Continuation of treatment during pregnancy

More and more HIV-infected women in whom pregnancy has been diagnosed, have been pretreated with antiretroviral agents.

As a rule, if pregnancy is diagnosed after the first trimester, the antiretroviral therapy (ART) should be continued. Interruption of treatment might give rise to an increase in viral load and a possible deterioration of immune function causing the danger of disease progression and, ultimately, of reduction of the immune status of mother and fetus. AZT should be administered as a component of a combination regimen starting at 32 weeks of gestation at the latest.

Women in whom pregnancy is diagnosed during the first trimester should be informed about the benefits and risks of treatment in this period. In cases of reduced immune status, in particular, ART could be continued even in the first trimester under careful laboratory and ultrasonic controls. However, substances which can have a toxic effect on the embryo should not be administered during early pregnancy (Table 1).

In other cases - especially if pregnancy is diagnosed very early - the fear of possible embryotoxic effects may lead to an interruption of ART until the end of the first trimester or 13 weeks of gestation. At present, however, there is not enough data available to give an unambiguous recommendation for each individual case. The clinical, immunological and virological situation of the patient and the known or expected effects on the fetus must be considered before making a decision. A continuously updated summary of the current state of knowledge about antiretrovi-ral drugs in pregnancy can be found on the internet at the web address http://hiv.net/link.php?id=189.

If treatment is interrupted, all drugs (NRTIs and PIs) should be withdrawn and re-administered simultaneously in order to prevent development of resistance. Functional monotherapy after discontinuation regimens with NNRTIs should be avoided.

Pharmacokinetic data demonstrate that detectable drug levels may persist up to three weeks after discontinuation of nevirapine. It is recommended either to continue the dual nucleoside analog components for a period of time after nevirapine discontinuation, or to replace nevirapine by a (boosted) PI, or continue the NNRTI including regimen.

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