Despite the well-documented cutaneous, mucosal and hepatotoxicity with nevirapine at higher CD4 T-lymphocyte counts, nevirapine remains an option for women with a CD4 T-lymphocyte count <250 cells/μL. Nevirapine is well tolerated in pregnancy, with several studies suggesting this to be the case even above the stated CD4 cell count cut-off [[23][[24][#[25]][26]]71]; has favourable pharmacokinetics in pregnancy [[27][[28][#[29]]Ent]74] and has been shown to reduce the risk of MTCT even when given as a single dose in labour, alone or supplementing zidovudine monotherapy or dual therapy [[30][[31][#[32]]Ent]77].

selleckchem Despite some concerns regarding diabetes, PTD (see below) and pharmacokinetics during the third trimester (discussed separately) several ritonavir-boosted PIs have been shown to be effective as the third agent in HAART in pregnancy (lopinavir [[21],[33]], atazanavir [34], saquinavir [[35],[36]]). In the European Collaborative Study, time to undetectable VL was longer in women initiating PI-based HAART; however, in this study 80% of these women were taking

nelfinavir [37]. In a more recent study, treatment with a boosted PI resulted in more rapid viral suppression (to <50 HIV RNA copies/mL) than nevirapine, except in the highest VL quartile [38]. In another multicentre study nevirapine-based HAART reduced VL more rapidly during the first 2 weeks of therapy than PI-based HAART with nelfinavir, atazanavir or lopinavir,

but time to undetectable was influenced by baseline VL rather buy BMS-354825 than choice of HAART [39]. The role of newer PIs (e.g. darunavir), integrase inhibitors and entry inhibitors in the treatment-naïve pregnant patient has yet to be determined; therefore other, more established, options should preferentially be initiated. The data on the association of HAART and PTD are conflicting. Some studies implicate boosted PIs, others do not. The data are summarized below. The association between HAART and PTD was first reported by the Swiss Cohort in 1998 [[15],[40]], and subsequently by a number of other European studies, including three analyses from the ECS [[15],[41][[42][#[43]]Ent]88]. clonidine Analysis of the NSHPC UK and Ireland data in 2007 found there to be a 1.5-fold increased risk of PTD when comparing women on HAART with those on mono- or dual therapy [44]. Several large studies from the USA have not found an association between HAART and PTD [[45],[46]]. In two further studies, one multicentre study from the Pediatric Spectrum of HIV Disease cohort and one single-centre study, an association between PTD and HAART was found only if HAART included a PI [[47],[48]]. Two of the earlier ECS reports had also noted that the increased risk of PTD in patients on HAART was particularly marked in patients on PI-containing HAART [[41],[43]].