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 Are Currently Receiving Antiretroviral Therapy

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

Panel's Recommendations for Pregnant Women Living with HIV Who Are Currently Receiving Antiretroviral Therapy
Panel's Recommendations
  • Women living with HIV who are receiving antiretroviral therapy (ART) who present for pregnancy care should continue their ART during pregnancy, provided that the regimen is tolerated, safe, and effective in suppressing viral replication (i.e., HIV viral load less than lower limits of detection of the assay) (AII).
  • Drugs that are not recommended for use because of toxicity (e.g., stavudine, didanosine) should be stopped and switched to another antiretroviral (ARV) drug in women who present during pregnancy on these medications (AIII), see Table 7.
  • Women who are receiving a dolutegravir-containing regimen and who present to care in the first trimester should receive counseling about the possible increased risk of neural tube defects (NTDs) and the risks and benefits of continuing dolutegravir or switching to another ARV regimen (AIII)a,b (see Interim Recommendations about the Use of Dolutegravir in Pregnancy in Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Table 7). The following considerations should be addressed:
    • NTDs may have already occurred;
    • Depending on the current gestational age, the additional risk of NTDs developing during the remaining time in the first trimester may be small;
    • There is a background risk of NTDs regardless of antiretroviral treatment (ART) regimen or HIV status (this risk ranges from 0.05% to 0.1% for women without HIV and for women with HIV who are receiving ART that does not include dolutegravir); and
    • Changes in ART, even in the first trimester, are often associated with viral rebound that may increase the risk of perinatal HIV transmission.
  • When women present to care on a atazanavir/cobicistat-, darunavir/cobicistat-, or elvitegravir/cobicistat-containing regimen, providers should consider switching to a regimen that is recommended for use in pregnant women due to concerns about pharmacokinetic changes and risk of virologic failure in the second and third trimesters of pregnancy (see Table 6 and Table 7) (BIII). If one of these regimens is continued, absorption should be optimized, and viral load should be monitored frequently (i.e., every 1–2 months).
  • If an ARV regimen is altered during pregnancy, drugs in the new regimen should be ARVs recommended for use in pregnancy (see Table 6 and Table 7) (BIII) and more frequent virologic monitoring is warranted (CIII).
  • HIV ARV drug-resistance testing should be performed to assist in the selection of active drugs when changing ARV regimens in pregnant women on therapy with virologic failure and HIV RNA levels >500 to 1,000 copies/mL (AII). In individuals with HIV RNA levels >500 but <1,000 copies/mL, testing may be unsuccessful but should still be considered (BII) (see Lack of Viral Suppression).
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
aThe first trimester is less than 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 ARV Guidelines, is consistent with the first trimester.
bAlthough dolutegravir is not Food and Drug Administration-approved for use in the first trimester, some Perinatal Panel members would consider using dolutegravir at 12 weeks gestational age by last menstrual period on an individual patient basis.

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