Thai national guidelines for the prevention of mother-to-child transmission of human immunodeficiency virus 2017
Article Category: Original Article
Published Online: Aug 31, 2017
Page range: 127 - 144
DOI: https://doi.org/10.5372/1905-7415.1102.547
Keywords
© 2017 Rangsima Lolekha, Kulkanya Chokephaibulkit, Nittaya Phanuphak, Surasith Chaithongwongwatthana, Sasisopin Kiertiburanakul, Pleonchan Chetchotisakd, Sarawut Boonsuk
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.
Figure 1
Effective contraceptive options for HIV-infected women [17, 58]
| Birth control options | Description |
|---|---|
| Sterilization Intrauterine device (IUD) | Male or female sterilization is the best option for those who do not want more children. HIV-infected women can safely use copper IUD (Cu-IUD) and levonorgestrel IUD (LNG-IUD) [ |
| Hormonal implant | Contraceptive implant is recommended for HIV-infected women because of its effectiveness for a long period (3–5 years), safety, and convenience. There is no study on the effect of antiretroviral (ARV) drugs on hormonal levels in patients who receive a contraceptive implant; however, there have been reports of breakthrough pregnancy in HIV-infected women who receive ARV after >24 months of Implanon implant [ |
| Contraceptive injection | In Thailand, depot medroxyprogesterone acetate (DMPA) 150 mg injection is available. This intramuscular contraceptive injection is effective, safe, and convenient. A study on the use of DMPA in HIV-infected women shows that there is no interaction between ARV and DMPA. A cohort study revealed no significant change in CD4 count or HIV VL level in patients who use non-nucleoside reverse transcriptase inhibitors (NNRTI) or protease inhibitors (PI), after receiving DMPA [ |
| Oral contraceptives | Oral contraceptive pills commonly used in Thailand are a combined hormonal type consisting of ethinyl estradiol (EE) estrogen, a progestin such as levonorgestrel (LNG), norethindrone (NET), and norgestimate (NGM). The amounts of hormone content vary. Generally, standard oral contraceptives have EE 30–35 mg in each tablet. If EE is <30 mg, the hormone is considered to be an ultra-low dose; the preparation aims to reduce hormonal side effects. HIV-infected women who take oral contraceptive pills should be informed about potential interactions between ARV (efavirenz or ritonavir-boosted PIs) and contraceptive hormones that could lower contraceptive efficacy. It is recommended to use oral contraceptives pills with EE ≥30 mg in each tablet [ |
Suggested antiretroviral drugs substitution for specific drug intolerance in adults
| Drug that cannot be tolerated | Recommended substitution |
|---|---|
| AZT, e.g. severe anemia | TDF (300 mg, every 24 h) |
| TDF, e.g. effects on kidney or allergy to drug | AZT (200–300 mg, every 12 h) |
| LPV/r, e.g. nausea and diarrhea | EFV (600 mg, every 24 h) |
| EFV, e.g. severe dizziness | LPV/r (200/50), 2 tablets every 12 h |
| LPV/r and EFV | NVP (if CD4 count before ART initiation <250 cells/μL). The use of NVP in pregnant women with CD4 count >250 cells/μL is not recommended because of a higher risk of hepatitis. |
| LPV, EFV, NVP | Boosted atazanavir (ATV/r, 300/100, once daily) |
| EFV, LPV/r, NVP, and ATV/r | Refer to an HIV specialist. In the meantime, pregnant women should at least receive AZT monotherapy. If only AZT is given during antenatal care and delivery, a single dose NVP must be given in addition to AZT during onset of labor. |
Recommended laboratory monitoring for HIV-infected pregnant women receiving antiretroviral therapy (ART)
| Monitoring | Baseline | Follow-up during pregnancy after ART initiation |
|---|---|---|
| CD4 count | - Perform CD4 count as soon as possible after diagnosis of HIV infection. | - Monitor CD4 count every 6 months. |
| HIV viral load (VL) | - Not needed Baseline VL is not recommended in the Thai guidelines. The main reason behind is the budget limitation, and mostly, baseline VL does not change management. | - Monitor HIV VL at 34–36 weeks of gestation Generally pregnant women with good ART adherence for >8–12 weeks should have HIV VL <1,000 copies/mL. HIV VL testing at 34–36 weeks GA is a benefit for those with poor adherence or with <4 weeks of ART or suspected drug resistance. If HIV VL is >1,000 copies/mL, consider performing elective caesarean section before the onset of labor. If HIV VL >50 copies/mL, give AZT/3TC/NVP to infants for 6 weeks to PMTCT. |
| Complete blood | - Perform CBC in all cases before ART initiation. | - Monitor CB C at 4–8 weeks after initiation of AZT. |
| count (CBC) | - If Hb <8 g/dL or Hct<24%, AZT should not be used. Use TDF instead. | - If Hb <8 g/dL or Hct <24%, change AZT to TDF. However, intrapartum AZT every 3 h during labor should still be given. |
| Creatinine (Cr) | - Cr levels in all cases before ART initiation. | - Monitor Cr at 3 and at 6 months after TDF initiation. |
| - If Cr clearance <60 mL/min, do not use TDF. | - If Cr clearance <60 mL/min while receiving TDF, switch to AZT. | |
| Alanine | - ALT levels in all cases before ART initiation. | - Repeat ALT level measurements if clinically indicated and every 6 months. |
| aminotransferase (ALT) | - If ALT >2.5 times the upper limit of normal (ULN), avoid NVP. | - If women receive NVP-based ART and ALT >2.5 times the ULN, change NVP to EFV or LPV/r. |
| Urine sugar | - Monitor urine sugar in all cases before ART initiation. | - Monitor urine sugar at every antenatal care visit. Monitor UA including urine protein every 6 months for women receiving TDF. |
| - If urine sugar is positive while receiving LPV/r, switch to EFV | ||
| Glucose challenge test (GCT) 50 g 50 g glucose challenge test (GCT): measuring the plasma or serum glucose concentration 1 h after a 50 g oral glucose load. | - Perform GCT in women with intrapartum diabetic risks. If blood sugar ≥140 mg/dL, perform 100 g OGTT 100 g oral glucose tolerance test (OGTT): measuring the fasting plasma or serum glucose concentration at 1, 2, and 3 h after a 100 g oral glucose load. All women whose blood glucose concentration exceeds the glucose threshold value (fasting blood sugar ≥105mg/dL, serum glucose at 1 h after oral glucose load ≥190 mg/dL, at 2 h ≥165 mg/dL, and at 3 h ≥145 mg/dL) should be referred to obstetricians for proper management. | - Monitor GCT in women who are receiving LPV/r at 24–28 weeks gestational age or at least 4 weeks after LPV/r initiation. If blood sugar ≥140 mg/dL, perform 100 g OGTT or consult obstetricians. |
Conception method options for HIV-concordant and serodiscordant couples
| Male | Female | Options of conception methods |
|---|---|---|
| HIV-negative | HIV-positive | Self-insemination Intrauterine insemination (IUI) Sexual intercourse on the day of ovulation while the female partner has VL<50 copies/mL; several methods may be used to prevent transmission to the male partner such as pre- and postexposure antiretroviral prophylaxis and male circumcision. |
| HIV-positive | HIV-negative | Assisted reproduction with the use of donor sperm IUI Sexual intercourse on the day of ovulation while the male partner has VL<50 copies/mL; pre- and postexposure antiretroviral prophylaxis may also be given to the female partner. |
| HIV-positive | HIV-positive | IUI Self-insemination while the male partner has VL <50 copies/mL Sexual intercourse on the day of ovulation while both partners have VL <50 copies/mL |
Recommendations for the use of antiretroviral drugs in HIV-infected pregnant women and HIV-exposed infants for HIV treatment and for prevention of mother-to-child transmission of HIV
| Antepartum period | Intrapartum period | Postpartum period | Newborn (formula feeding + ARVs) |
|---|---|---|---|
If CD4 <200 cells/μL, give TMP-SMX, 2 tablets every 24 h. | Continue the antepartum regimen plus AZT Consider omitting oral AZT during intrapartum period if HIV VL <50 copies/mL near time of delivery and good ART adherence. Intravenous AZT is not recommended and not available in Thailand. | Continue ART after delivery for all women If the women discontinue ART, do the following: (1) if the women received LPV/r-based ART before delivery, discontinue all drugs simultaneously postpartum; (2) if the women received TDF + 3TC + EFV before delivery, stop EFV but continue TDF/FTC or TDF + 3TC for 14 days postpartum | Standard MTCT risk: defined as an infant whose mother had documentation of low VL (<50 copies/mL) at ≥36 weeks GA. If the maternal VL from >36 weeks is not available, an infant can still be considered standard risk if mother received HAART for at least 12 weeks before delivery with history of good adherence. |
(1) Adding raltegravir (400 mg) every 12 h as a 4th agent in addition to basic ART regimen in HIV-infected pregnant women who present late at ANC (≥32 weeks GA) and never receive ART or (2) women who receive ART >12 weeks, but VL >1,000 copies/mL at GA ≥32 weeks. Raltegravir can be discontinued after delivery. | |||
| TDF/FTC/EFV (300/200/600 mg) one tablet once daily or TDF (300 mg) + 3TC (300 mg) + EFV (600 mg) once daily | For infants bom at <30 weeks of gestation, the dosage of AZT syrup is 2 mg/kg/dose every 12 h for 4 weeks [ | ||
LPV/r-ART should be used in pregnant women suspected to have NNRTI resistance, e.g. history of partners on ART and suspected to have drug resistance, or pregnant women who previously received AZT+SD-NVP, or received ART in the past but stopped the treatment before pregnancy, or has a history of NNRTI resistance. | |||
| (AZT + 3TC) 1 tablet + LPV/r (200/50) 2 tablets every 12 h; or | For infants bom at 30–35 weeks of gestation, the dosage of AZT symp is 2 mg/kg/dose every 12 h for 2 weeks then 3 mg/kg/dose every 12 h for 2 weeks [ | ||
| TDF/FTC (300/200 mg) or TDF (300 mg) + 3TC (300 mg) once daily + LPV/r (200/50) 2 tablets every 12 h | High MTCT risk: defined as an infant whose mother had VL >50 copies/mL at ≥36 weeks GA. If the maternal VL from >36 weeks is not available, an infant can still be considered high risk if (1) the mother received ART for <12 weeks before delivery, or (2) the mother has a report of poor ART adherence in the past 12 weeks. | ||
| Continue the regimen that suppressed VL <50 copies/mL. Modify the regimen as needed for complete viral suppression. EFV can be continued during pregnancy even in the first trimester. | Continue the regimen plus AZT Standard MTCT risk: defined as an infant whose mother had documentation of low VL (<50 copies/mL) at ≥36 weeks GA. If the maternal VL from >36 weeks is not available, an infant can still be considered standard risk if mother received HAART for at least 12 weeks before delivery with history of good adherence. | Continue the same regimen according to the National Adult HIV Treatment and Prevention Guidelines. | See infant recoimnendations above. |
| Delivery is expected within 2 h | A single dose of AZT 600 mg | Initiate ART according to the National Adult HIV Treatment | See recommendation of ARV regimen for infants with high MTCT |
| Delivery is expected after 2 h | AZT 300 mg every 3 h until delivery or a single dose of AZT 600 mg + a single dose of NVP 200 mg at the onset of labor. | and Prevention Guidelines. | risk above. |