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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Antepartum Care

Monitoring of the Woman and Fetus During Pregnancy

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

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) antiretroviral (ARV) drug regimens (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 treatment for the newborn (see Antiretroviral Management of Newborns) (AIII).
  • CD4 T lymphocyte (CD4) cell count should be monitored at the initial antenatal visit (AI). For patients who have been on antiretroviral therapy (ART) for ≥2 years and who have had consistent viral suppression and CD4 cell counts that are consistently >300 cells/mm3, CD4 cell count should be monitored at the initial antenatal visit; CD4 cell counts do not have to be repeated for these patients during this pregnancy, per the Adult and Adolescent Antiretroviral Guidelines (CIII). Women who have been on ART for <2 years, women with CD4 cell counts <300 cells/mm3, and women with inconsistent adherence and/or detectable viral loads should have CD4 cell 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 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 entering pregnancy while receiving ARV drugs or women who have suboptimal virologic response to ARV drugs 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).
  • Monitoring for 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 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 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.
  • An ultrasound, performed as soon as possible, is recommended to confirm gestational age and, if scheduled cesarean delivery is necessary, to guide the timing of the procedure (see Transmission and Mode of Delivery) (AII).
  • 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). In women with detectable HIV RNA levels in whom amniocentesis is deemed necessary, 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

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