What is the appropriate management for a 24-year-old primigravid woman with a history of intravenous (IV) heroin use, Human Immunodeficiency Virus (HIV) infection, and current pregnancy, who has a normal vital signs, a CD4 count of 500 cells/µL, and an HIV-1 viral load of 880 copies/mL, and who stopped taking her combination Antiretroviral Therapy (ART) two weeks ago?

From the Guidelines

The patient should resume her combination antiretroviral therapy (cART) immediately, as discontinuing treatment could lead to an increase in viral load, resulting in a decline in immune status and disease progression, as well as adverse consequences for both the fetus and the woman 1. Antiretroviral medications are safe during pregnancy and should not be discontinued, as the benefits of treatment significantly outweigh any potential risks. The recommended regimen typically includes two nucleoside reverse transcriptase inhibitors (NRTIs) plus either an integrase strand transfer inhibitor (INSTI) or a boosted protease inhibitor. Specific medications might include tenofovir disoproxil fumarate/emtricitabine plus dolutegravir or raltegravir.

Some key points to consider in the management of this patient include:

• The patient's current CD4 count of 500 cells/μL and relatively low viral load of 880 copies/mL indicate that her HIV infection is reasonably well-controlled, but continued therapy is essential to maintain viral suppression and protect the developing fetus.
• Continuing antiretroviral therapy during pregnancy is crucial to prevent mother-to-child transmission of HIV, which can occur during pregnancy, labor, delivery, or breastfeeding.
• With proper adherence to antiretroviral therapy, the risk of vertical transmission can be reduced to less than 1% 1.
• The patient should take these medications daily without interruption throughout pregnancy and postpartum.
• Additionally, she should be scheduled for regular prenatal visits to monitor both her HIV status and fetal development, with viral load testing each trimester.

It's also important to note that the decision to use any antiretroviral drug during pregnancy should be made by the woman after discussion with her clinician regarding the benefits versus risks to her and her fetus 1. Resistance testing is recommended for all pregnant women who are not currently receiving antiretroviral drugs before the initiation of therapy or prophylaxis and for those women with persistent viral replication while receiving antiretroviral treatment to optimize antiretroviral drug choice and to provide the most effective and durable regimen 1.

From the Research

Patient's Current Situation

• The patient is a 24-year-old primigravid woman with a history of intravenous heroin use and HIV infection.
• She has completed a methadone program and currently does not use tobacco, alcohol, or illicit drugs.
• She started combination antiretroviral therapy last year but stopped taking her medications 2 weeks ago when she found out she was pregnant.
• Her current CD4 count is 500 cells/µL and HIV-1 viral load is 880 copies/mL.

Antiretroviral Therapy

• According to 2, the primary goal of antiretroviral therapy for HIV infection is suppression of viral replication, and combination therapy with two or more antiretroviral agents is the optimal way to achieve this goal.
• 3 states that combination antiretroviral therapy has rapidly evolved and can change the natural history of HIV-1 infection from a deadly disease to a chronic, manageable condition.
• 4 recommends starting antiretroviral therapy as soon as possible after HIV diagnosis, and suggests several recommended starting regimens.

Treatment Considerations

• 5 suggests that combinations of emtricitabine and tenofovir with an integrase inhibitor show high levels of synergy in vitro, which may contribute to potent treatment efficacy.
• 6 states that decisions regarding whether to start combination antiretroviral therapy during primary infection and when to initiate treatment during chronic infection continue to evolve, and that several regimens are acceptable as initial therapy.
• The patient's viral load is currently 880 copies/mL, which is below the threshold of 5,000 to 20,000 copies per mL suggested by 2 for considering antiretroviral therapy, regardless of the CD4+ count.

Pregnancy Considerations

• The patient is pregnant and has stopped taking her antiretroviral medications 2 weeks ago, which may affect her viral load and CD4 count.
• It is essential to consider the patient's pregnancy status when making decisions about her antiretroviral therapy, as some medications may have potential risks or benefits for the fetus 2, 3, 4, 6.