Seidman Dominika L, Weber Shannon, Cohan Deborah
Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA.
Department of Family & Community Medicine, University of California San Francisco, San Francisco, CA, USA.
J Int AIDS Soc. 2017 Mar 8;20(Suppl 1):21295. doi: 10.7448/IAS.20.2.21295.
HIV prevention during pregnancy and lactation is critical for both maternal and child health. Pregnancy provides a critical opportunity for clinicians to elicit women's vulnerabilities to HIV and offer HIV testing, treatment and referral and/or comprehensive HIV prevention options for the current pregnancy, the postpartum period and safer conception options for future pregnancies. In this commentary, we review the safety of oral pre-exposure prophylaxis with tenofovir/emtricitabine in pregnant and lactating women and suggest opportunities to identify pregnant and postpartum women at substantial risk of HIV. We then describe a clinical approach to caring for women who both choose and decline pre-exposure prophylaxis during pregnancy and postpartum, highlighting areas for future research.
Evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine is safe in pregnancy and lactation. Identifying women vulnerable to HIV and eligible for pre-exposure prophylaxis is challenging in light of the myriad of individual, community, and structural forces impacting HIV acquisition. Validated risk calculators exist for specific populations but have not been used to screen and offer HIV prevention methods. Partner testing and engagement of men living with HIV are additional means of reaching at-risk women. However, women's vulnerabilities to HIV change over time. Combining screening for HIV vulnerability with HIV and/or STI testing at standard intervals during pregnancy is a practical way to prompt providers to incorporate HIV screening and prevention counselling. We suggest using shared decision-making to offer women pre-exposure prophylaxis as one of multiple HIV prevention strategies during pregnancy and postpartum, facilitating open conversations about HIV vulnerabilities, preferences about HIV prevention strategies, and choosing a method that best meets the needs of each woman.
Growing evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine during pregnancy and lactation is safe and effective. Shared decision-making provides one approach to identify at-risk women and offers pre-exposure prophylaxis but requires implementation research in diverse clinical settings. Including pregnant and breastfeeding women in future HIV prevention research is critical for the creation of evidence-driven public health policies and clinical guidelines.
孕期及哺乳期的艾滋病病毒（HIV）预防对母婴健康至关重要。孕期为临床医生提供了一个关键契机，可借此了解女性感染HIV的易感性，并提供HIV检测、治疗及转诊服务，和/或针对本次孕期、产后阶段的全面HIV预防方案，以及为未来妊娠提供更安全的受孕选择。在本评论中，我们回顾了替诺福韦/恩曲他滨口服暴露前预防在孕妇及哺乳期妇女中的安全性，并提出识别有高HIV感染风险的孕妇及产后妇女的机会。然后，我们描述了一种针对孕期及产后选择和拒绝暴露前预防的女性的临床护理方法，突出了未来研究的方向。
有证据表明，替诺福韦/恩曲他滨暴露前预防在孕期及哺乳期是安全的。鉴于影响HIV感染的众多个人、社区和结构因素，识别易感染HIV且适合暴露前预防的女性具有挑战性。针对特定人群有经过验证的风险计算器，但尚未用于筛查和提供HIV预防方法。性伴检测以及与感染HIV的男性接触是接触高危女性的额外方式。然而，女性感染HIV的易感性会随时间变化。在孕期定期进行HIV易感性筛查以及HIV和/或性传播感染检测，是促使医疗服务提供者纳入HIV筛查和预防咨询的实用方法。我们建议采用共同决策的方式，将暴露前预防作为孕期及产后多种HIV预防策略之一提供给女性，促进就HIV易感性、HIV预防策略偏好以及选择最符合每位女性需求的方法展开坦诚对话。
越来越多的证据表明，孕期及哺乳期使用替诺福韦/恩曲他滨进行暴露前预防是安全有效的。共同决策为识别高危女性并提供暴露前预防提供了一种方法，但需要在不同临床环境中开展实施研究。将孕妇和哺乳期妇女纳入未来的HIV预防研究对于制定基于证据的公共卫生政策和临床指南至关重要。
