COMMENTARY

Human Immunodeficiency Virus Type 2

Guideline and Commentary

John G. Bartlett, MD

Disclosures

June 06, 2012

In This Article

HIV-2 and Pregnancy

Recommendation: Clinicians caring for pregnant patients with suspected or diagnosed HIV-2 should consult with a provider with experience in HIV-2 testing and management, including perinatal ART for HIV-2-infected pregnant women and postnatal ART for HIV-2-exposed infants. (AIII)

HIV-2 Testing for Women During Pregnancy and Delivery

Recommendation: Clinicians should use HIV-1/HIV-2 type-differentiating immunoassays and nucleic acid testing protocols when screening for HIV in pregnant women who meet the criteria outlined in Table 1. (AIII)

HIV testing during pregnancy should be performed using a screening test that detects HIV-1 and HIV-2 antibodies. For pregnant women who meet the criteria outlined in Table 1, HIV-1/HIV-2 type-differentiating immunoassays and nucleic acid testing protocols should be used. In New York State, if a woman presents for delivery without documentation of a negative HIV test during the current pregnancy and is not known to have HIV infection, the mother must receive expedited HIV testing with her consent; if she declines, the newborn must receive testing with or without maternal consent. For more information regarding HIV testing during pregnancy, refer to HIV Testing During Pregnancy and at Delivery.

HIV-2 Treatment and Prophylaxis During Pregnancy

Recommendation: Zidovudine plus lamivudine with lopinavir/ritonavir is the currently recommended regimen for HIV-2-infected pregnant women. (AIII) For HIV-2-infected women who decline ART or who are unable to adhere to an ART regimen during pregnancy, single-drug prophylaxis with zidovudine during pregnancy and intrapartum should be used as an alternative for preventing HIV-2 mother-to-child transmission. (BIII)

The risk of mother-to-child transmission (MTCT) of HIV-2 is significantly lower than that of HIV-1.[39,40] However, high HIV-2 viral load levels may be associated with increased risk for MTCT. In one study, MTCT of HIV-2 occurred more frequently in the setting of high maternal viral load levels (>10,000 copies/mL).[41] Advanced HIV-2 disease has also been associated with HIV-2 MTCT,[42] as has early HIV-2 infection during pregnancy.[39] These findings suggest that ART for HIV-2, regardless of the clinical or immunological status of the patient, may be indicated during pregnancy, similar to the practice for HIV-1.

Based on available data on safety in pregnancy, zidovudine/lamivudine plus lopinavir/ritonavir is the preferred regimen.[40] Tenofovir plus emtricitabine with lopinavir/ritonavir can be considered as an alternative.[43,44] For additional information regarding prescribing ART for pregnant women, refer to Antiretroviral Therapy and Use of ART in HIV-Infected Pregnant Women.

For HIV-2-infected pregnant women who decline ART for their own health, but for whom prevention of MTCT is necessary, two NRTIs plus lopinavir/ritonavir is the recommended regimen.[40] Single-drug prophylaxis with zidovudine alone during pregnancy and intrapartum can be considered as an alternative for preventing HIV-2 MTCT.[40] All ART prescribing considerations, including postnatal ART management, for HIV-2-infected pregnant women should be in consultation with a provider who has experience in the management of ART in these patients.

Testing and Prophylaxis for HIV-2-Exposed Infants

Recommendations:

  • All infants born to mothers infected with HIV-2 should receive the standard 6-week zidovudine prophylactic regimen.[40,44] (AIII)

  • Clinicians should advise HIV-2-infected women about the risk of postpartum MTCT via breast milk. Breastfeeding is contraindicated for both HIV-1- and HIV-2-infected mothers, even when receiving ART. (AI)

  • NYSDOH strongly recommends that all New York State birth facilities use the pediatric HIV testing services at the Wadsworth Center (see Diagnosis of Pediatric HIV Infection in HIV-Exposed Infants for the recommended diagnostic testing schedule).

In New York State, the Newborn Screening Program screens newborns for HIV-1 antibodies using a dried blood spot sample collected from a heel-stick. HIV-2 antibodies, if present in the blood spot, may be detected by the EIA test due to cross-reactivity. This may present as HIV-1 test results that are inconsistent, inconclusive, or negative despite clinical evidence that is consistent with immunodeficiency. All infants who are born to HIV-infected mothers or who test positive for HIV antibodies on the newborn screening test are considered to be exposed to HIV and must have additional testing to definitively diagnose or exclude HIV infection. A blood specimen should be obtained from all exposed infants and should be sent to the Pediatric HIV Testing Service at the NYSDOH Wadsworth Center for diagnostic testing. The Pediatric HIV Testing Service performs an immunoassay that differentiates between HIV-1 and HIV-2 antibodies on all infant samples. If the sample is reactive for HIV-2 antibodies, then a qualitative HIV-2 RNA test is performed to definitively diagnose or exclude HIV-2 infection. See Diagnosis of Pediatric HIV Infection in HIV-Exposed Infants for the recommended diagnostic testing schedule.

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