A 25-year-old woman at 10 weeks gestation comes to the office for a consultation regarding a positive HIV-1 enzyme-linked immunosorbent assay and a confirmatory Western blot that were ordered as part of routine prenatal care. She has never been tested before and does not know when she was exposed to HIV. She has no other chronic medical conditions and has had no prior surgeries. The patient takes a daily prenatal vitamin but no other medication. She does not use tobacco or illicit drugs. The patient is a college student and lives with her boyfriend.
Physical examination is within normal limits. A complete blood count, basic metabolic panel, lipid panel, and hepatic function panel are all normal. HIV viral load is 3,240 copies/mL and CD4 count is 473 cells/mm³.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_98a0_69f1_853d_a30c4639d2d0_MD0002_00 Current guidelines recommend that all pregnant women with HIV begin taking combination antiretroviral therapy (ART) as soon as possible, regardless of initial viral load or CD4 counts, to minimize maternal risks of HIV infection and reduce perinatal transmission (Choices B and C). Drug-resistance testing is performed prior to treatment initiation; however, ART is begun immediately and modified according to results. Combination drug therapy is more effective than single drug therapy and should include a nucleoside reverse transcriptase inhibitor and either a protease or an integrase inhibitor. Early initiation of multidrug ART allows for optimal viral load reduction by the time of delivery as viral load dictates the mode of delivery: Patients with viral loads ≤1,000 copies/mL may deliver vaginally without intrapartum zidovudine (AZT).Patients with viral loads >1,000 copies/mL receive AZT intrapartum + cesarean delivery. Patients with viral loads ≤1,000 copies/mL may deliver vaginally without intrapartum zidovudine (AZT). Patients with viral loads ≤1,000 copies/mL may deliver vaginally without intrapartum zidovudine (AZT). Patients with viral loads >1,000 copies/mL receive AZT intrapartum + cesarean delivery. Patients with viral loads >1,000 copies/mL receive AZT intrapartum + cesarean delivery. Infants receive postexposure prophylaxis after delivery to further reduce their risk of viral transmission. Therapy and dosing varies based on the maternal viral load and specific infant risk factors. Mothers with HIV who live in areas where formula is readily available (eg, United States) should not breastfeed as HIV can be transmitted through breast milk. However, mothers with HIV living in developing countries should continue ART and breastfeed for 6 months to minimize infant morbidity and mortality from infectious diseases. (Choices A and E) Delaying ART until the third trimester or until delivery may not adequately reduce viral load at the time of delivery, significantly increasing the risk of vertical transmission. Educational objective: Pregnant women with HIV should be initiated on combination antiretroviral therapy (ART) as soon as possible, independent of HIV RNA viral load or CD4 count. Early initiation of ART, intrapartum zidovudine (AZT) administration, cesarean delivery, and postexposure ART prophylaxis for the infant decrease the risk of neonatal HIV transmission. Women who achieve optimal viral load reduction (≤1,000 copies/mL) may deliver vaginally without AZT. __________ References: When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery? (http://www.ncbi.nlm.nih.gov/pubmed/22441248) Cesarean section for HIV-infected women in the combination antiretroviral therapies era, 2000-2010. (http://www.ncbi.nlm.nih.gov/pubmed/23791563) Management of HIV infection during pregnancy in the United States: updated evidence-based recommendations and future potential practices. (http://www.ncbi.nlm.nih.gov/pubmed/27504071)

A 25-Year-Old Woman at 10 Weeks Gestation Comes to the Office