Switch to Truvada During Pregnancy
A pregnant woman currently using Apretude (cabotegravir long-acting injectable) for PrEP should be switched to daily oral Truvada (TDF/FTC) for the duration of pregnancy. 1
Rationale for Switching
Established Safety Profile of Truvada in Pregnancy
- Daily oral TDF/FTC (Truvada) is the recommended PrEP regimen for pregnant individuals with extensive safety data demonstrating no harm to infants exposed during pregnancy. 1
- TDF/FTC should be continued throughout pregnancy and for at least 7 days after the last potential HIV exposure. 1
- Multiple guidelines consistently recommend TDF/FTC as the standard of care for PrEP during pregnancy based on robust safety evidence. 1
Limited Data for Cabotegravir in Pregnancy
- Cabotegravir is not recommended during pregnancy due to inadequate data to support its use, and current guidelines advise switching to an oral triple-drug regimen if pregnancy is diagnosed in someone on Cabenuva (the treatment formulation). 2
- While emerging data suggest cabotegravir may have a growing safety profile in pregnancy, the evidence remains insufficient for routine recommendation. 1
- Recent pharmacokinetic modeling suggests monthly cabotegravir may maintain adequate drug levels in pregnancy, but bimonthly dosing may be suboptimal, particularly in the third trimester. 3
Practical Implementation
Timing of Switch
- Switch to daily oral TDF/FTC immediately upon pregnancy confirmation. 1
- Initiate with a double dose of TDF/FTC followed by single daily dosing thereafter. 1
Monitoring During Transition
- Continue quarterly HIV testing throughout pregnancy to ensure HIV-negative status. 1
- Cabotegravir has a prolonged half-life (approximately 52.8 days in pregnant women), meaning detectable drug levels will persist for months after the last injection. 4
- The washout period provides some continued protection during the transition to oral PrEP, but daily TDF/FTC should be started promptly to ensure continuous coverage. 5, 4
Postpartum Considerations
- If not breastfeeding, the patient may consider returning to cabotegravir long-acting injectable after delivery if desired. 1
- If breastfeeding, continue daily TDF/FTC as it remains the recommended regimen during lactation. 1
Key Caveats
The evidence hierarchy strongly favors established safety over theoretical benefit. While no congenital anomalies have been reported in limited case series of cabotegravir exposure during pregnancy 5, 4, the total number of exposed pregnancies remains small compared to the extensive experience with TDF/FTC. 1, 6
The safety risk tolerance for PrEP agents in HIV-negative pregnant women is appropriately lower than for antiretroviral treatment in women living with HIV, making the switch to the well-established TDF/FTC regimen the prudent clinical approach. 6