1. Women and Adolescents Case Presentations Vivian M Tamayo-Agrait, MD, FACOG, AAHIVMS Department of Obstetrics and Gynecology University of Puerto Rico Faculty, Florida/Caribbean AETC

2. Disclosures of Financial Relationships This speaker has no significant financial relationships with commercial entities to disclose. This speaker will not discuss any off-label use or investigational product during the program. This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.

3. Case #1: Pregnant perinatally infected adolescent This is the case of a 17 years old G1P0 adolescent with history of HIV diagnosed at 2 y/o who comes referred from a Pediatrics Immunology Clinic due to a positive pregnancy test. Past medical history: Bronchial asthma, lipodystrophy, major depression, suicidal attempt

4. Case #1: Pregnant perinatally infected adolescent Past ARV experience: –AZT and ddI (1997-1998): changed due to viremia –Lamivudine/AZT/ritonavir: ritonavir d/c due to nausea –Nelfinavir/AZT/3TC (1998-2000): changed due to viremia –Efavirenz/d4T/ddI (2000-2002) –Lopinavir/ritonavir, 3TC/d4T (2002-2004): changed to due viremia –Atazanavir/tenofovir/T-20 (2004-2006): d/c due to poor commitment with treatment –Atazanavir/ritonavir/tenofovir/3TC: treatment at initial visit

5. Case #1: Pregnant perinatally infected adolescent Patient brings results of three previous resistance tests (genotypes) that showed the following mutations: –2001: I84V, M46I, L90M –2006: no mutations detected –2007: no mutations detected

6. Case #1: Pregnant perinatally infected adolescent At initial visit, patient reported poor adherence with her ARV therapy. –Latest labs: CD4 count: 393 (31%) HIV RNA viral load: 85,826 copies/mL Patient was continued on current therapy and genotype was ordered which showed the following:

7. Case #1: Pregnant perinatally infected adolescent

8. Based on these results, patient was started on Lopinavir/ritonavir, raltegravir, etravirine, 3TC/AZT Importance of good adherence was stressed for both maternal and fetal reasons. Follow-up labs after 2 weeks on treatment showed: –CD4 count: 476 (31%) –HIV RNA viral load: 5617 copies/mL

9. Case #1: Pregnant perinatally infected adolescent Labs after 2 months on new regimen showed: –CD4 count: 530 (36%) –HIV RNA viral load: 115 copies/mL The patient’s pregnancy was complicated by delivery via emergency cesarean section at 28 weeks gestational age (WGA) due to eclampsia. She delivered a baby girl, weight 3 lbs. –The baby has been followed up at the Pediatrics Immunology Clinic and is confirmed negative.

10. Case #1: Pregnant perinatally infected adolescent After delivery, patient was lost to F/U for more than a year. –Patient had discontinued all her medications –She had abandoned care at her Immunology Clinic –Had a new sexual partner Adherence to medications stressed in all visits Injectable contraception (depot medroxyprogesterone) started Consistently shows poor compliance with treatments and appointments

11. Case #1: Topics for discussion Adherence difficulties in perinatally infected adolescents Managing multi-drug resistance during pregnancy Contraceptive alternatives for HIV infected women/adolescents

12. Case #2: Pregnancy complicated by multiple comorbidities This is the case of a 42 years old G4P2012 woman with history of HIV diagnosed 2 years ago (heterosexual contact), Diabetes Mellitus type 2, chronic hypertension referred for prenatal care (PNC). Had 2 prior PNC visits with another provider, but failed to report her serostatus to him. This is a desired pregnancy, since she has a new sexual partner (who is HIV negative) who has no children. Comes to the first visit in our clinic at 12 WGA.

13. Case #2: Pregnancy complicated by multiple comorbidities Current medications: –Efavirenz/tenofovir/emtricitabine (since HIV diagnosis) discontinued medication on her own when she found out she was pregnant –Metformin 500mg twice daily –Methyldopa 250mg twice daily Baseline: –CD4:368 (29%) –HIV RNA viral load: 6376 copies/mL –HgA1c: 8.5%, glucose=230 mg/dL –BP= 170/95

14. Case #2: Pregnancy complicated by multiple comorbidities Patient was admitted for metabolic control with insulin and optimization of anti-hypertension medication. She was immediately started on Lopinavir/ ritonavir and 3TC/AZT. Pregnancy ended at 17 WGA due to a spontaneous abortion.

15. Case #2: Pregnancy complicated by multiple comorbidities Post expulsion follow up: –Still desires another pregnancy –Oriented about all the co-morbidities that might also complicate a future pregnancy Advanced maternal age Chronic hypertension Diabetes type 2 –Continued on same ARV regimen, antihypertensive medications and was switched back to an optimized dose of metformin

16. Case #2: Pregnancy complicated by multiple comorbidities Post expulsion follow up: –Continues with undetectable viral load with current regimen –Following metabolic and blood pressure control closely –Recommended folic acid supplementation –Home insemination techniques and benefits explained to the couple

17. Case #2: Topics for discussion Importance of pre-conceptional counseling Managing co-morbidities in HIV infected pregnant women New recommendations about 1 st trimester use of efavirenz Barriers to disclosure of HIV serostatus to HCP Reproductive alternatives for HIV serodiscordant couples

18. #3: Preconceptional counseling for sero-discordant couples A serodiscordant couple (male HIV+, woman HIV-) is referred to our clinic for counseling on reproductive alternatives. Woman: 30 years old G2P1A1, without history of any systemic illness. Man: 35 years old, with history of HIV diagnosed 7 years ago due to past history of IVDA. He is ARV naïve and receiving continuous care at his local Immunology Clinic No fertility problems suspected (both have children with previous partners)

19. #3: Preconceptional counseling for sero-discordant couples Baseline evaluations (woman): –Rapid HIV test: negative Baseline evaluations (male): –CD4 count: 825 (40%) –Viral load: 3823 copies/mL –Hepatitis profile: negative –Semen analysis: normal

20. #3: Preconceptional counseling for sero-discordant couples Recommendations: –Infected partner should begin an effective ARV treatment –Timed intercourse and artificial insemination techniques (ideally including sperm washing) were discussed, including risk, benefits and costs –Couple referred to a Reproduction/Infertility specialist – PreP and PEP recommended prior and after insemination –Folic acid supplementation

21. Case #3: Topics for discussion Reproductive alternatives for serodiscordant couples Treatment as prevention PreP and PEP and their role in assisted reproduction