According to Dr. Theron Moodley, there have been many changes to the recommended algorithm for HIV testing. The first-line testing is often a fourth-generation HIV test, which includes HIV IgM and IgG, as well as, the p24 antigen. The fourth-generation HIV test increases recognition of acute HIV by several days to weeks before the previous first- to third-generation tests.
As per Dr. Theron Moodley, the other significant change is elimination of the western blot as the “confirmatory test.” The latter is replaced by an HIV differentiation immunoassay which decreases the time to final result from days to hours. In addition, the immuno-assay allows recognition of HIV-2 which accounts for disease mainly seen in West Africa and parts of India.
Reccomendation for Pregnant Woman with HIV
In Dr. Theron Moodley’s informed opinion, any pregnant woman who has HIV should be tested for the following in addition to routine prenatal laboratory studies:
HIV viral load
CD4 count
hepatitis A, B, and C antibodies
tuberculosis
liver function
renal function
HIV genotype resistance, if possible (which requires a viral load (VL) > 500 -1000 copies/mL)
The mainstay of therapy for HIV-positive pregnant women is combination ART to control disease progression for the mother and to prevent maternal fetal transmission of HIV. Several care models exist for pregnant women with HIV, including models where patients are treated by obstetric providers experienced in managing HIV in pregnancy or models where collaboration between obstetric and infectious disease providers exist.
The recommendations specific to pregnancy are updated frequently. Therefore, it is advised that anyone initiating ART be experienced in caring for pregnant women with HIV.
Considerations for Ideal Combination of ARV Drugs
When determining the ideal combination of ARV drugs, one should consider the following:
Teratogenicity
Toxicity to maternal health
Impact on obstetric outcomes such as preterm birth (PTB), low birth weight (LBW) and stillbirth
Hepatitis B coinfection
Assessment of resistance testing, if available
Prior ARV regimens
Minimizing pill burden to optimize compliance
Women who are on ART prior to pregnancy and have an undetectable viral load should continue their regimens. The Antiretroviral Pregnancy Registry, a prospective collection of cases of ARV drug exposure, demonstrates that prevalence of birth defects amongst all ARV first-trimester exposures is 2.9/100 live births (221/7738 exposures; 95% CI, 2.5-3.3) and following second- or third-trimester exposure is at 2.8/100 live births.
Therefore, risk of birth defects associated with ART is no greater than the background rate of birth defects and discontinuation may allow an increase in viral load, which is more detrimental to the fetus.
Some Other Specific Considerations
Certain ARV medications have raised concern. For example, there were reports of neural tube defects (NTDs) observed in non-human primates exposed to efavirenz in utero. However, a large meta-analysis that included 26 studies of 2,026 first-trimester human pregnancies showed no increased risk of NTDs following first-trimester exposures (RR 0.78; 95% CI 0.56-1.08).
Given these data and reassuring data from a French Perinatal cohort of more than 5000 babies, the most recent HIV Perinatal Guidelines recommend continuing efavirenz-containing regimens during the first trimester if the woman is virally suppressed.
In addition to teratogenicity, there are a number of studies which suggest an increased risk of PTB for babies exposed to ART. However, the mechanism of action remains unknown and many studies do not control for presence of well-known PTB risk factors. A few studies suggest that some ART regimens are associated with LBW, small for gestational age and stillbirth. Despite these concerns, the preponderance of evidence suggests that these risks are low and that the benefits of ART to both mother and baby warrant their use.
In pregnant women with a new HIV diagnosis, combination therapy is a must. Consultation with an infectious disease specialist is helpful given the number of new ARV medications and the complexities of some regimens. The HIV Perinatal Guidelines evaluate and recommend ARV regimens as “preferred” or “alternative” as new efficacy and safety data emerges.
The current preferred regimen is: a dual-nucleoside reverse transcriptase inhibitor combination (abacavir/lamivudine or tenofovir disoproxil fumarate (TDF)/emtricitabine or lamivudine) and either a ritonavir-boosted protease inhibitor (atazanavir/ritonavir or darunavir/ritonavir) or an integrase inhibitor (raltegravir).
ART should be initiated as early in pregnancy as possible without waiting for the first trimester to be completed and regardless of HIV viral load or CD4 count or while waiting for resistance data.
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