German-austrian recommendations for HIV1-therapy in pregnancy and in HIV1-exposed newborn - update 2008

Abstract

German-Austrian recommendations for HIV1-therapy in pregnancy - Update 2008 Bernd Buchholz (University Medical Centre Mannheim, Pediatric Clinic), Matthias Beichert (Mannheim, Gynecology and Obstetrics Practice), Ulrich Marcus (Robert Koch Institute, Berlin), Thomas Grubert, Andrea Gingelmaier (Gynecology Clinic of the Ludwig Maximilians University of Munich), Dr. med. Annette Haberl (HIV-Department, J. W. Goethe-University Hospital, Frankfurt), Dr. med. Brigitte Schmied (Otto-Wagner Spital, Wien). In Germany during the last years about 200-250 HIV1-infected pregnant women delivered a baby each year, a number that is currently increasing. To determine the HIV-status early in pregnancy voluntary HIV-testing of all pregnant women is recommended in Germany and Austria as part of prenatal care. In those cases, where HIV1-infection was known during pregnancy, since 1995 the rate of vertical transmission of HIV1 was reduced to 1-2%. This low transmission rate has been achieved by the combination of anti-retroviral therapy of pregnant women, caesarean section scheduled before onset of labour, anti-retroviral post exposition prophylaxis in the newborn and refraining from breast-feeding by the HIV1-infected mother. To keep pace with new results in research, approval of new anti-retroviral drugs and changes in the general treatment recommendations for HIV1-infected adults, in 1998, 2001, 2003 and 2005 an interdisciplinary consensus meeting was held. Gynaecologists, infectious disease specialists, paediatricians, pharmacologists, virologists and members of the German AIDS Hilfe (NGO) were participating in this conference to update the prevention strategies. A fifth update became necessary in 2008. The updating process was started in January 2008 and was terminated in September 2008. The guidelines provide new recommendations on the indication and the starting point for HIV-therapy in pregnancies without complications, drugs and drug combinations to be used preferably in these pregnancies and updated information on adverse effects of anti-retroviral drugs. Also the procedures for different scenarios and risk constellations in pregnancy have been specified again. With these current guidelines in Germany and Austria the low rate of vertical HIV1-transmission should be further maintained.

Pregnancy complications inHIV‐positive women: 11‐year data from theFrankfurtHIV Cohort

“…*Risk of transmission according to the recommendations of the German−Austrian Guidelines at the time of delivery .…”

“…Gingelmaier et al reported, in 2005, Medium NVP TVD † T20 No 2630 (10-90th percentile) 9/10/10 APGAR, score system to evaluate the newborn, APGAR is the acronym for: Appearance, Pulse, Grimace, Activity, Respiration; CBV, zidovudine/lamivudine; HAART, highly active antiretroviral therapy; HBV, hepatitis B virus; HCV, hepatitis C virus; NVP, nevirapine; T20, enfuvirtide; TVD, tenofovir/emtricitabine; VL, viral load. *Risk of transmission according to the recommendations of the German−Austrian Guidelines at the time of delivery [16][17][18]. † HAART regime tenofovir/emtricitabine and intensified (directly observed) with T20 application because of nonadherence and high VL.…”

“…National treatment policies changed several times within the study period. The major changes were: (1) if VL was undetectable, it was recommended that a vaginal birth should be offered and, if a caesarean delivery was chosen, then delivery should be delayed beyond 38 weeks; (2) the recommendation for initiation of HAART in treatment‐naïve pregnant women changed from 32 weeks of gestation to 28 weeks of gestation in singleton pregnancies to achieve complete VL suppression at the time of delivery; (3) new HAART regimes/options with better efficacy and possibly offering an overall improvement in maternal health were approved for use .…”

Increased rate of prematurity associated with antenatal antiretroviral therapy in a German/Austrian cohort of HIV‐1‐infected women

“…This discordance in findings may be partly explained by differences in study populations and methodology [22]. German–Austrian guidelines between 1998 and 2001 recommended that all HIV‐infected pregnant women should be offered an elective CS at 36 weeks' gestation before the onset of labour [18,19]. This recommendation reflected the finding in the early HAART era that a subgroup of women on HAART scheduled for elective CS were undergoing emergency CS or vaginal deliveries, with the attendant higher MTCT risk resulting from premature rupture of membranes [23,24].…”

“…Caesarean section (CS) deliveries performed before the onset of labour and rupture of membranes were categorised as primary (elective) and all others as emergency, regardless of indication (amnion infection syndrome, amnionitis or rupture of membranes). All HIV‐infected pregnant women were offered an elective CS, performed at 36+0 weeks' gestation in accordance with German–Austrian guidelines during the study period [18,19]. Because of the policy of early elective CS, premature delivery was defined as delivery before 36 weeks' gestation for the purpose of this analysis.…”