What is the recommended treatment for HIV (Human Immunodeficiency Virus) in pregnancy?

Treatment of HIV in Pregnancy

For pregnant women with HIV, a zidovudine and lamivudine-based antiretroviral regimen is recommended over tenofovir and emtricitabine-based regimens to reduce the risk of adverse neonatal outcomes while maintaining effective viral suppression. 1

Treatment Approach Based on Clinical Scenario

For Women Already on ART Before Pregnancy:

• Continue current HAART regimen if it contains zidovudine/lamivudine
• If on tenofovir/emtricitabine, consider switching to zidovudine/lamivudine
• Discontinue drugs with teratogenic potential (e.g., efavirenz) or with known adverse potential for pregnant women (e.g., combination stavudine/didanosine) 2
• In general, if treatment is required for maternal health, antiretroviral drugs should not be stopped during the first trimester 2

For Newly Diagnosed Women During Pregnancy:

• For women with HIV RNA >1000 copies/mL:

  • Initiate HAART (ideally containing zidovudine)
  • Consider delaying initiation until after the first trimester if possible
  • Continue HAART regimen during labor and delivery
  • Administer intravenous zidovudine during labor
  • Consider elective cesarean delivery if viral load remains ≥1000 copies/mL at 34-36 weeks gestation 2, 1

• For women with HIV RNA <1000 copies/mL:

  • Zidovudine monotherapy can be considered, given after the first trimester and as continuous infusion during labor
  • OR HAART (ideally containing zidovudine) 2

Recommended Antiretroviral Regimens

Preferred Backbone:

• Zidovudine (AZT) + Lamivudine (3TC) 2, 1

Third Agent Options:

• Ritonavir-boosted protease inhibitors (e.g., darunavir/ritonavir, atazanavir/ritonavir)
• Integrase strand transfer inhibitors
• Non-nucleoside reverse transcriptase inhibitors (with caution for nevirapine in women with CD4 >250/mm³ due to increased risk of hepatic toxicity) 2, 1

Special Considerations for Alternative Regimens

Consider tenofovir/emtricitabine-based regimens in cases of:

• Severe anemia
• Lamivudine-resistant hepatitis B
• Drug allergy or intolerance to zidovudine/lamivudine
• Lamivudine or zidovudine-resistant HIV
• Significant drug interactions
• When a once-daily regimen is highly valued 2, 1

Intrapartum and Postpartum Management

During Labor and Delivery:

• Continue HAART regimen
• Administer intravenous zidovudine if HIV RNA remains ≥1000 copies/mL 2, 1

For the Infant:

• Zidovudine prophylaxis for 6 weeks 2

Postpartum Maternal Management:

• Continue ART if indicated for maternal health (CD4 count <350/mm³ or AIDS-defining illness)
• If ART was initiated only for prevention of mother-to-child transmission, consider discontinuing therapy 2, 1
• When stopping nevirapine-containing regimens, continue the nucleoside backbone for 3-7 days after stopping nevirapine to reduce resistance risk 2

Safety Considerations

• Available data from the Antiretroviral Pregnancy Registry show no increase in the overall risk of major birth defects with first trimester exposure for tenofovir disoproxil fumarate (2.1%) compared with the background rate of 2.7% 3
• However, zidovudine has a longer safety track record in pregnancy and remains the mainstay of perinatal prevention efforts 2
• Pregnancy-associated changes in drug absorption, distribution, metabolism, and excretion require special consideration for antiretroviral dosing throughout pregnancy 4

Important Caveats

• Avoid breastfeeding in HIV-infected mothers to prevent postnatal transmission 3
• Management should involve a specialist with experience in treating pregnant women with HIV infection 2
• The goal of achieving viral suppression (<50 copies/mL) in >90% of women remains challenging, with studies showing suppression rates of approximately 75-82% 5