COMMENTARY

Herpes and HIV: New Advice from the CDC

Gray Davis, PhD; Lawrence Corey, MD

Disclosures

November 15, 2002

In This Article

Introduction

The US Centers for Disease Control and Prevention (CDC) recently issued new Sexually Transmitted Diseases Treatment Guidelines 2002,[1] which highlighted recent advances in the management of sexually transmitted diseases (STDs). Most of the substantive changes in the new guidelines relate to issues regarding the transmission of herpes simplex virus (HSV) and HIV. Two specific areas of emphasis include treatment of the pregnant HIV-infected woman to prevent transmission to the neonate, and diagnosis of new cases of HSV so that patients can be counseled about reducing transmission to future sexual partners.

Regimens to Reduce Mother-to-Child Transmission. One of the most significant changes in the management of HIV-infected individuals is the inclusion of nevirapine as a recommended option to prevent mother-to-child transmission. While the impact of nevirapine may be more limited in developed countries where most HIV-infected women receive zidovudine or combination antiretroviral therapy throughout pregnancy, its value in the developing world is of considerable magnitude. Many women in the southern hemisphere do not access prenatal healthcare until late in pregnancy, and most do not realize that they are HIV-infected. As a result, many HIV-infected women are identified too late to receive the standard zidovudine regimen.

The standard regimen recommended for HIV-infected women is zidovudine 100 mg 5 times daily (alternatives are 200 mg 3 times daily or 300 mg twice daily), initiated between week 14 and week 34 of gestation and continued throughout pregnancy. During labor the patient should receive a 2-mg/kg infusion for 1 hour and then a continuous infusion of 1 mg/kg body weight per hour until delivery. Beginning at 8-12 hours after birth, infants should be given oral zidovudine syrup (2 mg/kg every 6 hours) for the first 6 weeks of life. When administered in this regimen, zidovudine can reduce the rate of vertical HIV transmission by two thirds.[2] This regimen is relatively easy to deploy in countries where HIV-infected women are routinely treated, but in less-developed countries, shorter courses of zidovudine have also been shown to reduce transmission in both breastfeeding and nonbreastfeeding populations.[3,4,5] In the United States, standard practice is to control viremia as well as possible, and hence many HIV-infected women receive triple-drug combination therapy. There is no evidence to suggest that combination therapy with or without protease inhibitors is associated with increased rates of premature delivery or with low birth weight, low Apgar scores, or stillbirths.[6] Thus, clinicians should make their HIV management decisions based on the immunologic and virologic status of the mother.[7] Specific recommendations and unique considerations for pregnant women can be found in the Public Health Service Task Force's Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reducing Perinatal HIV-1 Transmission in the United States.[8]

A seminal study published in 1999 showed that nevirapine given once to the mother at the onset of labor (200-mg tablet) and once to the newborn within 72 hours of birth (2-mg/kg suspension) results in a 50% decrease in transmission compared with a short-course zidovudine regimen in which the mother received 300 mg zidovudine at the onset of labor, followed by one 300-mg tablet every 3 hours during labor, and the infant received zidovudine syrup (4 mg/kg) twice daily for 7 days after birth.[9] Of the 308 infants born to zidovudine-treated mothers, 74 were found to be HIV-infected or died by week 14-16, compared with only 41 of the 310 infants born to mothers treated with nevirapine. Thus, nevirapine appears to offer real benefits to HIV-infected women and their infants who either (1) are unaware that they are infected until near delivery, (2) do not have access to therapy, (3) present to the clinic too late for standard regimens, or (4) are deemed unlikely to comply with longer regimens.

Counseling. In the last few years, the benefit of counseling as one of the tools of prevention has become more widely accepted. The CDC is in the process of issuing a National Prevention Plan that emphasizes that the physician who diagnoses an infectious disease also has a responsibility to ensure that the patient receives counseling regarding high-risk behaviors and ways to prevent further transmission. Patients diagnosed with HIV should be counseled regarding high-risk behaviors that could lead to acquisition of other STDs and transmission of these infections to others. Providers who do not feel able or are unwilling to undertake prevention counseling should refer patients to other providers more equipped to provide these services.[10]

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