In this CME presentation, we discuss the recommendations for Antiretroviral Therapy (ART) to a couple who wants to conceive. We have compared the recommendations of Nepal, DHHS (US) and WHO

1. Conception and Antiretroviral
Treatment (ART)
Dr. Pravin Prasad
M.B.B.S., M.D. Clinical Pharmacology
Lecturer, Department of Pharmacology
Lumbini Medical College and Teaching Hospital
2 December, 2018 (16 Mangsir 2075), Sunday

2. Presentation Outline
ART recommendations for preconception period
WHO, DHHS (US), Nepal
Recommended ART regimens
Conception in HIV infected couples
Both partners infected
Serodiscordant couples
Hormonal Contraceptives and ART

3. Bibliography
National Centre for AIDS and STD Control. National HIV Testing and
Treatment Guidelines Nepal. Ministry of Health. Available at
http://www.searo.who.int/entity/nepal/documents/communicable_di
seases/national_hiv_testing_and_treatment_guidelines_2017_(23ju
ne2017).pdf?ua=1. Accessed on 22 November, 2018
Panel on Antiretroviral Guidelines for Adults and Adolescents.
Guidelines for the Use of Antiretroviral Agents in Adults and
Adolescents Living with HIV. Department of Health and Human
Services. Available at http://www.aidsinfo.nih.gov/ContentFiles/A-
dultandAdolescentGL.pdf. Accessed on 25 November, 2018
World Health Organization. Consolidated guidelines on HIV
prevention, diagnosis, treatment and care for key populations–2016
update. World Health Organization; 2016.

4. Rating scheme for
recommendations: DHHS, US
Strength of
Recommendation
Quality of Evidence for
Recommendations
A.Strong
B. Moderate
C. Optional
I. One or more randomized trials with
clinical outcomes and/or validated
laboratory endpoints
II. One or more well-designed, non
randomized trials or observational
cohort studies with long term
clinical outcomes
III. Expert opinion

5. Rating scheme for
recommendations: WHO
A strong recommendation (for or against) is one for which there is
confidence that the desirable effects of adherence to the recommendation
clearly outweigh the undesirable effects.
A conditional recommendation (for or against) is one for which the quality
of evidence may be low or may apply only to specific groups or settings; or
the panel concludes that the desirable effects of adherence to the
recommendation probably outweigh the undesirable effects or are closely
balanced, but the panel is not confident about these trade-offs in all
situations.

6. ART during Pregnancy:
Recommendations
Recommendations (initiate as
priority)
WHO DHHS
Serodiscordant
couples
• Strongly recommended
• High quality of
evidence
• A
• I/(II)
Pregnant lady • Strongly recommended
• Moderate quality of
evidence
• A
• II

7. ART Combination in Pregnancy:
National Recommendation(Nepal)
Tenofovir (TDF)+ [Lamivudine (3TC) or
Emtricitabine (FTC)] + Efavirenz (EFV)
Fixed dose combination
• Less frequently associated with severe
adverse effects
• Better virological and treatment response
No increased risk of birth defects in first
trimester of pregnancy

8. ART regimens during pregnancy:
DHHS
Preferred Two-NRTI Backbones
Abacavir (ABC)/Lamivudine (3TC)
Tenofovir disoproxil fumarate
(TDF)/Emtricitabine (FTC)
TDF/ 3TC

9. ART regimens during pregnancy:
DHHS
Preferred PI Backbones (ritonavir boosted, along
with preferred two-NRTI regimen)
Atazanavir(ATV)
Darunavir (DRV)
Preferred integrase inhibitor regimens (along with
preferred two-NRTI regimen)
Raltegravir (RAL)

10. Conception in HIV infected couples
Partners should be screened and treated for genital
tract infections before attempting to conceive
• A-II
Partners living with HIV infection should attain
maximum viral suppression before attempting
conception to prevent HIV sexual transmission
• A-I
and, for women living with HIV, to minimize the risk of
HIV transmission to the infant
• A-II

11. Conception in serodiscordant
couples
To prevent transmission of HIV to non-infected
partner:
When the woman is infected, consider assisted
insemination
• A-III
When the man is infected, consider using of
HIV-uninfected sperm donor
• B-III

12. Conception in serodiscordant
couples
When the partner living with HIV is on ART and:
Has achieved sustained viral suppression, unprotected sexual
intercourse during peak fertility is an approach to conception
with very low risk of sexual HIV transmission to the partner
• B-II
Has not been able to achieve viral suppression or status is not
known, administration of antiretroviral pre-exposure
prophylaxis (PrEP) to the partner is recommended
• A-I
Counsel to limit unprotected sex to the period of peak fertility
• A-III

13. Hormonal contraceptives and ART
Potential to alter the effectiveness of hormonal
contraceptives
Efavirenz
Ritonavir (RTV)-boosted PIs
WHO concludes: Interactions does not warrant
discontinuation of each other
Consistent use of condoms recommended

14. Conclusion
ART has essential role before planning pregnancy
Initiation of ART should be done on a priority basis for
pregnant lady
Multiple ART regimens are available to be used during
pregnancy
Nepal: Same regimen as for adults
Every effort should be made to protect the non-
infected partner when attempting conception
Use of non-hormonal contraceptives recommended
when under ART

15. Thank you…