1. SPECIAL CONSIDERATIONS August 2012 1 www.aidsetc.org

2. August 2012 2 www.aidsetc.org 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.

3. 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) August 2012 3 www.aidsetc.org

4. 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) August 2012 4 4 www.aidsetc.org

5. 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 www.aidsetc.org 5

6. 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 6 www.aidsetc.org

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 2012www.aidsetc.org 7

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 August 2012 8

9. 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) August 2012www.aidsetc.org 9

10. 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 www.aidsetc.org 10

11. 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. August 2012 11 August 2012www.aidsetc.org

12. 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. August 2012 12 www.aidsetc.org

13. 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) August 2012www.aidsetc.org 13

14. 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 August 2012www.aidsetc.org

15. 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 www.aidsetc.org 15