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.

  •   Table of Contents

Download Guidelines

Antepartum Care

Monitoring of the Woman and Fetus During Pregnancy

Last Updated: December 24, 2019; Last Reviewed: December 24, 2019

Panel's Recommendations Regarding Monitoring of the Woman and Fetus during Pregnancy
Panel’s Recommendations
  • Plasma HIV RNA levels of pregnant women with HIV should be monitored at the initial antenatal visit (AI), 2 to 4 weeks after initiating (or changing) an antiretroviral (ARV) drug regimen (BI), monthly until RNA levels are undetectable (BIII), and then at least every 3 months during pregnancy (BIII). HIV RNA levels also should be assessed at approximately 34 to 36 weeks’ gestation to inform decisions about mode of delivery (see Transmission and Mode of Delivery) and to inform decisions about optimal management for the newborn (see Antiretroviral Management of Newborns with Perinatal HIV Exposure or HIV Infection) (AIII).
  • CD4 T lymphocyte (CD4) cell count should be monitored at the initial antenatal visit (AI). Patients who have been on antiretroviral therapy (ART) for ≥2 years and who have had consistent viral suppression and CD4 counts that are consistently >300 cells/mm3 do not need to have their CD4 counts monitored after the initial antenatal visit during this pregnancy, per the Adult and Adolescent Antiretroviral Guidelines (CIII).Women who have been on ART for <2 years, women with CD4 counts <300 cells/mm3, and women with inconsistent adherence and/or detectable viral loads should have CD4 counts monitored every 3 to 6 months during pregnancy (CIII).
  • HIV drug-resistance testing should be performed in women whose HIV RNA levels are above the threshold for standard resistance testing (i.e., >500 copies/mL to 1,000 copies/mL) before:
    • Initiating ART in ARV-naive pregnant women who have not been previously tested for ARV resistance (AII);
    • Initiating ART in ARV-experienced pregnant women (AIII); or
    • Modifying ART regimens for women who become pregnant while receiving ARV drugs or women who have suboptimal virologic response to ARV drugs that were started during pregnancy (AII).
  • ART should be initiated in pregnant women prior to receiving results of ARV-resistance tests. ART should be modified, if necessary, based on the results of the resistance assay (BIII).
  • Laboratory testing for monitoring of complications of ARV drugs during pregnancy should be based on what is known about the adverse effects of the drugs a woman is receiving (AIII).
  • Women who are taking ART during pregnancy should undergo standard glucose screening at 24 to 28 weeks’ gestation (AIII). Some experts suggest glucose screening early in pregnancy for women who are receiving protease inhibitor (PI)-based regimens that were initiated before pregnancy, in accordance with recommendations for women who are at risk for glucose intolerance (BIII). For more information on PIs, see Combination Antiretroviral Drug Regimens and Maternal and Neonatal Outcomes.
  • Amniocentesis, if clinically indicated, should be performed on women with HIV only after initiation of an effective ART regimen and, ideally, when HIV RNA levels are undetectable (BIII). If a woman with detectable HIV RNA levels requires amniocentesis, consultation with an expert in the management of HIV in pregnancy should be considered (BIII).
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

Download Guidelines