Artikel
Successful and rapid reduction of viral load one week prior to C-section with ART including enfuvirtide
Erfolgreiche und schnelle Senkung der Viruslast innerhalb einer Woche vor geplanter Sectio mit Enfuvirtid-haltiger ART
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Veröffentlicht: | 2. Juni 2010 |
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Introduction: Prevention of MTCT is mainly based on a reduction of maternal viral load (VL) <1000 c/ml prior to delivery. Late presenters are at increased risk of transmitting HIV to the newborn. According to the German-Austrian recommendations antiretroviral therapy (ART) during pregnancy is either started for maternal indication (CD4 <350/µl) or for fetal indication around 32 weeks of gestational age, usually consisting of an AZT/3TC and PI-based regimen (LPV/r or SQV/r) (http://www.uni-duesseldorf.de/AWMF/ll/055-002.htm). Enfuvirtide (T20) has previously been successfully and safely given to pregnant women, especially in the setting of multidrug resistance or when a rapid reduction of VL was needed. About 30 cases have been published yet. Nevertheless the experience with this drug during pregnancy is limited (Haberl A et al. Use of Enfuvirtide in HIV+ Pregnant Women [Abstract 627b]. CROI. 2008).
Case report: We report a 24 yo African woman (G1P1) diagnosed HIV-positive during the 27th week of pregnancy (CD4 51/µl [4.6%]; VL of 1.3 mio c/ml at diagnosis). Resistance testing revealed a wild type virus. ART was initiated with TDF/FTC/SQV/r. At 30 weeks the CD4 count had risen to 149/µl (10.5%) and VL was 2,000 c/ml. At 32 weeks gestational age when she presented with abdominal pain, CD4 count was 51/µl (8.5%) and VL 20,000c/ml. At week 37 CD4 count was still low (49/µl [(7%]) and VL was dramatically increased to 800,000 c/ml. The patient now admitted poor adherence and was admitted to the obstetrics ward for directly observed therapy. ART was switched to AZT/3TC/NVP and T20 due to suspected resistance and for rapid reduction of VL prior to C-section to reduce the risk of MTCT. Within nine days the VL was reduced to 7,000 c/ml and a C-section done. After delivery the maternal ART was switched to TDF/FTC/NVP and has had a virologically and immunologically successful response since. Antepartum the mother received AZT i.v., the child received prophylactic ART for 6 weeks consisiting of AZT/3TC and NVP. HIV-PCR remained negative at 4 months of age.
Conclusions: T20 can be a safe and powerful intensification to ART in late-presenting HIV-positive pregnant women to prevent MTCT. It is generally well tolerated and does not cross the placental barrier. Observed injecting of T20 improves adherence and can lead to a rapid VL reduction. In the case presented here a 2log reduction in one week prior to c-section was achieved.