferred
Alternative
Use in special circumstances
Drugs that have changed categorization:
Didanosine and stavudine
Use in special circumstances owing to toxicity concerns
Atazanavir
Preferred owing to increased information on safety
Darunavir
Alternative PI for use in ARV-naive pregnant women
Raltegravir
Use in special circumstances when preferred or alternative agents cannot be used
August 2012

7. HIV-Infected Pregnant Women Who Are ARV Naive
The decision to initiate an ARV drug regimen in the 1st trimester or after 12 weeks’ gestation depends on (AIII)
CD4 cell count
HIV RNA levels
Maternal conditions
Earlier initiation of ARV combination therapy may be more effective in reducing transmission but risks and benefits must be weighed
August 2012

8. HIV-Infected Pregnant Women Receiving ARV Therapy
Women receiving efavirenz as part of an effective ART regimen may continue it during pregnancy (CIII)
The risk of neural tube defects is limited to the first 5-6 weeks of pregnancy
Most pregnancies are not recognized before 4-6 weeks
ARV changes can lead to loss of viral control and increased risk of perinatal transmission
August 2012

9. Failure of Viral Suppression
Discussion of the use of raltegravir in late pregnancy for women with high viral loads
Efficacy and safety of this approach has not been evaluated
Concerns that the addition of a single agent to a failing regimen may:
Increase resistance
Decrease future effectiveness
August 2012

10. ARVs and Pregnancy Outcome
Guidelines include a table of studies assessing the association between ART and preterm delivery
See Table 7
August 2012

11. Intrapartum Care
IV zidovudine is no longer required for HIV-infected women receiving combination ARV regimens who have HIV RNA <400 copies/mL near time of delivery (BII)
HIV-infected women with HIV RNA ≥400 copies/mL (or unknown) near time of delivery should be administered IV zidovudine during labor regardless of mode of delivery (AI)
IV is the recommended route of zidovudine administration
Oral administration may be considered if IV is not possible
August 2012

12. Postpartum Care Neonatal dosing recommendations for
Zidovudine
Nevirapine
Neonatal prophylaxis regimens
Discussion on the NICHD-HPTN 040 study
Concerns about lopinavir/ritonavir in neonates
Pharmacokinetic data on nevirapine in preterm infants
August 2012

13. Postpartum Care (2) Management of the HIV-exposed infant
Infants receiving zidovudine/lamivudine-containing prophylaxis (AI)
Higher risk of hematological toxicity (vs zidovudine alone)
Recheck hemoglobin and neutrophil counts at 4 weeks after initiation of prophylaxis
Health care providers should routinely inquire about premastication of food fed to infants, instruct HIV-infected caregivers to avoid this practice, and advise on safer feeding options (AII)
August 2012