What is the role of ART in the management of pregnant women with HIV infection?

Updated: Apr 02, 2019
  • Author: Ashley T Peterson, MD; Chief Editor: Ronald M Ramus, MD  more...
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Answer

Answer

Mother-to-child transmission is linked to viral load. As such, antepartum antiretroviral therapy should be offered to all pregnant women infected with HIV to reduce the risk of perinatal transmission to below 2%. [28] Combination antiretroviral therapy should be offered in all cases.

If a pregnant woman has received antiretroviral medication in the past but is not currently on any medication, the choice of regimen may vary according to the history of prior use, the indication for stopping treatment in the past, gestational age, and resistance testing. In this setting, if there is no resistance to the drugs and the regimen suppressed viral load, antiretroviral medication can be used again, but avoid drugs with teratogenic potential or adverse maternal effects.

If a patient who is on an ART regimen presents for prenatal care, continuing her treatment during the first trimester is reasonable, provided that care is taken to avoid medications that are contraindicated in early pregnancy (stavudine, didanosine, full-dose ritonavir). HIV antiretroviral drug resistance testing is recommended if a viral load is detectable. Considerations of drugs not usually used early in pregnancy may be necessary if drug resistance is confirmed and the patient receives extensive counseling regarding risk and benefits.

In an HIV-infected pregnant woman who has never been exposed to antiretroviral medication, ART regimen determination is similar to non-pregnant patients however certain medications should be avoided (dolutegravir, elvitegravir, and tenofovir alafenamide). ART should be started as soon as possible, including during the first trimester. Again, recommendations are for drug-resistance testing and care to avoid medications that may potentially cause adverse maternal and fetal effects.

If prenatal HIV testing was not performed and a rapid HIV test returns preliminarily positive, the patient should be treated and managed as high-risk for transmission. Certainly, the gestational age and obstetrical scenario may dictate the treatment options available, but as the exposure risk to antiretroviral medication is minimal to both mother and fetus, antiretroviral therapy should be initiated. [4]

The patient with a positive rapid test must be counseled regarding the possibility of a false-positive screen, and the results should be documented as preliminary in the medical chart. If this test was performed on arrival in labor, treatment with the ZDV protocol through labor is recommended, followed by avoiding breastfeeding and administration to the neonate until confirmatory testing on the mother becomes available.


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