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

Antiretroviral Drug Resistance and Resistance Testing in Pregnancy

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

Panel's Recommendations Regarding Antiretroviral Drug Resistance and Resistance Testing in Pregnancy
Panel's Recommendations
  • HIV drug-resistance genotype studies should be performed in women living with HIV whose HIV RNA levels are above the threshold for resistance testing (i.e., >500 to 1,000 copies/mL) before:
    • Initiating antiretroviral therapy (ART) in antiretroviral (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 are entering pregnancy while receiving ARV drugs or 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 studies; ART should be modified, if necessary, based on the results of the resistance assay (BIII).
  • If an integrase strand transfer inhibitor (INSTI) is being considered for an ART-naive patient and INSTI resistance is a concern, providers should supplement standard resistance testing with a specific INSTI genotypic resistance assay (BIII). INSTI resistance may be a concern because:
    • A patient received prior treatment that included an INSTI,
    • A patient has a history with a sexual partner on INSTI therapy, or
    • A patient is starting or changing ART regimen late in pregnancy, in which case an INSTI might be selected because of its ability to rapidly decrease viral load.
  • Documented zidovudine resistance does not affect the indications for use of intrapartum zidovudine (BIII).
  • Choice of ARV regimen for an infant born to a woman with known or suspected drug resistance should be determined in consultation with a pediatric HIV specialist, preferably before delivery (see Antiretroviral Management of Newborns with Perinatal HIV Exposure or Perinatal HIV) (AIII).
  • Pregnant women living with HIV should be given ART to maximally suppress viral replication, which is the most effective strategy for preventing development of resistance and minimizing risk of perinatal transmission (AII).
  • All pregnant and postpartum women should be counseled about the importance of adherence to prescribed ARV medications to reduce the potential for development of resistance (AII).
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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