To the Editor:
The Department of Health and Human Services has published separate guidelines for pregnant versus nonpregnant adults and adolescents. 1–2 In contrast to recommendations for antiretroviral (ARV) therapy for nonpregnant women, the guidelines for pregnant women have a lower viral load threshold for initiating highly active antiretroviral therapy (HAART) and zidovudine monotherapy is an option for pregnant women with very low HIV RNA levels. Although several studies have described ARV use during pregnancy and subsequent pregnancy outcomes, 3 no studies have reviewed maternal ARV choices immediately postpartum among women initiating HAART during pregnancy. Many of these women may not have maternal indicators for initiation of HAART. The objective of this study was to describe ARV choices among pregnant women pre- and postpartum.
A chart review of a random sample (n = 57) of 174 pregnant women enrolled into the HIV Outpatient Program (HOP) clinic based at the Medical Center of Louisiana at New Orleans between January 1, 2000 and December 31, 2002 was performed. The sample was obtained using data from the Centers for Disease sponsored Adult Spectrum of Disease database. Age, race, CD4 cell counts, and HIV RNA levels during pregnancy did not differ significantly between the random sample and total cohort of 174 women. Characteristics of the random sample are shown in Table 1. The median first documentation of pregnancy was at 15.5 weeks (range: 3–37 weeks) of gestation, and the median time of delivery or miscarriage (n = 7) was at 38.5 weeks (range: 16–42 weeks) of gestation. All 14 women initiating HAART started zidovudine, lamivudine, and nelfinavir.
Zidovudine monotheraphy was the most common regimen started during pregnancy. Our study sample may be different from other pregnant populations, however, because most women had relatively high CD4 cell counts and low HIV RNA levels. The majority (7/9 or 78%) of women not meeting criteria outlined in the guidelines for nonpregnant adults elected to remain on their HAART regimens postpartum. These results suggest women who initiate HAART during pregnancy should be considered as a unique population when studying long-term ARV risks and benefits. Larger studies in various geographic locations are warranted to determine if the findings from this study are consistent across diverse populations.
1. Guidelines for use of antiretroviral agents in HIV-1-infected adults and adolescents. July 14, 2003. Panel on clinical practices for the treatment of HIV infection convened by the Department of Health and Human Services (DHHS). Available at http://AIDSinfo.nih.gov
2. Public Health Service Task Force Recommendations for use of antiretroviral drugs in pregnant HIV-1 infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States. Available at: http://AIDSinfo.nih.gov
3. Watts DH. Drug therapy: management of human immunodeficiency virus infection in pregnancy. N Engl J Med