Improving the Management of HIV Disease Vol. 6, no. 5 [World Conference on AIDS (12th: 1998: Geneva)]

QUESTIONS TO THE ANTIRETROVIRAL THERAPY AND RESISTANCE TESTING PANELS

maximal prophylactic benefit currently
possible.
DR SAAG: "Maximally suppressive" is a
term used in the setting of an established
infection, with high-level, ongoing replication throughout the body. In that setting, maximally suppressive regimens are
required to yield the best opportunity to
limit clinical progression and delay or
prevent the development of resistance. In
the case of postexposure, replication (if it
is to occur) is restricted initially to a single location in the body at relatively low
levels. The objective is to prevent uninfected cells from becoming infected.
Cumulative data from animal model
experiments, basic science, natural history, and treatment intervention studies
suggest that the "virologic hurdle" to
establish infection in the setting of an

acute occupational exposure is quite
high. As an example, meaningful protection from infection can be achieved with
the use of relatively "weak" treatment
regimens (eg, zidovudine monotherapy).
Therefore, the use of dual nRTI therapy,
or other nonmaximally suppressive regimens, may be appropriate in certain settings (eg, low-inoculum exposures and
exposures from antiretroviral-naive
source patients).
42. What should we do in a
general hospital when
an accident occurs with
a health care worker and
we do not know about
the HIV serostatus of the

DR YENI: In the case of high-risk occupational exposure and a source patient
with unknown HIV serostatus but a risk
for infection or with clinical or biological
symptoms suggestive of HIV disease,
immediate maximally suppressive prophylaxis of HIV infection should be given
to the health care worker. If there is no
argument for HIV infection in the source
patient, prophylaxis may be considered
in the case of massive exposure, and
must be discussed on an individual basis.
The results of a rapid HIV test in the
source patient will dictate the health care
worker follow-up. The risks of transmission of other infectious agents (particularly hepatitis B and hepatitis C viruses)
should also be considered.

I V Bl P IATAL TANMISIO 9PEVETO

regard. If the virus is well-suppressed in
the mother using a regimen that appears
safe in pregnancy, I would continue that
regimen. One might consider replacing
stavudine with zidovudine in the newborn during the first few weeks of life.
44. What is the recommendation for prevention of
perinatal transmission in
pregnant women whose
virus has the 215 reverse
transcriptase mutation
or who is intolerant of
zidovudine?
DR SCHOOLEY: At this point there is
little evidence that there is anything
"magic" about zidovudine in the prevention of perinatal transmission. As the
data have emerged, it appears that the
key points are employing a drug regimen

that has an impact on plasma HIV RNA
levels in the mother and having 1 or more
antiretrovirals that are active against the
potentially transmittable virus in the
neonate. In developing the mother's regimen, it is further important that care be
taken not to limit her own therapeutic
options downstream by placing her on a
regimen that allows viral replication in
the presence of selective pressure. Thus,
in a case such as this, I would be quite
comfortable crafting a regimen in the
mother that is likely to drive plasma HIV1 RNA levels below detection and choosing a nonzidovudine-containing regimen
for the immediate perinatal period for
the child. This is a rapidly changing area
with respect to available formulations
and it is best approached by working
closely with a pediatrician who is facile
with the use of antiretroviral drugs in the
perinatal period.

DR HIRSCH: I would not use zidovudine
and stavudine concurrently in any patient
because of the proven antagonism
between these drugs. Although zidovudine is the only drug that is well-established in the reduction of maternal-newborn HIV-1 transmission, I doubt that
there is any magic to zidovudine in this

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VOLUME 6, OCTOBER 1998