From the Guidelines
The recommended first-line HIV medication regimen for pregnant women is a combination of zidovudine and lamivudine, due to the potential increased risk of early neonatal death and preterm delivery associated with tenofovir and emtricitabine, particularly when combined with lopinavir/ritonavir 1.
Key Considerations
- The choice of antiretroviral regimen should prioritize minimizing the risk of mother-to-child transmission while also considering the potential risks and benefits to the mother and fetus.
- Zidovudine and lamivudine are recommended over tenofovir and emtricitabine, especially when combined with lopinavir/ritonavir, due to the potential increased risk of adverse outcomes 1.
- Women with specific conditions, such as active hepatitis B, severe anemia, or drug allergies, may require alternative regimens, including those based on tenofovir and emtricitabine 1.
Regimen Components
- The preferred NRTI backbone consists of zidovudine and lamivudine, which have been shown to have a more favorable safety profile compared to tenofovir and emtricitabine in pregnancy 1.
- The choice of third agent should be based on individual patient factors, including viral resistance patterns, medication tolerability, and potential drug interactions.
Monitoring and Management
- Regular monitoring of viral load, CD4 count, and medication side effects is crucial throughout pregnancy to ensure optimal treatment outcomes.
- Viral load testing is recommended at 34-36 weeks to inform delivery planning and minimize the risk of mother-to-child transmission.
Clinical Decision-Making
- Clinicians should consider individual patient values and preferences when selecting an antiretroviral regimen, weighing the potential benefits and risks of different regimens 1.
- Public health perspectives may also influence treatment decisions, taking into account resource use and population-level outcomes 1.
From the Research
HIV Medication in Pregnancy
The recommended first-line HIV medication regimen for pregnant women is a crucial aspect of managing the disease during pregnancy.
- Tenofovir disoproxil fumarate (TDF) is often recommended as part of antiretroviral therapy (ART) for pregnant women with HIV, as well as for those with hepatitis B virus (HBV) monoinfection at high risk of transmitting infection to their infants 2.
- The combination of dolutegravir with emtricitabine and tenofovir alafenamide or tenofovir disoproxil fumarate has been shown to be effective and safe for initial treatment of HIV-1 infection, including in pregnant women 3.
- Tenofovir and emtricitabine have been found to have lower pharmacokinetic exposure during pregnancy, but this does not appear to be associated with virological failure or mother-to-child transmission 4.
- Dolutegravir, abacavir, and lamivudine have been compared to ritonavir-boosted atazanavir plus tenofovir disoproxil fumarate and emtricitabine in previously untreated women with HIV-1 infection, with the dolutegravir regimen showing non-inferior efficacy and a similar safety profile 5.
Key Considerations
- Pregnancy reduces tenofovir exposure, but the relative size of this reduction is not impacted by concomitant antiretroviral drugs or viral infection 2.
- The safety and efficacy of dolutegravir in women with HIV-1 have been established, supporting its use in treatment-naive women, including those who are pregnant 5.
- The choice of HIV medication during pregnancy should be based on the individual patient's needs and medical history, as well as the potential risks and benefits of each medication regimen 6, 3.