Pregnancy with TB and AIDS- An Issue of Concern

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Dr Diwakar Tejaswi

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Aug 27, 2008, 9:10:55 PM8/27/08
to Aidsbeyond border

Dear Forum Members,

I wish to share my concern with the forum. It is related to pregnancy with TB and AIDS.

As per the existing guidelines we cannot use HAART with Nevirapine and Anti TB drugs with Rifampicin as they interact and results in lower levels of both the drugs.

It can be used with another anti TB drug Rifabutine but it is too costly ( around Rs 40 - Rs 50 per tab day therapy). Also on the other hand Nevirapine should not be used in women with CD4 more than 250 due to fear of hepatotoxicity as per the recommendations. Under the condition it is adviced to use Efavirenz after 2nd or in 3rd trimester, otherwise we have to use safe PIs (which is very costly)

I have seen teratogenicity in a child where Efavirenz was used in 2nd and 3rd trimester at some center.

Under the condition it might be advisable to use Abacavir in place of either Nevirapine or Efavirenz or other PIs during pregnancy or otherwise we can continue using Rifampicine and Nevirapine with a bit enhanced dosage and with a very close followup irrespective of CD4 base line during pregnancy.

Nevirapine is the most widely available nonteratogenic third agent (apart from 2 NRTIs) in resource poor settings and in many clinics in developing countries, including Haiti ZL Clinics (Zanmi Lasante clinics), is used in the first line regimen for ART and PPTCT regardless of maternal CD4 count with close hepatic monitoring.

A large Brazilian study has demonstrated minimal toxicity from this approach.
 
Dr Diwakar Tejaswi MBBS(Gold Medalist); MCH; FCCP; Ph.D.
Consultant Physician and Medical Director
Regional AIDS Training Centre and Network in India(RATNEI)
International Health Organization
Res: MIG 161, Lohianagar,Kankarba gh, Patna 800020, India
India Office: B-33, Indirapuri Colony, Patna 800014, India
Phone: +91-612-3299323 (O); 2586788 (Telefax O); Clinic- Telefax: +91-612-2206964; Mobile: +91-9835078298; Res: +91-612-2351771
www.ihousa.org
e-mail: <diwakartejaswi@ yahoo..com>
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prayashealth

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Aug 30, 2008, 6:44:49 AM8/30/08
to AIDS-Beyo...@googlegroups.com
Dr Diwakar Tejaswi brings out an important issue here. The guidelines are addrssing this issue. However I failed to understand why ther should be teratogenecity in 2nd or 3rd trimester (it would occur only during the phase of organogenesis, isn't it? Can anybody explain?
PRAYAS

Ajith

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Aug 30, 2008, 11:37:21 PM8/30/08
to AIDS-Beyo...@googlegroups.com

Dear Dr Tejaswi,
 
PPTCT is a concern to all who care pregnant mothers especially in devoloping resourse poor countries.I congradulate Dr Tejaswi for bringing this issue in various fora including AIDS Beyond borders.
India officially still follow single dose nevirapine regimen as the national regimen . But better regimens are available and the regimen can be and should be selecetd according to the feasibility and affordability of implimentation.Even though we are confident in rolling out 3 drug ART program we are yet to be combitant and confident enough to roll out multi drug PPTCT program probably due to logistical reasons.
 
Regarding nevirapine  in pregnancy: even though it is not contra indicated in pregnancy it carries 2-10 times higher risk of side effects in pregnancy and generally jaundice is the last thing a gynecologist want for a pregnant lady even if she is HIV negative. It is possible to  try nevirapine with close monitoring of hepatic enzymes in centers with very high commitment and dedicated PPTCT system in place . ( probably very few in the country !).But in the current scenario of consumer activism  and dissemination against HIV I doubt how many gynecologist will take that risk especially in a state like Kerala. ( remember the national guideline does not support it; WHO and other guide lines warns against it).Thus there is no defence between pregnant ladies on Anti TB drugs  and not on Anti TB drugs.
Regarding Abacavir --It is equally expensive as rifabutin--Rs 2000 or more and 3 NNRTI combination is less effective than 2 NRTI+ PI or 2 NRTI + NNRTI is suppressing viral load.Also Abacavir is a category C drug and should be used only when there is no other option.( interestingly zidovidne and lamivudine also are category C and nevirapine category B and efavirenz category D).
 
Probably other candidates as a  third drugs  for near future for those who can afford  are tenofovir( around Rs 1000/ month) and boosted ataznavir (both category B)(around Rs 2500/month) which can become  relatively less costly.
 
I strongly believe it is important  we come out with a better, more effective and practical PPTCT regimens --smiler to that of WHO guidelines --which can give the best feasible PPTCT regimen which Will give the best protection to child from infection and mother from drug resistance. 
 
with best regards
 
Dr Ajithkumar
Trichur

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