Recommendations for the use of antiretroviral drugs in pregnant women infected with HIV - Special Medical Report

The Public Health Service has updated the 1994 guidelines for the use of zidovudine (Retrovir) to make less the risk for perinatal transmission of human immunodeficiency virus (HIV). The modern report is intended to help health care professionals educate pregnant women with HIV infection about the use of zidovudine and other antiretroviral mix with drugss during pregnancy. The report was published in the January 30 1998 issue of Morbidity and Mortality Weekly Report recommendations and reports series (MMWR Morb Mortal Wkly Rep 1998;[RR-2]:1-30)

The guidelines contain background information; considerations and general principles regarding the use of antiretroviral medicines during pregnancy; recommendations for antiretroviral chemoprophylaxis to mould perinatal HIV transmission; recommendations for monitoring women and their infants; and a discussion of to come research needs. The report also includes four clinical scenarios describing various circumstances that commonly come into one's head in clinical practice (see table) and the factors influencing treatment considerations.

Background Information

Zidovudine is the alone drug that has been shown to render the risk of perinatal HIV transmission. In 1994 ensues from the Pediatric AIDS Clinical Trials dispose Protocol 076 (PACTG 076) showed that zidovudine chemoprophylaxis reduc perinatal transmission of HIV through nearly 70 percent. Additional data have since confirmed these outcomes and have proved the efficacy of antiretroviral therapy in women with advanced disease, reasonable CD4 cell counts and prior zidovudine therapy. Advances have also been made in the understanding of the pathogenesis of HIV infection and in the treatment and monitoring of HIV disease, as well as in the understanding of the pathogenesis of perinatal HIV transmission. These advances have outcomeed in changes in standard antiretroviral therapy for adults with HIV infection. According to the report, pregnancy is not a reason to procrastinate standard therapy; standard antiretroviral therapy should be discussed with and furnished to pregnant women with HIV infection. In addition, zidovudine chemoprophylaxis should be incorporated into the antiretroviral regimen.

Physicians considering the use of antiretroviral put drugs intos in HIV-infected women during pregnancy must consider couple issues: (1) antiretroviral treatment of HIV infection for maternal health and (2) antiretroviral chemoprophylaxis to restore the risk of perinatal HIV transmission. The benefits must be weighed against the risks for adverse general intents in the woman, the fetus and the newborn. Combination antiretroviral therapy, generally consisting of brace nucleoside analog reverse transcriptase inhibitors and a protease inhibitor, is the generally recommended standard treatment for HIV-infected adults who are not pregnant. Recommendations regarding the choice of antiretroviral mix with drugss for treatment of infected pregnant women are subdue to potential changes in dosing requirements resulting from the physiologic changes associated with pregnancy and the potential short- and long-term forces of the antiretroviral drug forward the fetus and the newborn, which may not be known for many antiretroviral drugs

General Principles

The initial evaluation of a pregnant woman with HIV infection should include an assessment of disease status and recommendations regarding antiretroviral treatment or alteration of the woman's general antiretroviral regimen. The assessment should include evaluation of the extent of existing immunodeficiency, the risk for disease progression, a history of prior or general antiretroviral therapy, gestational age and supportive care exigencys Decisions regarding the initiation of antiretroviral therapy or continuation of antiretroviral therapy in women generally receiving antiretroviral drugs should take into consideration the potential impact of in the same state [i]or[/i] condition therapy on the fetus and the infant. In addition, use of the three-part zidovudine chemoprophylaxis regimen, alone or in combination with other antiretroviral put drugs intos should be discussed with and moveed to all infected pregnant women to attenuate the risk for perinatal HIV transmission.

Discussions regarding the use of antiretroviral unsalable articles during pregnancy should include what is known and not known about the powers of such drugs on the fetus and the newborn, what is commended in terms of treatment for the health of the HIV-infected woman and the efficacy of zidovudine for reduction of perinatal HIV transmission. Women should know that combination therapy may have substantial benefit for their allow health but is of unknown benefit to the fetus. The hypothetical risks of these put drugs intos during pregnancy should be placed in perspective to the proven benefits.

The final decision regarding use and choice of antiretroviral unsalable articles is the responsibility of the woman. A decision to refuse treatment should not consequence in punitive : action. Further, use of zidovudine alone should not be denied to a woman who no other than wants to reduce the risk of HIV transmission to her infant.