Pregnancy poses unique challenges for HIV treatment, as physiological changes can dramatically alter drug metabolism and clearance, potentially compromising viral suppression at critical moments for both mother and child. This detailed case study demonstrates how personalized dosing strategies might address these pharmacokinetic hurdles in complex clinical scenarios.
A young woman with perinatally acquired HIV and class III obesity received monthly high-dose cabotegravir/rilpivirine injections (600mg/900mg) throughout pregnancy, with continuous therapeutic monitoring tracking drug concentrations. Despite the expected 50% decrease in cabotegravir and 27% reduction in rilpivirine levels between first and third trimesters, both medications remained well above therapeutic thresholds. Viral suppression below 20 copies/mL was maintained throughout pregnancy, with no adverse outcomes for mother or infant.
This approach represents a significant departure from standard HIV care during pregnancy, which typically relies on oral medications with more frequent dosing adjustments. The successful outcome challenges conventional thinking about injectable HIV therapies in pregnancy, where concerns about unpredictable drug levels have historically limited their use. However, this remains a single case study in a patient with multiple comorbidities, including obesity that may have influenced drug distribution patterns. The intensive monitoring required—with plasma drug level assessments throughout pregnancy—would be resource-intensive to implement broadly. While promising for treatment adherence and convenience, larger controlled studies would be essential before this personalized high-dose approach could be recommended as standard care for pregnant individuals with HIV.