The guiding principle for the treatment of women of childbearing potential or pregnant women is that therapeutic decisions should be based solely on their need and eligibility for ART. The special circumstances of pregnancy or breast-feeding raise additional issues concerning toxicity to mothers and children, the choice of ARV drugs, and the prevention of HIV transmission from mothers to infants. The recommended first-line regimen for this patient subgroup is:
AZT + 3TC + NVP
While d4T might be necessary as a substitute for AZT, close monitoring should be done given the increased risk of lactic acidosis developing due to d4T use.
The choice of ART for women with the potential to become pregnant must involve a consideration of the possibility that the ARV drugs may be received early in the first trimester, before the recognition of pregnancy and during the primary period of fetal organ development. EFV should be avoided in such women because of its potential for teratogenicity. Women who are receiving ART and do not wish to become pregnant should have effective and appropriate contraceptive methods available to them in order to reduce the likelihood of unintended pregnancy. In those women for whom effective contraception can be assured, EFV remains a viable option for the NNRTI component of the regimen. Women who are receiving ART and become pregnant should continue their treatment unless they are in the first trimester of pregnancy and EFV has been part of the regimen, in which circumstances EFV should be discontinued and replaced by NVP.
For pregnant women it may be desirable to initiate ART after the first trimester, although for such women who are severely ill the benefit of early therapy clearly outweighs any potential fetal risks, and therapy should be initiated in these cases. Additionally, the dual NRTI combination of d4T/ddl should be avoided in pregnancy and only used when no other alternatives exist, because of the potential increased risk of lactic acidosis with this combination in pregnant women. Recent studies have shown an increased risk of liver toxicity due to NVP as part of ART for pregnant and non pregnant women above 250cells/mm3. Monitoring of liver function when initiating therapy and regular follow up is required for all women on NVP based regimens
The recommended second line regimen for pregnant women is;
ABC +ddI + SQV/r or NFV
Several country programmes are already considering the use of short-course triple combination therapy for the prevention of MTCT in women who are not yet in need of treatment for their own HIV infection, and the cessation of therapy postpartum if the women do not require its continuation for their own health. The use of HAART in such situations should prevent the emergence of resistance to the drugs and should also be highly effective in reducing perinatal HIV transmission to infants. However, this intervention also exposes both mother and fetus to potential drug toxicities in situations where therapy is not required for maternal health. Studies are in progress with a view to assessing the safety and efficacy of this approach for women and their infants, particularly for the prevention of MTCT in breast-feeding women.
It is important to note that ARV drugs have the potential to either decrease or increase the bioavailability of steroid hormones in hormonal contraceptives. The limited data available suggest that potential drug interactions between many ARVs (particularly some NNRTIs and PIs) and hormonal contraceptives may alter safety and effectiveness of both the hormonal contraceptives and the ARVs. It is not known whether the contraceptive effectiveness of progestogen-only injectable contraceptives (such as depot medroxyprogesterone acetate and norethisterone enantate) would be compromised, as these methods provide higher blood hormone levels than other progestogen-only hormonal contraceptives, as well as the combined oral contraceptives. Studies are underway to evaluate potential interactions between depot medroxyprogesterone acetate and selected PI and NNRTI drugs. Thus, if a woman on ARV treatment decides to initiate or continue hormonal contraceptive use, the consistent use of condoms must be recommended for preventing HIV transmission and may also compensate for any possible reduction in the effectiveness of the hormonal contraceptive.