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The probability of HIV transmission is directly correlated with the viral load, especially the
viral load at the time of delivery.
Regardless of HIV viral load and CD4 count, all HIV-infected pregnant women should be
offered antiretroviral therapy (ART) to reduce perinatal transmission.
Elective cesarean delivery reduces the risk of perinatal transmission and should be offered at
week 38 if the viral load is likely to exceed 1000 copies/mL at delivery; there is no benefit if
the viral load is less than 1000 copies/mL or when the procedure is done after rupture of
membranes.
Combination ART is more effective than a single-drug regimen in reducing perinatal
transmission.
Longer duration of antepartum antiretroviral prophylaxis is more effective than shorter
duration.
Antiretroviral drugs reduce perinatal transmission by several methods, accounting for the
recommendation for a combination antepartum, intrapartum, and infant ART.
In women who are already receiving ART, the regimen needs to be reviewed for its adequacy
in controlling HIV, its teratogenic potential, its pharmacologic effects, and patient tolerance
during pregnancy.
In the absence of antepartum ART, intrapartum antiretroviral drugs should be administered in
combination with infant antiretroviral prophylaxis to reduce the risk of perinatal transmission.
Four weeks of zidovudine prophylaxis should be given to infants born to mothers with
suppressed viremia during pregnancy. Six weeks of combination ART should be administered
to infants born to mothers who did not receive antepartum care or did not have a sustained
viral response during pregnancy.
Breastfeeding is not recommended in women with HIV infection in the United States. [1]
If a woman with HIV infection presents late in pregnancy, ART should be initiated immediately,
before availability of resistance testing.
The preferred initial regimen in pregnancy is a backbone of dual nucleoside analogue reverse
transcriptase inhibitors (NRTI) with either a low-dose ritonavir-boosted protease inhibitor (PI) or an
integrase Inhibitor.
Two-NRTI backbone
Atazanavir (ATV) is recommended to be combined with low-dose ritonavir (RTV): ATV 300 mg
plus RTV 100 mg PO daily as a single daily dose; some experts increase ATV/RTV dose to
400/100 mg daily during second and third trimester; manufacturer recommends dose
increase in pregnancy if combined with tenofovir or H2 blocker in treatment-experienced
patients and with efavirenz in treatment-naive patients [8] or
Darunavir (DRV) 600 mg combined with 100 mg RTV twice daily [9] : Once-daily dosing
achieves low trough in pregnancy and should not be used, especially in treatment-
experienced patients.
Raltegravir (RAL) 400 mg twice daily [10] : No data on use of once-daily raltegravir 600-mg HD
formulation in pregnancy; rapid reduction in viral load potentially useful if present late in pregnancy;
hepatic enzyme elevation has occurred when used in late pregnancy
NRTI backbone
Zidovudine with lamivudine (300 mg ZDV/150 mg 3TC) twice a day: Combination with most
experience in pregnancy; can cause hematological toxicity
Protease inhibitor ̶ based regimen
Lopinavir (LPV) 400 mg plus ritonavir (RTV) 100 mg PO BID if no lopinavir-associated mutations:
Insufficient data for any dosage recommendations in the presence of any lopinavir-associated
resistance substitution; [11] some authors increase dose to 600 mg/150 mg twice a day in second
and third trimester of pregnancy; once-daily LPV/RTV dosing is not recommended during
pregnancy; oral solution should not be used in pregnancy because of its high alcohol content
Efavirenz (EFV) 600 mg PO daily: Although there are concerns of potential neural tube
defects in women of childbearing age before pregnancy is detected, increasing data in
pregnancy are reassuring [7] or
Rilpivirine (RPV) 25 mg PO daily if pretreatment HIV viral load is less than 100,000 copies/mL
and CD4 exceeds 200 cells/µL: Limited pregnancy data with highly variable
pharmacokinetics.
If the regimen contains stavudine, didanosine, or full-dose ritonavir, a regimen change should be
considered.
Intrapartum Care
Intrapartum AZT should be administered to pregnant HIV-infected women if the HIV viral load is
1000 or more copies/mL or unknown at time of delivery, irrespective of mode of delivery. [13]
AZT 2 mg/kg IV is administered over 1 hour, then continuous infusion of 1 mg/kg/h from onset of
labor to delivery.
Oral AZT, if part of the combination regimen, should be stopped while IV AZT is administered.
IV AZT is not required if the patient is receiving combination therapy and the HIV viral load is
consistently less than 1000 copies/mL near time of delivery and adherence is reliable.