Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States
Antepartum Care
HIV-Infected Women Who Are Currently Receiving Antiretroviral Treatment
(Last updated:9/14/2011)
Panel’s Recommendations:
• In general, pregnant women receiving and tolerating an antiretroviral therapy (ART) regimen that is currently effective in suppressing viral replication should continue on the regimen; however, the use of efavirenz should be avoided in the first trimester (AIII).
• HIV antiretroviral (ARV) drug-resistance testing is recommended for pregnant women who have detectable viremia (e.g., >500–1,000 copies/mL) on therapy (see Failure of Viral Suppression) (AI).
• Pregnant women receiving and tolerating nevirapine-containing regimens who are virologically suppressed should continue the regimen, regardless of CD4 count (AIII). |
In general, women who have been receiving antiretroviral treatment (ART) for their HIV infection should continue that treatment during pregnancy. Discontinuation of therapy could lead to an increase in viral load with possible decline in immune status and disease progression as well as adverse consequences for the fetus, including increased risk of HIV transmission. Continuation of therapy, therefore, is recommended when pregnancy is identified in HIV-infected women receiving ART.
HIV-infected women receiving ART who present for care during the first trimester should be counseled regarding the benefits and potential risks of administration of ARVs during this period. Clinicians should review the safety and risk/benefit profiles and reproductive considerations for the ARV agents used in the current HIV therapeutic regimen. The use of efavirenz should be avoided during the first trimester of pregnancy. If a first-trimester pregnancy is confirmed in a woman who is receiving efavirenz, an alternative ARV drug should be substituted when possible (see Monitoring of the Woman and Fetus during Pregnancy).
Resistance testing should be performed in women who are on therapy but in whom viral replication is not fully suppressed. The results can be used to select a new regimen with a greater likelihood of suppressing viral replication to undetectable levels. It should be noted that resistance assays vary depending on the HIV RNA level required to detect resistance mutations. Some assays require HIV RNA levels of >500–1,000 copies/mL; other assays can be performed on patients with lower viral loads.
Pregnant women for whom nevirapine-containing regimens are achieving viral suppression and who are tolerating therapy should continue that regimen, regardless of current CD4 count. Although hepatic toxicity is a concern in women starting a nevirapine-containing regimen who have CD4 counts >250 cells/mm3, an increased risk of hepatic toxicity has not been seen in women receiving nevirapine-based therapy for whom the therapy has produced immune reconstitution.