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HIV and Pregnancy

Treatment of Pregnant HIV-Infected Patients:

Pregnant women with HIV infection  should be offered therapy based on the same virologic, immunologic, and clinical parameters as non pregnant women.

The goal of therapy is to provide maximal virologic suppression to optimize the health of the mother and minimize transmission of virus to the fetus. The choice of drugs and the timing of initiating therapy may, however, be influenced by the pregnancy.

Most antiretroviral drugs are safe in pregnant women; to the extent they have been studied. Many of the toxicities caused by antiretroviral agents may contribute to parallel complications of pregnancy, (e.g., the hyperglycemia associated with protease inhibitors may exacerbate pregnancy-associated diabetes). There are specific concerns regarding the use of nucleosides during pregnancy, especially stavudine and didanosine, in view of their association with hepatic steatosis and lactic acidosis in several pregnant women. There is also particular concern about the association of efavirenz with fetal abnormalities in monkeys. Finally, combination ART may be associated with an increased risk for preterm delivery. Antiretroviral regimens must be chosen carefully and monitored.

Transmission of HIV from mother to fetus has been observed at all maternal plasma HIV RNA levels. There seem to be a correlation between the HIV plasma RNA copy number and the risk of transmission. Clinical trials have shown that ART can greatly reduce the likelihood that virus will be transmitted to the fetus or infant. Zidovudine monotherapy and nevirapine monotherapy have been most carefully studied, and both seem to be safe for the mother and fetus and are effective in substantially reducing the rate of maternal-fetal transmission. However, monotherapy is no longer indicated in settings in which combination ART is feasible. Moreover, single-dose nevirapine monotherapy can produce HIV resistance because of the long half-life of nevirapine. It is logical to use combination ART regimens for treating the mother to lower her viral load effectively and produce durable viral suppression.

Current guidelines indicate that combination ART, usually including zidovudine, should be recommended for infected women who meet the standard criteria for treatment or who have HIV RNA levels greater than 1000 copies/mL, regardless of immunologic or clinical status. Women who are in the first trimester of pregnancy may prefer delaying therapy until after 10 to 12 weeks of gestation if they are concerned about the teratogenicity of drugs administered during the early part of their pregnancy. . Prior to antiviral therapy, the risk of HIV transmission from an infected mother to her newborn was approximately 25%-35%. By giving ZDV after the first trimester of pregnancy, then intravenously during the delivery process, and then after delivery to the newborn for six weeks showed a reduction in the risk of transmission to less than 10%. Women who are not receiving zidovudine or nevirapine but who have HIV plasma RNA levels less than 1000 copies/mL seem to have a low risk of transmitting HIV to their offspring. There are no clear guidelines about how best to manage pregnant women whose virus is resistant to zidovudine and nevirapine.

All HIV-infected pregnant women should be managed by an obstetrician with experience in dealing with HIV-infected women. Maximal obstetric precautions to minimize transmission of the HIV virus, such as avoiding scalp monitors and minimizing labor after rupture of the uterine membranes, should be observed. In addition, the potential use of an elective Caesarean section (C-section) should be discussed, particularly in those women without good viral control of their HIV infection where the risk of transmission may be increased. Breastfeeding should be avoided if alternative nutrition for the infant is available since HIV transmission can occur by this route.

HIV AIDS Services

Lifestyle and Home Remedies:

Although it’s important to receive medical treatment for HIV/AIDS, it’s also essential to take an active role in your own care. The following suggestions may help you stay healthy longer:

  • Eat healthy foods. Emphasize fresh fruits and vegetables, whole grains and lean protein. Healthy foods help keep you strong, give you more energy and support your immune system.
  • Avoid certain foods. Food-borne illnesses can be especially severe in people who are infected with HIV. Avoid unpasteurized dairy products, raw eggs and raw seafood such as oysters, sushi or sashimi. Cook meat until it’s well-done or until there’s no trace of pink color.
  • Get immunizations. These may prevent infections such as pneumonia and the flu. Make sure the vaccines don’t contain live viruses, which can be dangerous for people with weakened immune systems.
  • Take care with companion animals. Some animals may carry parasites that can cause infections in people who are HIV-positive. Cat feces can cause toxoplasmosis, while pet reptiles can carry salmonella. Continue reading

HIV cure: How to Monitor the Patient on Antiviral Therapy

Monitoring Antiviral Therapy:

The goals of antiviral therapy are to enhance immunity and delay or prevent clinical advancement to symptomatic disease without inducing important side effects or selecting for drug resistant virus. Currently, the best marker of a drug’s activity is a decrease in the viral load.

Ideally, before initiating treatment, the viral load and the CD4 cell count should be checked and the viral load test then repeated after approximately four weeks of treatment. If the patient is beginning a regimen that includes two to three drugs for which the patient’s virus does not appear to be resistant, it is expected that the amount of virus should decrease by at least hundredfold during this interval i.e., 4 weeks. The ultimate goal is for the viral load to decrease to undetectable levels which should occur by approximately 24 weeks. Those that are not having an appropriate response to therapy need to be questioned to make sure that they are taking their medications correctly, and if not, why. If the viral load is not going to undetectable levels and the patient is taking the medications correctly, then it is likely that there is a resistant virus to some of the medications. Drug-resistance testing then should be performed and the patient should be managed as described in the next section. Continue reading


HIV cure and treatment guidelines

What are the key principles in managing HIV infection?

First of all, there is no evidence that people infected with HIV can be cured by the currently available therapies. In fact, individuals who are treated for years and are repeatedly found to have no virus in their blood experience a prompt rebound in the number of viral particles when therapy is discontinued. The decision to start therapy must balance the risk versus the benefits of treatment. The risks of therapy include the short- and long-term side effects of the drugs, as well as the possibility that the virus will become resistant to the therapy which can limit options for future treatment.

A major reason that resistance develops is the patient’s failure to correctly follow the prescribed treatment, for example, if the patient is not taking the medications at the correct time. If virus remains detectable on any given regimen, resistance eventually will develop. With certain drugs, resistance may develop in a matter of weeks, such as with lamivudine (Epivir, 3TC), emtricitabine (Emtriva, FTC), the drugs in the class of nonnucleoside analogue reverse transcriptase inhibitors (NNRTI) such as nevirapine (Viramune, NVP), delavirdine (Rescriptor, DLV), and efavirenz (Sustiva, EFV), and the integrase inhibitor raltegravir (Isentress, RAL). Thus, if these drugs are used as part of a combination of drugs that does not suppress the viral load to undetectable levels, resistance will develop rapidly and the treatment will lose its effectiveness. In contrast, HIV becomes resistant to certain other drugs, such as zidovudine (Retrovir, AZT), stavudine (Zerit, D4T), and protease inhibitors (PIs), over months. In fact, for some Protease Inhibitors whose effects are enhanced by giving them in combination with the ritonavir (Norvir, RTV) to delay their clearance by the body, resistance appears to be markedly delayed. These drugs are discussed in more detail in subsequent sections, but it is important to note that when resistance develops to one drug, it often results in resistance to other related drugs of the same class, it is called cross-resistance. Nevertheless, HIV-infected individuals must realize that antiviral therapy can be and typically is very effective as long as drug resistance has not developed even in patients with very low CD4 count and high viral load. Continue reading