From the Guidelines
The recommended antepartum antiviral treatment for pregnant women living with HIV is immediate initiation of a combination antiretroviral therapy (cART) regimen, with Dolutegravir with TAF/FTC (or TDF/FTC if TAF/FTC is not available) being the preferred regimen due to its high antiviral efficacy and low rates of adverse birth outcomes 1.
Key Considerations
- The goal of antepartum antiviral treatment is to achieve and maintain viral suppression (HIV RNA <50 copies/mL) to prevent mother-to-child transmission.
- Treatment should begin as early as possible in pregnancy if the woman is not already on therapy, and should continue throughout pregnancy, labor, and postpartum.
- Medication adherence is crucial, and treatment should be individualized based on antiretroviral history, resistance testing, comorbidities, and potential drug interactions.
- Regular monitoring of viral load is essential, with testing recommended at initial prenatal visit, 2-4 weeks after starting therapy, monthly until viral suppression is achieved, then at least every 3 months during pregnancy.
Alternative Regimens
- BIC/TAF/FTC is an alternative regimen, with recent pharmacokinetic studies showing sufficient bictegravir levels during pregnancy and low rates of birth defects in infants born to persons with first-trimester exposure 1.
- TXF/XTC plus twice-daily darunavir (600 mg) plus ritonavir 100 mg is recommended when dolutegravir is not an option or when HIV has been acquired after receiving long-acting cabotegravir for preexposure prophylaxis 1.
Important Notes
- The 2025 recommendations from the International Antiviral Society-USA panel 1 supersede previous guidelines, such as those from 2007 1, and should be followed for optimal patient outcomes.
- The choice of antiretroviral regimen should be based on the most recent and highest-quality evidence available, with consideration of individual patient factors and potential drug interactions.
From the FDA Drug Label
The Centers for Disease Control and Prevention recommend that HIV-1 infected mothers not breastfeed their infants to avoid risking postnatal transmission of HIV-1 Because of the potential for: (1) HIV transmission (in HIV-negative infants); (2) developing viral resistance (in HIV-positive infants); and (3) adverse reactions in a breastfed infant similar to those seen in adults, instruct mothers not to breastfeed if they are taking tenofovir disoproxil fumarate for the treatment of HIV-1
The recommended antepartum antiviral treatment for pregnant women living with HIV is not explicitly stated in the provided drug label. However, it is mentioned that tenofovir disoproxil fumarate can be used during pregnancy, and the Centers for Disease Control and Prevention recommend that HIV-1 infected mothers not breastfeed their infants to avoid risking postnatal transmission of HIV-1.
- Key points:
- Tenofovir disoproxil fumarate can be used during pregnancy.
- HIV-1 infected mothers should not breastfeed their infants.
- The drug label does not provide a direct recommendation for antepartum antiviral treatment. 2
From the Research
Antepartum Antiviral Treatment for Pregnant Women with HIV
The recommended antepartum antiviral treatment for pregnant women living with Human Immunodeficiency Virus (HIV) involves the use of combination antiretroviral therapy (ART) to significantly reduce the transmission of HIV from mother to child 3, 4.
Key Considerations for Antiretroviral Treatment
Key considerations for antiretroviral treatment in pregnancy include:
- Maternal and fetal safety
- Antiretroviral pharmacokinetics
- Regimen efficacy
- Potential for birth defects or adverse neonatal outcomes
- Individualized delivery planning based on maternal viral load 3, 4
Antiretroviral Regimens
Commonly used antiretroviral regimens for pregnant women include:
- Dual-nucleoside reverse transcriptase inhibitors plus an integrase strand transfer inhibitor
- Ritonavir-boosted protease inhibitor 4
- Efavirenz (EFV) and coformulated emtricitabine (FTC) and tenofovir disoproxil fumarate (TDF) 5
Benefits and Risks of Antiretroviral Treatment
The benefits of antiretroviral treatment in pregnancy include:
- Reduced risk of perinatal transmission of HIV
- Improved health outcomes for mothers and infants The risks and adverse events associated with antiretroviral treatment in pregnancy include:
- Anaemia
- Elevation of transaminases
- Nausea/vomiting
- Glucose intolerance
- Nephrolithiasis
- Diarrhoea
- Hypertension
- Insulin-requiring diabetes
- Prematurity
- Anaemia in neonates
- Cutaneous angioma
- Cryptorchidism
- Transient hepatitis 6, 7
Recommendations for Antiretroviral Treatment
Recommendations for antiretroviral treatment in pregnancy include:
- Early and consistent use of antiretroviral therapy throughout pregnancy and childbirth
- Suppressive antiretroviral treatment during pregnancy to eliminate transmission of HIV from mother to child
- Individualized treatment planning based on maternal viral load and other factors 4