HIV Treatment Considerations in Pregnancy

HIV Treatment Considerations in Pregnancy

Women who could become pregnant require special consideration when deciding on the appropriate antiretroviral regimen because of the various effects of certain ARVs on pregnant women and the fetus.

Efavirenz (Sustiva), which is a component of Atripla, is especially worrisome because this drug is known to cause serious neurologic consequences in the fetus and should be avoided in pregnancy. Women should be on birth control if they are sexually active while on efavirenz.

Other ARVs that should be used with caution in pregnant women include didanosine [Videx] and stavudine [Zerit] together, which can lead to serious metabolic and liver conditions in women.

Women with CD4 counts above 250 cells/mm3 have been shown to be at higher risk of life-threatening liver toxicity and rash when starting nevirapine, as reviewed above, so this agent should also be used with caution in pregnant women.

Important Psychosocial Considerations for HIV-Positive Women

We have reviewed many of the biological and pharmacologic issues that are important in the treatment of HIV-positive women. However, many social and cultural issues, with special relevance to women, affect HIV treatment considerations just as they affect HIV prevention.

Only 60% of HIV-positive females who qualify for HAART in the U.S. are on this life-saving therapy, compared to 75% of HIV-positive men who qualify for therapy. The reasons for this gender disparity need to be further elucidated, but some of the reasons lie in community beliefs regarding HIV/AIDS.

An interesting survey in 2005 interviewed 500 African Americans in the U.S. about their beliefs about HIV (65% were women). Of those surveyed, 53% believed that a cure for AIDS exists, but was being withheld from the poor; 44% felt that people taking new medications were "guinea pigs"; and 27% thought that AIDS was created in a government lab.²⁹

Clearly, conspiracy beliefs and suspicions regarding the medical establishment in the African American community will affect HIV-positive women more than men, given the disproportionate percentage of minorities.

Another reason that women are less likely to engage in HIV treatment or care lies in higher rates of physical and sexual abuse in women. A history of abuse has been shown to decrease the likelihood that a woman will start and stay on an antiretroviral regimen.

In addition, women who suffer from substance abuse issues, such as cocaine addiction, are also at increased risk of not starting treatment for their HIV when relevant.

And let's not forget the overwhelming effect of stigma, which disproportionately effects women both internationally and domestically.

A national survey performed by the American Foundation for AIDS Research (AMFAR) and released in 2008 revealed the following disturbing results regarding stigma against HIV-positive women: of almost 5,000 individuals polled, approximately 70% would not want an HIV-positive female dentist; 60% would not want an HIV-positive physician or childcare provider; and 50% would not want an HIV-positive food server. Only 14% of Americans polled felt that HIV-positive women should have children. This is less than the percentage of Americans who felt that women with schizophrenia or Down's Syndrome should have children, at 17% and 19% respectively.

Strategies to improve HIV prevention and treatment in women need to address physical and sexual abuse, stigma, community beliefs, and substance abuse issues in order to be successful.