Common Antivirals for HIV Could Increase Neonatal Death

The BMJ Rapid Recommendation panel recommended that pregnant women living with HIV should not receive tenofovir and emtricitabine as a first choice treatment, due to the high risk for neonatal death, prematurity, and still birth. This new recommendation contradicts current practice guidelines that recommend the 2 common antiviral drugs for preventing the vertical transmission of HIV.

The recommendation was based on 2 systematic reviews that assessed the harms and benefits of antiviral therapies and the values and preferences of women who are considering therapy. The reviews included the results from the Promoting Maternal and Infant Survival Everywhere (PROMISE) trial, which found that the combination of tenofovir plus emtricitabine increased the risk for pregnancy-related adverse events but were more effective at preventing transmission between mothers and infants.
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The panel made a weak recommendation that women receive zidovudine and lamivudine instead of tenofovir and emtricitabine. In addition, the panel strongly recommended against prescribing tenofovir and emtricitabine with lopinavir or ritonavir as adding lopinavir/ritonavir to the regime is associated with greater risk of preterm delivery before 34 weeks and early neonatal death. These recommendations reflect qualitative assessments of patients’ values, where women placed extremely high value on their child’s safety and avoiding early neonatal death.

Women with active hepatitis B (HVB) and a high risk for vertical transmission of HVB, severe anemia, drug allergies or intolerances, or zidovudine- or lamivudine-resistant HIV or HVB were more likely to choose treatments with tenofovir and emtricitabine.

“The recommendations are meant to support shared decision making between pregnant women and their healthcare provider,” the authors wrote “Healthcare providers should make all necessary efforts to inform women of all of the benefits and harms for all reasonable treatment options.”

—Melissa Weiss

Reference:

Siemieniuk RAC, Lytvyn L, Mah Ming J, et al. Antiretroviral therapy in pregnant women living with HIV: a clinical practice guideline [published online September 11, 2017]. BMJ. https://doi.org/10.1136/bmj.j3961.