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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General Principles Regarding Use of Antiretroviral Drugs during Pregnancy

Overview

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

Panel's Recommendations: General Principles Regarding Use of Antiretroviral Drugs during Pregnancy
Panel's Recommendations
  • Initial evaluation of pregnant women living with HIV should include an assessment of HIV disease status and plans to initiate, continue, or modify antiretroviral therapy (ART) (AI). The National Perinatal HIV Hotline (888-448-8765) provides free clinical consultation on all aspects of perinatal HIV care.
  • All pregnant women living with HIV should initiate ART as early in pregnancy as possible, regardless of their plasma HIV RNA copy number or CD4 T lymphocyte count, to prevent perinatal transmission (AI). It is recommended that the HIV viral load be maintained below the limit of detection throughout pregnancy and lifetime of the individual living with HIV (AII).
  • To minimize the risk of perinatal transmission, antiretroviral (ARV) drugs should be administered at all time points (including antepartum and intrapartum) to the woman as well as postnatally to the neonate (AI).
  • The known benefits and potential risks of all medications, including ARV drugs used during pregnancy and postpartum, should be discussed with all women living with HIV (AIII).
  • The importance of adherence to ARV drug regimens should be emphasized during patient counseling (AII).
  • ARV drug-resistance genotype studies should be performed before starting ARV drug regimens in women who are ARV-naive (AII) or ARV-experienced (AIII) and before modifying ARV drug regimens (AII) in women whose HIV RNA levels are above the threshold for resistance testing (i.e., >500 to 1,000 copies/mL).
  • In pregnant women who are not already receiving ART, ART should be initiated before results of drug-resistance testing are available, because earlier viral suppression has been associated with lower risk of transmission. If ART is initiated before results are available, the regimen should be modified, if necessary, based on resistance assay results (BIII).
  • Coordination of services among prenatal care providers, primary care and HIV specialty care providers, and, when appropriate, mental health and drug abuse treatment services, intimate partner violence support services, and public assistance programs is essential to help ensure that women living with HIV adhere to their ARV drug regimens (AII).
  • Providers should initiate counseling about key intrapartum and postpartum considerations during pregnancy, including mode of delivery, maternal lifelong HIV therapy, family planning and contraceptive options, infant feeding, infant ARV prophylaxis, timing of infant diagnostic testing, and neonatal circumcision (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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