What information have the results of clinical trials provided about antiretroviral therapy (ART) for HIV infection during pregnancy?

Answer

These clinical trials have provided the following guiding principles:

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. Presumptive HIV treatment with combination ART including 6 weeks of zidovudine 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]

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