Discontinuing combination antiretroviral therapy during the first trimester of pregnancy: insights from plasma human immunodeficiency virus-1 RNA viral load and CD4 cell count.

OBJECTIVE: Options for human immunodeficiency virus-1-infected women who are already receiving antiretroviral medications when they become pregnant include the continuation or discontinuation of the therapy during the first trimester. These two strategies are compared in terms of plasma human immunodeficiency virus viral load and CD4 cell count. STUDY DESIGN: Seventy women who attended the II Department of Obstetrics and Gynecology were identified. Four different periods for laboratory evaluations were decided: presuspension, suspension, second trimester, and third trimester. RESULTS: Thirty-two women (46%) discontinued antiretroviral therapy; 38 women (54%) did not. Whereas plasma HIV virus viral load and CD4 cell count did not significantly vary during pregnancy in patients who did not interrupt the therapy, these two variables were influenced significantly by the discontinuation of treatment (P<.001 for both). Human immunodeficiency virus viral load increased during the suspension period and regressed promptly to basal levels as soon as the therapy was reintroduced. A transitory decrease in CD4 cell count was also documented, but the recovery tended to be slower. CONCLUSION: The suspension of combination antiretroviral therapy during the first trimester of pregnancy transiently corresponds to an increase in human immunodeficiency virus viral load and a decline of CD4 cell count.

Combination antiretroviral therapy in 100 HIV-1-infected pregnant women.

BACKGROUND: In recent years, combination antiretroviral therapy has substantially improved the prognosis of human immunodeficiency virus type-1 (HIV-1) infection. However, at present, information regarding the effects of these regimens during pregnancy is limited. METHODS: Side-effects, vertical transmission rate and neonatal outcome associated with different combination therapies were evaluated retrospectively in a consecutive series of 100 women who attended the II Department of Obstetrics and Gynecology for the management of HIV-1 infection in pregnancy. RESULTS: Antiretroviral treatment was initiated at a median of 16 weeks gestation with a range from pre-pregnancy until 31 weeks gestation. Twentythree women continued their pre-pregnancy therapy during the first trimester of gestation. Protease inhibitors were incorporated in 23 of the final therapeutic regimens. Twentyfive women did not receive zidovudine. Most women (97) delivered by Caesarean section and none breast-fed. Prematurity rate for the entire series was 19%. When women who actively used illicit drugs were excluded, only seven of 69 (10%) women were found to deliver prematurely. The use of protease inhibitors was limited by an elevated frequency of severe gastrointestinal disturbances. The rate of congenital malformations did not appear to differ significantly from that reported in the literature for the general population. Only one of 102 live newborns was found to be HIV-1-infected (1.0%, 95% confidence interval; 0.3-4.6%). CONCLUSIONS: The present findings confirm the remarkable efficacy of combination antiretroviral therapy, Caesarean section and refraining from breast-feeding in lowering the rate of vertical HIV-1 transmission. Moreover, they are suggestive that combination antiretroviral therapy may not be related to major neonatal toxicity. The necessity to discontinue the therapy during the first trimester of pregnancy and to systematically incorporate zidovudine into combination regimens is discussed.