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. 2015 May-Jun;26(3):145-50.
doi: 10.1155/2015/731043.

A case series of third-trimester raltegravir initiation: Impact on maternal HIV-1 viral load and obstetrical outcomes

I Boucoiran  1 , K Tulloch  2 , N Pick  3 , F Kakkar  4 , J van Schalkwyk  1 , D Money  1 , M Boucher  5
Affiliations

A case series of third-trimester raltegravir initiation: Impact on maternal HIV-1 viral load and obstetrical outcomes

I Boucoiran et al. Can J Infect Dis Med Microbiol. 2015 May-Jun.

Abstract
in English, French

Objective: To describe the impact of initiating raltegravir (RAL)-containing combination antiretroviral therapy (cART) regimens on HIV viral load (VL) in pregnant women who have high or suboptimal VL suppression late in pregnancy.

Methods: HIV-infected pregnant women who started RAL-containing cART after 28 weeks' gestation from 2007 to 2013 were identified in two university hospital centres.

Results and discussion: Eleven HIV-infected women started RAL at a median gestational age of 35.7 weeks (range 31.1 to 38.0 weeks). Indications for RAL initiation were late presentation in pregnancy (n=4) and suboptimal VL suppression secondary to poor adherence or viral resistance (n=7). Mean VL at the time of RAL initiation was 73,959 copies/mL (range <40 to 523,975 copies/mL). Patients received RAL for a median of 20 days (range one to 71 days). The mean decline in VL from the time of RAL initiation to delivery was 1.93 log, excluding one patient who received only one RAL dose and one patient with undetectable VL at the time of RAL initiation. After eight days on RAL, 50% of the women achieved a VL <1000 copies/mL (the threshold for recommended Caesarean section to reduce the risk for perinatal transmission). There were no cases of perinatal HIV transmission.

Conclusion: The present study provides preliminary data to support the use of RAL-containing cART to expedite HIV-1 VL reduction in women who have a high VL or suboptimal VL suppression late in pregnancy, and to decrease the risk of HIV perinatal transmission while avoiding Caesarean section. Further assessment of RAL safety during pregnancy is warranted.

Objectif: Décrire les répercussions de l’amorce d’une antirétrovirothérapie prophylactique associative (ARPA) contenant du raltégravir (RAL) sur la charge virale (CV) du VIH chez les femmes enceintes dont la suppression de la CV est élevée ou sous-optimale en fin de grossesse.

Méthodologie: Les chercheurs ont extrait le dossier des femmes enceintes infectées par le VIH qui avaient amorcé une ARAP contenant du RAL après 28 semaines de grossesse dans deux centres hospitaliers universitaires entre 2007 et 2013.

Résultats et exposé: Onze femmes infectées ont entrepris un traitement de RAL à une médiane de 35,7 semaines de grossesse (plage de 31,1 à 38,0 semaines). Les indications pour entreprendre le RAL étaient une présentation tardive au suivi de grossesse (n=4) et une suppression sous-optimale de la CV en raison d’un mauvais respect du traitement ou d’une résistance virale (n=7). La CV moyenne au début du traitement au RAL était de 73 959 copies/mL (plage de moins de 40 copies/mL à 523 975 copies/mL). Les patientes ont pris du RAL pendant une médiane de 20 jours (plage de un à 71 jours). La diminution moyenne de la CV entre le début du RAL et l’accouchement était de 1,93 log, à l’exception d’une patiente qui n’a reçu qu’une dose de RAL et d’une patiente dont la CV n’était pas décelable au moment d’entreprendre le RAL. Au bout de huit jours de RAL, 50 % des femmes présentaient une CV inférieure à 1 000 copies/mL (le seuil pour recommander une césarienne afin de réduire le risque de transmission périnatale). Il n’y a d’ailleurs eu aucun cas de transmission périnatale du VIH.

Conclusion: La présente étude fournit des données provisoires pour soutenir l’utilisation d’ARPA contenant du RAL afin d’accélérer la réduction de la CV du VIH-1 chez les femmes qui présentaient une CV élevée ou une suppression sous-optimale de leur CV pendant la grossesse, ainsi que pour réduire le risque de transmission périnatale du VIH tout en évitant une césarienne. Une évaluation plus approfondie de l’innocuité du RAL est justifiée pendant la grossesse.

Keywords: HIV-1; Integrase inhibitor; Pregnancy; Raltegravir; Viral load.

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Figures

Figure 1)
Figure 1)
Examples of HIV RNA viral load evolution after raltegravir (RAL) initiation late in pregnancy. Case 4: a 33-year-old woman from Haiti who had recently immigrated to Canada was first seen at the authors’ clinic at 35 weeks’ gestation. A combination of zidovudine (AZT), lamivudine (3TC), boosted lopinavir (LPV/r) and RAL was immediately started. An elective Caesarean section was performed at 38 weeks, after intravenous zidovudine. At delivery, the HIV viral load was retrospectively found to be 154 copies/mL. Case 9: a 29-year-old First Nations nulliparous woman coinfected with hepatitis C with a history of substance abuse was first seen at 10 weeks’ gestation. Because of tolerance and adherence issues, her viral load was 32,820 copies/mL at 34 weeks’ gestation. She was admitted to hospital for supervised combination antiretroviral drug therapy (ART) containing RAL and received a total of seven days of this regimen. An emergent Caesarean section was performed at 35 weeks’ gestation in the context of preterm labour, after an intravenous loading dose of AZT and a single-dose of oral nevirapine 200 mg. At delivery, her HIV viral load was retrospectively found to be 338 copies/mL. Both newborns were uninfected. ABC Abacavir
Figure 2)
Figure 2)
Time to achieve a HIV viral load <1000 copies/mL and <50 copies/mL after raltegravir initiation during the third trimester (n=10). Dotted lines represent CIs
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