February 7, 2001
The use of combination antiretroviral therapy in pregnant women, if it is indicated, is important in order to provide optimal care. Moreover, HAART is associated with a risk of transmission that appears to be about 1%, better than ZDV and elective C-section. However, since a small paper four years ago at the Geneva World AIDS conference, there has been concern about whether there may be any effect on obstetrical outcome. Because HIV-infected women often have other risk factor complications, including young age, drug use, or poor health, large careful studies are needed to examine this.
Tuomala and colleagues presented us with a large, careful study, and happily, the results were reassuring. Using the WITS cohort, they examined the association of maternal antiviral use with important perinatal outcomes. They also were able to look at other risk factors -- including maternal CD4 count, viral load, age, parity, blood pressure, and hard drug use. There was an association with ZDV use in the first half of pregnancy with GI toxicity, mostly nausea. Low CD4 and high viral load were associated with anemia. The most important finding from this study was that ZDV use lowered the risk of still birth, prolonged rupture of the membranes, and increased pre-term birth and low birth rate. HAART use also appeared to be protective, but relatively few patients in the cohort so far have been on HAART, limiting the ability to show that it was statistically significant. Protease inhibitors did not cause increased hyperglycemia or diabetes.
Clearly this study is good news, and consistent with other papers since 1996 which have not shown adverse perinatal outcomes with antiretroviral drug use. It is no surprise that ZDV may be poorly tolerated in the first trimester. For women who are beginning therapy during this pregnancy, it is important to wait until morning sickness is resolved. While guidelines suggest starting anytime after 14 weeks, there are no data that suggest any advantage to starting early in the second trimester. Waiting to 18 to 22 weeks also gives time for maternal education, and forming a good doctor-patient relationship to reinforce adherence, as well as improving tolerability.
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