Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States
Introduction
(Last updated:7/31/2012; last reviewed:7/31/2012)
Recommendations regarding HIV screening and treatment of pregnant women and prophylaxis for perinatal transmission of HIV have evolved considerably in the United States over the last 25 years, reflecting changes in the epidemic and the science of prevention.1,2 With the implementation of recommendations for universal prenatal HIV counseling and testing, antiretroviral (ARV) prophylaxis, scheduled cesarean delivery, and avoidance of breastfeeding, the rate of perinatal transmission of HIV has dramatically diminished to less than 2% in the United States and Europe.3-6
These guidelines update the September 14, 2011, Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. The Department of Health and Human Services Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission, a working group of the Office of AIDS Research Advisory Council, develops these guidelines. The guidelines provide health care providers with information for discussion with HIV-infected pregnant women to enable the patient/provider team to make informed decisions regarding the use of ARV drugs during pregnancy and use of scheduled cesarean delivery to reduce perinatal transmission of HIV. The recommendations in the guidelines are accompanied by discussion of various circumstances that commonly occur in clinical practice and the factors influencing treatment considerations. The Panel recognizes that strategies to prevent perinatal transmission and concepts related to management of HIV disease in pregnant women are rapidly evolving and will consider new evidence and adjust recommendations accordingly. The updated guidelines are available from the AIDSinfo website (http://aidsinfo.nih.gov).
Health care providers considering the use of ARV agents for HIV-infected women during pregnancy must take into account two separate but related issues:
- ARV treatment of maternal HIV infection and
- ARV chemoprophylaxis to reduce the risk of perinatal transmission of HIV.
The benefits of ARV drugs for a pregnant woman must be weighed against the risks of adverse events to the woman, fetus, and newborn. Combination drug regimens are considered the standard of care both for treatment of HIV infection and for prevention of perinatal transmission of HIV.
2,7 After provider counseling and discussion on ARV drug use during pregnancy, a pregnant woman’s informed choice on whether to take ARV drugs for her treatment, for prevention of mother-to-child transmission, and/or to follow other medical recommendations intended to reduce perinatal transmission of HIV should be respected. Coercive and punitive policies are potentially counterproductive; they may undermine provider-patient trust and could discourage women from seeking prenatal care and adopting health care behaviors that optimize fetal and neonatal well-being.
The current guidelines have been structured to reflect the management of an individual mother-child pair and are organized into a brief discussion of preconception care followed by principles for management of a woman and her infant during the antepartum, intrapartum, and postpartum periods. Although perinatal transmission of HIV occurs worldwide, these recommendations have been developed for use in the United States. Alternative strategies may be appropriate in other countries. Policies and practices in other countries regarding the use of ARV drugs for reduction of perinatal transmission of HIV may differ from the recommendations in these guidelines and will depend on local considerations, including availability and cost of ARV drugs, accessibility of facilities for safe intravenous infusions during labor, and local recommendations regarding breastfeeding by HIV-infected women.