Page 135 - HIV/AIDS Guidelines

diseases (STDs) is recommended for all HIV-infected women and their partners, regardless of contraceptive
use.

The data on the association between hormonal contraception and the risk of acquisition of HIV are
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conflicting. A retrospective secondary analysis of two studies of serodiscordant couples in Africa in which
the HIV-infected partner was not receiving ART found that women using hormonal contraception (the vast
majority using injectable DMPA) had a twofold increased risk of acquiring HIV (for HIV-infected male/HIV-
uninfected female couples) or transmitting HIV (HIV-infected female/HIV- uninfected male couples). 28
HIV-infected women using hormonal contraception had higher genital HIV RNA concentrations than did
28
women not using hormonal contraceptives. Oral contraceptive use was not significantly associated with
transmission of HIV; however, the number of women using oral contraceptives in this study was insufficient
to adequately assess risk. It is important to note that not all studies have supported a link between hormonal
contraception and transmission or acquisition of HIV and that individuals in this study were not receiving
ART. Further research is needed to definitively determine if hormonal contraceptive use is an independent
risk factor for acquisition and transmission of HIV. 27,29

Intrauterine devices (IUDs) appear to be a safe and effective contraceptive option for HIV-infected women. 30-
33 Although studies have focused primarily on non-hormone-containing IUDs (e.g., copper IUD), several
small studies have also found levonorgestrel-releasing IUDs to be safe. 31, 34-35

Pregnant Women
Clinicians should review the Perinatal Guidelines for a detailed discussion of the management of HIV-
1
infected pregnant women. The use of combination ARV regimens is recommended for all HIV-infected
pregnant women, regardless of virologic, immunologic, or clinical parameters (AI). Pregnant HIV-infected
women should be counseled regarding the known benefits versus risks of ARV use during pregnancy to the
woman, fetus, and newborn. A woman’s decision regarding ARV use should be respected. Coercive and
punitive approaches undermine provider-patient trust and could discourage women from seeking prenatal
care and adopting health care behaviors that optimize maternal, fetal, and neonatal well-being.

Prevention of Perinatal Transmission of HIV. Both reduction of HIV RNA levels and use of ARVs appear
to have an independent effect on reduction of perinatal transmission of HIV. 36-38 The goal of ARV use is to
achieve maximal and sustained suppression of HIV RNA levels during pregnancy.

As in non-pregnant individuals, genotypic resistance testing is recommended for all pregnant women before
ARV initiation (AIII) and for pregnant women with detectable HIV RNA levels while on therapy (AI).
Optimal prevention of perinatal transmission may require initiation of ARV before results of resistance
testing are available. If results demonstrate the presence of significant mutation(s) that may confer resistance
to the prescribed ARV regimen, the regimen should be modified.
Long-term follow-up is recommended for all infants born to women who have received ARVs during
pregnancy, regardless of the infant’s HIV status (see the Perinatal Guidelines ).
1
Regimen Considerations. Pregnancy should not preclude the use of optimal drug regimens. Because
recommendations on ARVs to use for treatment of HIV-infected pregnant women are subject to unique
considerations, recommendations specific to the timing of therapy initiation and the choice of ARVs for
pregnant women may differ from those for non-pregnant individuals. These considerations include the
following:

• potential changes in pharmacokinetics and, thus, dosing requirements, which result from physiologic
changes associated with pregnancy;

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents I-19

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