妊娠期 HIV 感染

对于正在接受抗逆转录病毒治疗 (ART) 的 HIV 感染女性，如果该治疗有效且耐受性良好，应在孕期继续给予 ART。对于当前未接受 ART 的女性，应在孕期诊断为 HIV 后尽早开始使用适合的方案治疗，因为越早进行病毒抑制，传播风险越低。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

抗逆转录病毒治疗方案复杂；应咨询专科医师，以获得关于最佳组合用药方案的指导。本文所列出的选择是基于当前美国针对孕妇的指导。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0 其他国家请参考当地指南以选择方案。

推荐将核苷类逆转录酶抑制剂 (NRTI) 作为联合治疗方案的基础。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

来自 BMJ 快速建议制定专家组，以患者为中心的指南证据不支持使用恩曲他滨/替诺福韦作为孕妇一线治疗药物，因为这可能增加婴儿死亡和早产的风险。该小组建议采用包含拉米夫定/齐多夫定的方案，但是支持这一建议的证据薄弱。对于存在严重贫血、拉米夫定/齐多夫定药物过敏、拉米夫定或齐多夫定耐药型 HIV 或乙型肝炎合并感染的患者，恩曲他滨/替诺福韦可能可能是首选方案。有力证据表明，在与洛匹那韦/利托那韦结合使用时，拉米夫定/齐多夫定比恩曲他滨/替诺福韦更好，因为后者可能造成更高的新生儿风险。然而，值得注意的是：目前的美国指南和英国艾滋病协会不支持这些建议，最新的美国指南（2018 年 5 月更新）仍然建议将恩曲他滨/替诺福韦作为首选推荐，而拉米夫定/齐多夫定作为替代选择。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

BMJ Rapid Recommendations: antiretroviral therapy in pregnant women living with HIV

MAGICapp: recommendations, evidence summaries and consultation decision aids

最近一项使用两项美国队列研究数据的调查发现，恩曲他滨/替诺福韦+洛匹那韦/利托那韦相关的不良分娩结局（包括早产和低出生体重）的风险并未高于拉米夫定/齐多夫定+洛匹那韦/利托那韦。[88]Rough K, Seage GR 3rd, Williams PL, et al. Birth outcomes for pregnant women with HIV using tenofovir-emtricitabine. N Engl J Med. 2018 Apr 26;378(17):1593-603.http://www.ncbi.nlm.nih.gov/pubmed/29694825?tool=bestpractice.com

针对经选择患者组全部患者的治疗推荐

抗逆转录病毒治疗方案复杂；应咨询专科医师，以获得关于最佳组合用药方案的指导。本文所列出的选择是基于当前美国针对孕妇的指导。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0 其他国家请参考当地指南以选择方案。

蛋白酶抑制剂 (PI) 或整合酶链转移抑制剂 (INSTI) 是 2 种 NRTI 基础上加用的首选药物也可以使用非核苷类逆转录酶抑制剂 (NNRTI)；然而，对于初治孕妇没有首选的 NNRTI。

在妊娠早期服用多替拉韦会增加胎儿神经管缺陷的风险。[86]Food and Drug Administration. FDA Drug Safety Communication: FDA to evaluate potential risk of neural tube birth defects with HIV medicine dolutegravir (Juluca, Tivicay, Triumeq). May 2018 [internet publication].https://www.fda.gov/Drugs/DrugSafety/ucm608112.htm[87]European Medicines Agency. New study suggests risk of birth defects in babies born to women on HIV medicine dolutegravir. May 2018 [internet publication].http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news/2018/05/news_detail_002956.jsp&mid=WC0b01ac058004d5c1不应在妊娠早期（依据末次月经时间推测的孕龄<14 周）使用该药，也不应将该药用于尝试妊娠的非孕妇、计划妊娠的女性或者不能始终采取有效避孕措施的女性。然而，在妊娠早期之后，该药为首选的 INSTI。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

为了降低围产期传播风险，对于 HIV-1 RNA 水平 > 1000 拷贝/mL 或邻近分娩时病毒载量未知的女性，建议在妊娠 38 周时行择期剖宫产。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

如果病毒未受抑制的患者在计划剖宫产日期前因临产而就诊，应进行紧急剖宫产。在出现胎膜破裂的患者中，关于剖宫产对预防母婴传播的益处在产程开始或胎膜破裂后多长时间消失，尚没有足够的数据来解答该问题。

针对经选择患者组全部患者的治疗推荐

应在术前 3 小时开始静脉给予齐多夫定。

患者也应尽可能按计划在产程中和分娩前继续接受产前 ART。

对于 HIV RNA 水平≤1000 拷贝/mL 且接受 ART 的女性，不建议常规进行择期剖宫产，因为这些患者的围产期传播率较低。这些患者是否因此获益，以及是否增加感染、手术创伤、院内死亡和延长住院时间的风险，已知证据有限或没有已知证据。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0[12]Kourtis AP, Ellington S, Pazol K, et al. Complications of cesarean deliveries among HIV-infected women in the United States. AIDS. 2014 Nov 13;28(17):2609-18.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4509679/http://www.ncbi.nlm.nih.gov/pubmed/25574961?tool=bestpractice.com[89]ACOG Committee on Obstetric Practice. ACOG committee opinion: scheduled cesarean delivery and the prevention of vertical transmission of HIV infection. Number 234, May 2000 (replaces number 219, August 1999). Int J Gynaecol Obstet. 2001 Jun;73(3):279-81.http://www.ncbi.nlm.nih.gov/pubmed/11424912?tool=bestpractice.com

如果需对这些患者进行择期剖宫产或引产，则应根据产科适应征，选择标准时机进行。

不管采用哪种分娩方式，孕妇应尽可能按计划在产程中和分娩前继续接受产前 ART。

针对经选择患者组全部患者的治疗推荐

对于 HIV RNA 在 50-999 拷贝/mL 之间的女性，可考虑静脉给予齐多夫定；然而，没有足够的数据来确定这是否能为防止该群体的围产期传播提供额外的防护。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

所有围产期暴露于 HIV 的婴儿都应接受产后 ART，以降低围产期传播的风险。ART 应从尽可能接近分娩的时间开始，最好在 6 至 12 小时内。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

在妊娠期间接受 ART 且在邻近分娩时已获得持续病毒抑制的母体，婴儿应接受为期 4 周的齐多夫定治疗，其发生围产期 HIV 传播风险较低。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

围产期传播风险较高的婴儿（例如母亲未接受产前和/或产时 ART；母亲接受了产前 ART 治疗，但在临产时未达到病毒抑制；母亲在妊娠期或哺乳期发生初始或急性 HIV 感染）应接受以下两种 ART 联合治疗中的一种：齐多夫定 6 周加 3 次预防性剂量的奈韦拉平（出生后 48 小时内，首次给药后 48 小时，二次给药后 96 小时）；或齐多夫定+拉米夫定+奈韦拉平（治疗剂量）的经验性 HIV 治疗。应在出生至 6 周龄使用该经验性方案，但是如果新生儿 HIV 检测的回报结果为阴性，一些执业医师可能会停止使用拉米夫定和奈韦拉平（或拉米夫定和拉替拉韦），仅继续使用齐多夫定 6 周。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

建议向儿童 HIV 专科医生咨询。

母乳喂养有将 HIV 传播给婴儿的风险，因此不建议母乳喂养。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0 该建议可能不适用于某些国家，特别是低收入和中等收入国家，这些国家获取配方奶的成本有限、无法获得安全用水或者配方奶的数量不足。但是，建议尽可能使用人工喂养。

对于无视风险选择母乳喂养的女性，建议采取风险控制的措施（例如：母乳喂养期间婴儿接受 ART 进行预防、最初 6 个月纯母乳喂养、逐渐断奶、及时治疗母体乳腺炎和婴儿鹅口疮、婴儿监测）。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0