Women taking PrEP during conception, pregnancy and breastfeeding
Conception in serodiscordant couples
Women without HIV infection who have sexual partners with documented HIV infection are at risk of HIV acquisition during natural attempts to conceive (i.e. without a condom) if their HIV-positive partner has a detectable or variably detectable plasma viral load. Providers should discuss with their patients the available information about the potential risks and benefits of PrEP in these circumstances 19. For women wanting to conceive where their HIV-positive male partner is stably virologically suppressed on combination antiretroviral therapy (cART), PrEP should still be offered to the woman if she expresses concerns about the risk of acquiring HIV in this setting.
Pregnancy
Among women without HIV infection, the risk of acquiring HIV increases by approximately two-fold during pregnancy 20. In addition, if a woman acquires HIV infection during pregnancy there is a higher risk of HIV transmission to the infant than if the woman were to become pregnant during chronic HIV infection because the HIV viral load is much higher during acute HIV infection.
The use of TD*-containing regimens by HIV positive women throughout pregnancy has not been associated with adverse pregnancy outcomes, but lowered BMD has been observed in newborns exposed to TD* in utero 22 as has a lower length and head circumference at 1 year of age 23.
The World Health Organization has included PrEP as an HIV prevention strategy during pregnancy 26 and a number of other jurisdictions recommend PrEP for safe conception and for use during pregnancy and breastfeeding 27.
Some women with HIV-positive partners may prefer to continue PrEP while pregnant, due to the increased risk of acquisition of HIV if their partners are not reliably virologically supressed during pregnancy, or due to high levels of anxiety 27.
Providers should discuss with their patients available information on potential adverse pregnancy outcomes when beginning or continuing PrEP during pregnancy so that they can make an informed decision. It should be noted that TD* is classified as category B3 by the Australian Therapeutic Goods Administration (TGA) 29, meaning that, to date, tenofovir has been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. However, studies in animals have shown evidence of an increased occurrence of foetal damage, the significance of which is considered uncertain in humans.
Therefore, the ASHM PrEP Guidelines Panel’s recommendation is that PrEP may be continued during pregnancy in women at risk for HIV acquisition, or who are unduly affected by anxiety about HIV acquisition.
Acknowledgement of Country