Antiretroviral Therapy during Pregnancy: Safety and Efficacy

Angel Miguel^*
*Correspondence: Angel Miguel, Department of Internal Medicine, Sotiria Thoracic Diseases General Hospital, 11527 Athens, Greece, Email:

Introduction

Antiretroviral Therapy (ART) has revolutionized the management of Human Immunodeficiency Virus (HIV) infection, transforming it from a fatal disease into a manageable chronic condition. For pregnant women living with HIV, ART is critical not only for the health of the mother but also for preventing mother-to-child transmission (MTCT) of the virus. This article explores the safety and efficacy of ART during pregnancy, discussing its impact on maternal health, fetal development and MTCT rates. The global burden of HIV remains significant, with an estimated 38 million people living with the virus as of 2020. Pregnant women with HIV face unique challenges, as they must manage their health while minimizing the risk of transmitting the virus to their unborn child. Antiretroviral therapy has been a cornerstone in addressing these challenges, offering hope for healthy pregnancies and HIV-free infants [1].

Description

Efficacy of antiretroviral therapy in preventing MTCT

Mechanisms of transmission: Mother-to-child transmission of HIV can occur during pregnancy, labor, delivery, or breastfeeding. Without intervention, the risk of MTCT ranges from 15% to 45%. However, with effective ART, this risk can be reduced to less than 2%.

Role of art in reducing MTCT: ART works by suppressing the viral load in the mother's blood to undetectable levels, which significantly decreases the likelihood of the virus crossing the placenta or being transmitted during childbirth. Key studies have demonstrated the efficacy of ART in preventing MTCT:

• The PACTG 076 trial (1994) was a landmark study showing that zidovudine (AZT) could reduce MTCT rates by nearly 70%.

• Subsequent studies have shown that combination ART (cART) is even more effective, reducing MTCT rates to below 1%.

Timing and regimen: The timing of ART initiation is crucial. The World Health Organization (WHO) recommends that all HIV-positive pregnant women start ART as soon as possible, regardless of their CD4 count. Common ART regimens during pregnancy include a combination of two nucleoside reverse transcriptase inhibitors (NRTIs) and a non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor (PI) [2-4].

Safety of antiretroviral therapy during pregnancy

Maternal safety: ART is generally safe for pregnant women, but certain antiretroviral drugs have been associated with adverse effects:

• Zidovudine (AZT) can cause anemia.

• Protease inhibitors (PIs) may increase the risk of preterm birth and preeclampsia.

• Efavirenz (EFV) was previously avoided in the first trimester due to potential teratogenic effects, but recent studies have shown it to be safer than initially thought.

Fetal and neonatal safety: The impact of ART on fetal and neonatal health is a critical consideration:

• Birth Defects: Some studies have suggested a slightly increased risk of birth defects with certain ART regimens, but the overall risk remains low.

• Preterm Birth and Low Birth Weight: There is evidence that ART, particularly regimens including PIs, may increase the risk of preterm birth and low birth weight. However, the benefits of ART in preventing MTCT generally outweigh these risks.

• Long-term Outcomes: Children exposed to ART in utero are monitored for potential long-term effects. Most studies indicate that these children do not have a higher risk of developmental delays or chronic health issues compared to unexposed children [5].

Clinical guidelines and recommendations

WHO guidelines: The WHO recommends lifelong ART for all pregnant and breastfeeding women with HIV, known as Option B+. This approach simplifies treatment and ensures continuous viral suppression.

National guidelines: Many countries have adopted similar guidelines, with specific recommendations based on local epidemiology and healthcare infrastructure. In the United States, the Department of Health and Human Services (DHHS) provides detailed guidelines for the use of ART in pregnant women, emphasizing individualized care and regular monitoring.

Case studies and real-world evidence

Success stories: Countries with robust ART programs have reported significant reductions in MTCT rates. For instance:

• In Botswana, the MTCT rate dropped from 40% in the early 2000s to less than 2% by 2016.

• In Thailand, the MTCT rate decreased to less than 1% following the implementation of nationwide ART programs.

Challenges and considerations: Despite these successes, challenges remain:

• Access to art: In some low-resource settings, access to ART remains limited, posing a significant barrier to eliminating MTCT.

• Adherence: Ensuring adherence to ART is crucial for its efficacy. Pregnant women may face additional barriers to adherence, including stigma, lack of social support and economic constraints.

Antiretroviral therapy (ART) during pregnancy is critical for preventing mother-to-child transmission of HIV and ensuring the health of both the mother and the baby. The safety and efficacy of ART in pregnant women have been well-documented, leading to significant advancements in managing HIV in this population. The safety of ART during pregnancy has been extensively studied, with most antiretroviral drugs demonstrating a favorable safety profile. However, specific drugs, such as efavirenz, have been associated with teratogenic effects when used during the first trimester. Newer guidelines recommend safer alternatives during early pregnancy.

Overall, the benefits of ART in reducing HIV transmission and improving maternal health outweigh the potential risks of adverse effects. Ongoing monitoring and adjustments in the ART regimen are crucial to manage any side effects and ensure optimal outcomes. ART is highly effective in reducing the viral load in pregnant women to undetectable levels, which is essential for preventing the transmission of HIV to the baby. Studies have shown that when ART is used consistently and appropriately, the risk of mother-tochild transmission can be reduced to less than 1%. Additionally, ART helps in maintaining the mother’s health by controlling the HIV infection, thereby reducing the likelihood of opportunistic infections and other HIV-related complications.

Conclusion

Antiretroviral therapy during pregnancy is both safe and effective, significantly reducing the risk of mother-to-child transmission of HIV and improving maternal health. While certain antiretroviral drugs may pose risks, the benefits of ART in preventing MTCT generally outweigh these concerns. Ongoing research and improved access to ART will continue to enhance outcomes for HIV-positive pregnant women and their children.

Acknowledgement

None.

Conflict of Interest

None.

References

1. Bernadette, Jakeman, Sapna Bhatia, Carolyn Cotton and Keenan Ryan, et al. “Delayed HIV diagnosis in a cystic fibrosis patient: Not just another exacerbation.” J AIDS Clin Res 34 (2021): 101545

   Google Scholar, Crossref, Indexed at

2. Stefan, Esser, Raffi Francois Guiseppe Nunnari and Ignacio Pérez‐Valero, et al. "Switching regimens in virologically suppressed HIV‐1‐infected patients: evidence base and rationale for integrase strand transfer inhibitor (INSTI)‐containing regimens." HIV Med 17 (2016): 3-16.

   Google Scholar, Crossref, Indexed at

3. Sharon R., Lewin, Deeks, Steven G. and Diane V. Havlir. "The end of AIDS: HIV infection as a chronic disease." Lancet 382 (2013): 1525-1533.

   Google Scholar, Crossref, Indexed at

4. Jerod N., Scholten, Alaine Umubyeyi, Mustapha Gidado and Pedro G. Suarez, et al. “Coronavirus disease 2019 diagnosis in low- and middle-income Countries: The big new bully disrupting tb and hiv diagnostic services.” J AIDS Clin Res 24 (2022): 289-293.

   Google Scholar, Crossref, Indexed at

5.  Mehmet, Ozgun Ozen, Mark A. Lifson, Fatih Inci and HakanInan, et al. “Advances in biosensing strategies for HIV-1 detection, diagnosis and therapeutic monitoring.” J AIDS Clin Res 103 (2016): 90-104.

   Google Scholar, Crossref, Indexed at