Antiretroviral-Drug Prescribing in HIV-Positive Pregnant Women Often Not Guideline-Based

By Reuters Staff

December 23, 2019

NEW YORK (Reuters Health) - Antiretroviral drug (ARVs) prescribing practices in pregnant women living with HIV in the United States often don't align with national guidelines, a new study suggests.

"The U.S. Perinatal ARV Treatment guidelines are continually updated to reflect recent evidence-based safety and efficacy outcomes. Our study demonstrates discordance between guideline recommendations and actual prescribing practices, even when prescribing for treatment-naive pregnant women living with HIV," Dr. Kathleen Powis from Massachusetts General Hospital in Boston and colleagues write in JAMA Network Open.

Their study is thought to be the first to analyze U.S. doctors' ARV prescribing practices in pregnant women with HIV. It was conducted at 18 academic research hospitals and included 1,867 pregnancies (among 1,582 women with HIV) in the Pediatric HIV/AIDS Cohort Study Surveillance Monitoring of ART Toxicities study between 2008 and 2017.

About 42% of women started ARV medication prior to conception, 34% resumed ARV during pregnancy, and 24% initiated therapy during pregnancy.

Among all pregnancies, only 49.5% of ARV prescriptions were classified as preferred or alternative according to the guidelines. More than a quarter (26.4%) of pregnancies had ARV prescriptions with "insufficient evidence for use during pregnancy" and 7.3% involved ARVs that were not recommended for use during pregnancy.

A higher proportion of treatment-naive pregnant women initiating ARVs were prescribed preferred or alternative ARVs (70%) compared with those resuming therapy (52%) or those treated before conception (36%).

About 20% of pregnant women starting treatment were either prescribed ARVs that had insufficient evidence for use during pregnancy or were not recommended during pregnancy.

Women with a viral load greater than 1,000 copies/mL in early pregnancy were more apt to receive guideline-recommended ARV (adjusted odds ratio, 2.03) compared with women with a viral load of 400 copies/mL or less.

The researchers note that the findings are derived from academic institutions and may not generalize to all U.S. locations. Also, they did not have access to data that would have prompted clinicians to opt for nonpreferred or alternative ARV regimens, such as findings of ARV drug resistance, prior ARV side effects, existence of high third-trimester viral load or the stated preferences of the patient.

"Understanding how well prescribing practices align with guideline recommendations, as well as why deviations occur, is of great public health importance," write Dr. Powis and colleagues.

They say their findings "highlight the importance of conducting quantitative and qualitative research to better understand the extent to which individual, social, institutional, and structural determinants are associated with prescribing practices that do not align with guideline recommendations."

The study had no commercial funding and the authors have no relevant disclosures.

Dr. Powis did not respond to a request for comment by press time.

SOURCE: JAMA Network Open, online December 18, 2019.