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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Intrapartum Care

Intrapartum Antiretroviral Therapy/Prophylaxis

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

Panel's Recommendations for Intrapartum Antiretroviral Therapy/Prophylaxis
Panel's Recommendations
  • Women should continue taking their antepartum combination antiretroviral therapy (ART) on schedule as much as possible during labor and before scheduled cesarean delivery (AIII).
  • Intravenous (IV) zidovudine:
    • Should be administered to women living with HIV if HIV RNA is known or suspected to be >1,000 copies/mL (or if HIV RNA is unknown) near delivery (AI).
    • Is not required for women who are receiving ART regimens and who have HIV RNA ≤50 copies/mL during late pregnancy and near delivery and no concerns regarding adherence to the ART regimen (BII).
    • May be considered for women with HIV RNA between 50 and 999 copies/mL. There are inadequate data to determine whether administration of IV zidovudine to women with HIV RNA levels between 50 and 999 copies/mL provides any additional protection against perinatal transmission. This decision can be made on a case by case basis, taking into consideration the woman's recent ART adherence, her preferences, and involving expert consultation if needed (CII).
  • Scheduled cesarean delivery at 38 weeks’ gestation (compared to 39 weeks for most indications) is recommended for women who have HIV RNA >1,000 copies/mL near delivery (see Transmission and Mode of Delivery) (AI).
  • Women who present in labor with unknown HIV status should undergo expedited antigen/antibody HIV testing (AII).
    • If the results are positive, an HIV-1/HIV-2 antibody differentiation test and an HIV-1 RNA assay should be done as soon as possible and maternal (IV zidovudine)/infant (combination antiretroviral [ARV] prophylaxis) ARV drugs should be initiated pending results of the differentiation test (AII).
    • If the maternal HIV differentiation test is positive or if acute infection is suspected because the differentiation test is negative but the HIV RNA test is positive, infant ARV drugs should be managed as discussed in Antiretroviral Management of Newborns with Perinatal HIV Exposure or Perinatal HIV (AI). Women with positive expedited testing should not initiate breastfeeding until HIV infection is definitively ruled out (see Postpartum Follow-Up of Women Living with HIV Infection) (AII).
    • If the maternal HIV differentiation test is negative and acute HIV infection has been reasonably excluded with a negative HIV RNA test, the maternal and infant ARV drugs should be stopped (AIII).
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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