by An OB-GYN from Southeast U.S. called regarding an HIV-positive 37-year old pregnant woman in her 34th week of pregnancy. The woman had hepatitis C co-infection but underwent treatment and was considered cured prior to this pregnancy. The patient is also currently enrolled in a methadone maintenance treatment program. She had been started on ARVs before the pregnancy, but has not filled her prescriptions for three months. Her HIV viral load, which was previously undetectable, is now 7000 copies/µL and CD4 count is 363 cells/µL. The physician requested help in considering an ARV change, as well as developing a plan for delivery and postpartum care of the mother and her newborn.
The Perinatal HIV Hotline provided multidisciplinary consultation with input from an OB HIV specialist, an HIV-expert clinical pharmacist, an infectious diseases (ID) specialist, and a pediatric ID specialist. Specific recommendations were made on: (1) adjusting ARV medications with the primary goal of decreasing HIV viral load rapidly over the remainder of the pregnancy; (2) avoiding medication interactions, specifically with methadone; (3) ways to help support medication adherence for the remainder of the pregnancy and after delivery; (4) intrapartum ARVs and other management interventions for the mother; and (5) ARV management for the newborn. The NCCC team encouraged weekly maternal viral load testing until delivery and coordination with the hospital’s laboratory to have expedited HIV PCR testing available for the infant immediately after delivery. The importance of social services and ancillary support services was discussed. The physician called three weeks later to share that the patient’s viral load had decreased to 361 copies/uL. Three days after the baby was born, the family physician caring for the family also called to share that the infant’s initial birth HIV testing was negative. The team further assisted by walking the caller through the timeframe for follow-up infant testing and monitoring over the first year of life, as well as indicated monitoring and treatment for the mother.