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Preferred antiretroviral agents for treatment-naïve pregnant individuals with HIV in resource-rich settings

Preferred antiretroviral agents for treatment-naïve pregnant individuals with HIV in resource-rich settings
  Considerations
Dual NRTI backbone

Tenofovir alafenamide-emtricitabine

or

Tenofovir alafenamide plus lamivudine
  • Tenofovir alafenamide-emtricitabine is available as a fixed-dose combination
  • Once-daily administration

Tenofovir disoproxil fumarate-emtricitabine

or

Tenofovir disoproxil fumarate-lamivudine
  • Tenofovir disoproxil fumarate-emtricitabine and tenofovir disoproxil fumarate-lamivudine* are available as fixed-dose combinations
  • Once-daily administration
  • Tenofovir disoproxil fumarate has potential for renal toxicity; these combinations should be used with caution in patients with renal insufficiency
Abacavir-lamivudine
  • Available as a fixed-dose combination
  • Once-daily administration
  • HLA-B5701 testing is required prior to use; abacavir should not be used in patients who test positive because of the risk of a hypersensitivity reaction
  • Not recommended if pre-treatment HIV RNA level >100,000 copies/mL
Third drug – Integrase inhibitor
Dolutegravir
  • Rapid viral load reduction; preferred for women presenting late in pregnancy, with high viral load, or with acute HIV
  • Useful when drug interactions with protease inhibitor regimens are a concern
  • Well tolerated
  • Once-daily administration
  • Available as a fixed-dose combination with abacavir and lamivudine
  • Not recommended for patients with recent exposure to cabotegravir as part of pre-exposure prophylaxis
Third drug – Protease inhibitors
Darunavir plus ritonavir
  • Preferred for initial treatment of patients with early (acute or recent) HIV infection and a history of cabotegravir exposure as part of pre-exposure prophylaxis
  • Well tolerated
  • Pharmacokinetic data available and increasing experience with use in pregnancy
  • Requires twice-daily administration during pregnancy
Preferred regimens for ART of treatment-naïve pregnant women with HIV consist of one of the dual NRTI combinations listed above plus one of the third drugs (a protease inhibitor or integrase inhibitor) listed above.

ART: antiretroviral therapy; HLA: human leukocyte antigen; NRTI: nucleoside reverse transcriptase inhibitor.

* The fixed-dose combination tenofovir disoproxil fumarate-lamivudine is available in the United States and may be available in some other countries.
Adapted from: Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States, HIV.gov 2023. Available at: clinicalinfo.hiv.gov/en/guidelines/perinatal/recommendations-arv-drugs-pregnancy-what-to-start-regimens-naive (Accessed on February 15, 2024).
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