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

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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Special Populations

Acute HIV Infection

Last Updated: June 12, 2019; Last Reviewed: December 7, 2018

Panel's Recommendations Regarding Acute HIV Infection During Pregnancy
Panel's Recommendations
  • When acute HIV infection is suspected in pregnancy or during breastfeeding, a plasma HIV RNA test should be obtained in conjunction with a routine HIV antibody screening test or an antigen/antibody immunoassay test. See Acute and Recent (Early) HIV Infection in the Adult and Adolescent Antiretroviral Guidelines and the Centers for Disease Control and Prevention (CDC) HIV testing algorithm for more information (AII).
  • Repeat HIV testing in the third trimester is recommended for pregnant women with initial negative HIV antibody tests who are known to be at risk of acquiring HIV, who are receiving care in facilities that have an HIV incidence of ≥1 case per 1,000 pregnant women per year, or who reside in jurisdictions with elevated HIV incidence (see Prenatal and Perinatal Human Immunodeficiency Virus Testing, Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings and the CDC HIV testing algorithm) (AII).
  • All pregnant women with acute or recent HIV infection should start antiretroviral therapy (ART) as soon as possible to prevent perinatal transmission, with the goal of suppressing plasma HIV RNA to below detectable levels (AI).
  • In women with acute HIV infection, baseline genotypic resistance testing should be performed simultaneously with initiation of ART (AII), and the regimen should be adjusted, if necessary, to optimize virologic response (BIII).
  • In pregnant and breastfeeding women with acute HIV infection, a dolutegravir-based regimen with tenofovir disoproxil fumarate plus emtricitabine should be initiated (after the first trimestera in pregnant women), and breastfeeding should be discontinued (see Table 6) (AII). Dolutegravir should not be initiated in women during the first trimestera,b of pregnancy due to concerns about a possible increased risk of neural tube defects (NTDs) (AIII).
  • Alternatively, a ritonavir-boosted, protease inhibitor-based regimen can be initiated (AIII). See Interim Panel Recommendations Regarding the Use of Dolutegravir in Pregnancy in Recommendations for the Use of Antiretroviral Drugs during Pregnancy.
  • When dolutegravir use is continued after delivery, clinicians should recommend the use of postpartum contraception and discuss contraceptive options with patients (AIII).
  • Infants born to women who received a diagnosis of acute HIV infection during pregnancy or breastfeeding are at high risk of perinatal HIV transmission and should receive an ARV regimen that is appropriate for this elevated risk (see Table 8 in Antiretroviral Management of Newborns with Perinatal HIV Exposure or Perinatal HIV) (AII). Consultation with a pediatric HIV specialist regarding appropriate infant management is strongly recommended (see Antiretroviral Management of Newborns with Perinatal HIV Exposure or Perinatal HIV).
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 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.
b Although 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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