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Interactions between highly active antiretroviral therapy and over-the-counter agents: a cautionary note
  1. Jerome Federspiel12,
  2. Melanie J Bukhari2,
  3. Matthew M Hamill34
  1. 1 Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
  2. 2 Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
  3. 3 Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
  4. 4 Sexual Health, Berkshire Healthcare NHS Foundation Trust, Slough, UK
  1. Correspondence to Dr Jerome Federspiel; jfederspiel{at}

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In conjunction with BMJ Case Reports, DTB will feature occasional drug-related cases that are likely to be of interest to readers. These will include cases that involve recently marketed drugs for which there is limited knowledge of adverse effects and cases that highlight unusual reactions to drugs that have been marketed for several years.


Highly active antiretroviral therapy (HAART) has dramatically lowered rates of mother-to-child HIV transmission among patients with access to treatment. Barriers to complete viral suppression increase rates of transmission, even with only low levels of viral replication. Here, we present the case of a pregnant patient who developed a detectable viral load in pregnancy, thought to be related to calcium supplement consumption or emesis while using a dolutegravir-based HAART regimen. Ultimately, with adjustments, the patient again reached an undetectable viral load and had an uncomplicated perinatal and neonatal outcome. We discuss new data on the use of dolutegravir in pregnancy and precautions for maintaining viral suppression while on antiretroviral therapy in pregnancy.


The advent of, and access to, highly active antiretroviral therapy (HAART) has revolutionised HIV care and restored near-normal life expectancy. The use of optimal active antiretroviral therapy (ART) can reduce mother-to-child transmission (MTCT) rate from 15%–30% to less than 0.5%.1 2 Optimal therapy requires initiation of ART prior to pregnancy, adherence throughout pregnancy, abstaining from breastfeeding and an undetectable viral load near time of delivery; even a modest elevation in viral load (50–399 copies per mL (cpm), compared with <50) is associated with a 22-fold increase in the rate of transmission.2 Here, we describe a patient who developed an elevated HIV viral load in pregnancy, thought …

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  • Contributors Drs MJB and MMH originated the idea for the manuscript. Dr JF drafted the manuscript. Drs MJB and MMH reviewed the draft manuscript for important intellectual contributions.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.