Human Immunodeficiency Virus (HIV, AIDS) (cont.)
Should patients with the "flu-like" or "mono-like" illness of primary HIV infection be treated?
There are theoretical reasons why patients identified with HIV around the time they are first infected (primary, acute infection) may benefit from the immediate initiation of potent antiviral therapy. Preliminary evidence suggests that unique aspects of the body's immune response to the virus may be preserved by this strategy. It is thought that treatment during the primary infection may be an opportunity to help the body's natural defense system to work against HIV. Thus, patients may gain improved control of their infection while on therapy and perhaps even after therapy is stopped. At one time, the hope was that if therapy was started very early in the course of the infection HIV could be eradicated. Most evidence today however suggests that this is not the case. Consequently, early treatment is not likely to result in a cure, although other benefits may still exist. The current recommendation is that patients with primary infection should be referred to clinical studies where the potential role of therapy can be discussed and further explored. If emotional or social situations make adherence to such treatment questionable, however, the patients are clearly better off delaying therapy.
What about treatment for HIV during pregnancy?
One of the greatest advances in the management of HIV
infection has been in pregnant women. Prior to antiviral therapy, the risk of
HIV transmission from an infected mother to her newborn was approximately 25%-35%. The first major advance
in this area came with studies giving ZDV after the first trimester of
pregnancy, then intravenously during the delivery process, and then after
delivery to the newborn for six weeks. This treatment showed a reduction in the
risk of transmission to less than 10%. Although less data are available with
more potent drug combinations, clinical experience suggests that the risk of
transmission may be reduced to less than 5%. Current recommendations are to
advise HIV-infected pregnant women regarding both the unknown side effects of
antiviral therapy on the fetus and the
promising clinical experience with potent therapy in preventing transmission. In
the final analysis, however,
pregnant women with HIV should be treated essentially the same as nonpregnant
women with HIV. Exceptions would be during the first trimester, where therapy
remains controversial, and avoiding certain drugs that may cause greater concern
for fetal toxicity, such as EFV.
All HIV-infected pregnant women should be managed by an obstetrician with
experience in dealing with HIV-infected women. Maximal obstetric precautions to
minimize transmission of the HIV virus, such as avoiding scalp monitors and
minimizing labor after rupture of the uterine membranes, should be observed. In addition, the
potential use of an elective Caesarean section (C-section) should be discussed,
particularly in those women without good viral control of their HIV infection
where the risk of transmission may be increased. Breastfeeding should be avoided
if alternative nutrition for the infant is available since HIV
transmission can occur by this route. Updated guidelines for managing HIV-infected women
are updated on a regular basis and can be found at http://www.hivatis.org.
Next: What about treating non-HIV-infected people who are exposed to the blood or genital secretions
of an HIV-infected person? »
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