Which ART regimens are used 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

Treatment of women infected with HIV should not be withheld because of pregnancy. Although the decision regarding starting or maintaining current antiretroviral therapy is based on the same criteria as in nonpregnant patients, several considerations must be taken into account because of potential effects on the fetus.

The regimen chosen should also take into account prior therapy and response to that regimen, as well as resistance testing. Gestational age and potential fetal and neonatal toxicity must also be taken into account when selecting a regimen.

The mechanism of action with which these drugs reduce perinatal transmission includes lowering maternal viral load; however, as these drugs cross the placenta, there appears to be prenatal prophylaxis as well. The third component, prophylaxis of the newborn, further decreases the risk of perinatal transmission.

The antiretroviral drugs used in pregnancy fall broadly into 3 categories: the nucleoside and nucleotide analogue reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PIs).   Additionally, raltegravir is an integrase inhibitor with a growing body of data that is reassuring in pregnancy. There are insufficient data to allow recommendations regarding the use of entry inhibitors in pregnancy.

Guidelines for perinatal ART were revised in January 2017 regarding which agents are considered preferred, alternative, or to be used under special circumstances. Combination regimens, usually including 2 NRTIs with either an NNRTI or 1 or more protease inhibitors (PIs) are recommended. For further information, see Table 1 and refer to updated guidelines (published annually).

Table 1. ART agents during pregnancy [18] (Open Table in a new window)

ART Class

Preferred*

Alternate

Special Circumstances

Insufficient Data to Recommend

NRTIs

tenofovir disoproxil fumarate + emtricitabine or lamivudine

abacavir + lamivudine

zidovudine + lamivudine

didanosine (not recommended)

 

stavudine (not recommended)

 

tenofovir alafenamide

NNRTIs

 

efavirenz

rilpivirine

nevirapine (not recommended, ART naive)

 

etravirine

 

PIs

atazanavir + ritonavir

darunavir + ritonavir

lopinavir + ritonavir

indinavir

nelfinavir

saquinavir

darunavir + cobicistat

atazanavir + cobicistat

fosamprenavir

tipranavir

Integrase Inhibitors raltegravir    

dolutegravir

elvitegravir/ cobicistat

elvitegravir/ cobicistat/ emtricitabine/ tenofovir

alafenamide 

Entry and Fusion Inhibitors

-

-

-

enfuvirtide

maraviroc

Pharmacoenhancers

-

ritonavir

 

cobicistat

 


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