Recommendations for use of antiretroviral (ARV) drugs in pregnant women in different clinical scenarios in resource constrained settings
| Clinical situation | Recommendation | |
|---|---|---|
| EFV, efavirenz; NVP, nevirapine; 3TC, lamivudine; ZDV, zidovudine. | ||
| (1) Start NVP with half dose for the first 2 weeks as recommended for adults in WHO guidelines. | ||
| (2) Monitor closely clinical and biochemical tolerance in the first month of ARV use | ||
| (3) Stop NVP in case of NVP associated toxicity, continue ZDV only until labour | ||
| Source: World Health Organization.91 | ||
| Newly diagnosed HIV infected pregnant women without indication for ARV treatment | Mother | |
| • ZDV ± 3TC+NVP from 32 weeks gestation, through delivery (I), (2), (3); stop NVP and continue ZDV + 3TC for 3 days after delivery | ||
| • alternatively: ZDV + 3TC from 34–36 weeks boosted with single dose NVP at onset of labour | ||
| • alternatively: ZDV from 34–36 weeks boosted with single dose NVP at onset of labour | ||
| • Single dose NVP in settings where none of the more potent ARV combinations are feasible or available | ||
| Infant | ||
| • Single dose NVP within 72 hours of delivery and one week daily ZDV (extend ZDV for a second week with a second dose of NVP 5–7 days after the first one if ZDV + 3TC + NVP was the maternal regimen and breastfeeding has been initiated) | ||
| • If delivery occurred within 2 hours of maternal single dose of NVP, infant should receive an additional dose of NVP immediately after birth as well as the routine dose within 72 hours | ||
| Newly diagnosed HIV infected women, with indications for ARV treatment, who may become pregnant | Exclude pregnancy before starting treatment. | |
| Avoid EFZ | ||
| Prefer ZDV + 3TC ± NVP regimen. | ||
| Newly diagnosed HIV infected pregnant women with indications for ARV treatment | Delay start of treatment until after the first trimester of pregnancy | |
| Proceed as for non-pregnant adults (1), (2), (3) except EFV | ||
| Newly diagnosed HIV infected pregnant women, with indications for ARV treatment, who did not initiate therapy during pregnancy | In both cases proceed as for non-pregnant adults (WHO guidelines) with first line regimen recommended | |
| • received short course MTCT prophylaxis | Initiate ARV treatment as soon as possible, including in postpartum period | |
| • did not receive any MTCT prophylaxis | ||
| HIV infected pregnant women newly diagnosed at the time of delivery | If there is time, offer rapid test; if no time, rapid test as soon as possible (and acceptable) after delivery. | |
| If test positive, initiate post-exposure prophylaxis in infant: single dose NVP within 72 hours of delivery plus 1 week ZDV. | ||
| HIV infected women on ARV treatment for their own disease | Exclude pregnancy before starting treatment. EFV should be avoided in women who can potentially become pregnant | |
| Discontinue drugs with teratogenic potential (EFV) or with known adverse potential for the pregnant mother (d4TiddI) | ||
| Consider switching to regimens which include ZDV, 3TC or NVP | ||