Combined Antiretroviral Therapy (cART) During Pregnancy

There are two goals of cART during pregnancy. The first goal is to reduce maternal viral load below the limit of detection throughout pregnancy in order to sustain her immune system and controls opportunistic infection. The second goal is to reduce the risk of mother to child transfer (MTCT) by lowering maternal antepartum viral load and providing infant pre- and postexposure prophylaxis.

Pregnancy presents clinical issues that may require specialized OB/HIV care, including:

Patient counseling prior to cART should include:

Beginning therapy:

Combined Antiretroviral Therapy is recommended for all HIV+ pregnant women regardless of CD4 count and viral load. Current recommendations for beginning antiretroviral therapy are similar to those for a non-pregnant individual. In general, it is recommended that pregnant women who are starting therapy for their own health be treated as soon as possible, including in the first trimester. For women who are beginning therapy only to prevent mother-to-child transmission, delaying cART until after the first trimester can be considered. Regardless of the recommendations, a women's informed decision to use, refuse or delay cART must be respected.

Safety of antiretroviral drugs during pregnancy:

Almost all patients who undergo cART will experience some side effects. Recent studies indicate that there are differences in pharmacokenetics between men and women. Women appear to be at higher risk for ART associated lactic acidosis, nevirapine-associated rash and hepatotoxicity and fat redistribution. Patients need to be able to recognize side effect and report them as early as possible.

Fetal effects associated with ART use

Reducing Mother to Child Transmission (MTCT):

Ideally, antepartum cART will suppress maternal HIV plasma levels to "undetectable" during pregnancy. Several studies indicate that Cesarean delivery prior to labor and rupture of membranes significantly reduces perinatal transmission of HIV. Finally, breast feeding is a known mode of transmission and should be avoided.