Safety of antiretrovirals in pregnancy

Abstract

Highly active antiretroviral therapy (HAART) of three or more drugs is used extensively in industrialised countries for pregnant women with HIV, both to treat their own infection and to prevent mother-to-child transmission (MTCT). However, experts agree that current practice is based on limited randomised controlled trial data and guidelines are largely informed by observational studies and expert opinion. The British HIV Association (BHIVA) Pregnancy Guidelines note that ‘The Cochrane Systematic Review of randomised controlled trials in this area shows how limited the guidelines would be were they to be restricted to such high-level evidence’1 (see box). Despite this, good results using HAART, showing both reduction in transmission to less than 2% and benefits to maternal health, have been reported from several cohorts and observational studies in industrialised countries.2-4 Research and programmes from resource-limited settings have largely focused on short-course regimens of antiretrovirals in pregnancy, with the objective of reducing MTCT, but data are gradually emerging from cohorts of women from these settings receiving HAART. That a woman should receive HAART if it is indicated for her own health is not controversial. Benefits to a woman’s health clearly outweigh the known or theoretical risks associated with antiretroviral use, and her health and survival are paramount. The more complicated question is whether or not this is the best strategy for those women who do not yet meet the eligibility criteria for treatment but need intervention as prophylaxis to reduce transmission to their child, and it becomes still more difficult in settings where there may be limited monitoring of maternal and infant health. This article does not set out to discuss that question, but gives a brief overview of what is currently known about the risk/benefits associated with antiretroviral treatment, when it is considered appropriate, in pregnancy.