2019 Ryan White HIV/AIDS Program CLINICAL CONFERENCE

Rating Scheme for Recommendations

StrengthofRecommendation

QualityofEvidence for Recommendation

A: Strong

I:One or more RCTswith clinicaloutcomes and/or validated lab endpoints II:One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes

B: Moderate

C:Optional

III:Expert opinion

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General Principles for the Use of ARVs in Pregnancy • ART is recommended for all pregnant women to prevent perinatal transmission and to optimize the health of the mother (AI) • Perinatal transmission is directly related to HIV viral load • Undetectable VL (<50 c/ml) at time ofdelivery associated with 0.09% transmission (UK/Ireland. Townsend2014) • Early initiation of ART increases viral suppression by time of delivery and further reduces risk of transmission • French Perinatal Cohort: with NDVL at delivery: 0% transmission with preconception ART,0.2% with 1 st trimester, 0.5%with 2 nd trimester, 0.9%with 3 rd trimester initiation (Mandelbrot2015) • HIV drug resistance tests shouldbe performed but ART initiation shouldnot be delayed while waiting for results (AII) • ARV drugs further reduce transmission risk through infantpre- and pos-exposure prophylaxis

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General Principles for the Use of ARVs in Pregnancy • Choice of ART regimen should be informed by current adult treatment guidelines but there are special considerations in pregnancy:

• Risk of birth defects or other adverse pregnancy outcomes • Availability of pregnancy-specific pharmacokineticdata • Maternal factors (e.g., nausea/vomiting, comorbid conditions)

• Women who become pregnant on ART should continue their regimen during pregnancy, provided the regimen is safe, effective in suppressing viral replication and tolerated ( AII ) • Drugs not recommended due to toxicity (e.g. d4T, ddI) should be stopped and women switched to another ART regimen ( AIII ) • EVG/COBI, ATV/COBI, DRV/COBI regimens: considerswitching due to PK concerns in 2 nd /3 rd trimester ( BIII )

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