Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States

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The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

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Recommendations for Use of Antiretroviral Drugs During Pregnancy

Pregnant Women Living with HIV Who Have Never Received Antiretroviral Drugs (Antiretroviral Naive)

Last Updated: December 7, 2018; Last Reviewed: December 7, 2018

Panel's Recommendations for Pregnant Women Living with HIV Who Have Never Received Antiretroviral Drugs
Panel's Recommendations
  • Antiretroviral therapy (ART) is recommended for all pregnant women living with HIV to reduce the risk of perinatal transmission of HIV and to optimize the health of the mother (AI). Initiation of ART as soon as HIV is diagnosed during pregnancy is recommended, based on data demonstrating that earlier virologic suppression is associated with a lower risk of transmission (AII).
  • HIV drug-resistance studies should guide the selection of ART regimens in women whose HIV RNA levels are above the threshold for resistance testing (i.e., >500 to 1000 copies/mL), unless drug-resistance studies have already been performed (see Antiretroviral Drug Resistance and Resistance Testing in Pregnancy) (AII). When ART is initiated before the results of the drug-resistance assays are available, the ARV regimen should be modified, if necessary, based on the resistance assay results (BIII).
  • The choice of regimen should be informed by current adult treatment guidelines; what is known about the use of specific drugs in pregnancy; the risk of teratogenicity (see Table 6 and Table 10); and maternal factors such as nausea, vomiting, and comorbid conditions. ART regimens that are preferred for the treatment of pregnant women living with HIV who are ARV-naive include: a dual nucleoside reverse transcriptase inhibitor combination (abacavir/lamivudine or tenofovir disoproxil fumarate/emtricitabine or lamivudine) and either a ritonavir-boosted protease inhibitor (atazanavir/ritonavir or darunavir/ritonavir) or an integrase strand transfer inhibitor (dolutegravir [after the first trimester]a or raltegravir) (see Table 6 and Interim Panel Recommendations Regarding the Use of Dolutegravir in Pregnancy in Recommendations for the Use of Antiretroviral Drugs During Pregnancy) (AIII). 
  • Dolutegravir is not recommended for use in pregnant women during the first trimestera,b and in nonpregnant women who are trying to conceive, due to concerns about a possible increased risk of neural tube defects (AIII).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion
a The first trimester is <14 weeks (up to 13 6/7 weeks) gestational age by last menstrual period. The term “12 weeks post-conception,” used in the Adult and Adolescent Antiretroviral Guidelines, is consistent with the first trimester).
b Although dolutegravir is not Food and Drug Administration-approved for use in the first trimester, some Panel members would consider using dolutegravir at 12 weeks gestational age by last menstrual period on an individual patient basis.

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