Dolutegravir recommended as the preferred HIV treatment in pregnancy
Guidelines published by the US Department of Health and Human Services Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission now recommend dolutegravir plus a dual nucleoside reverse transcriptase inhibitor (NRTI) backbone as the preferred antiretroviral therapy (ART) for women with HIV infection who are pregnant or trying to conceive.
Previously, the guidelines recommended either dolutegravir or ritonavir-boosted darunavir in addition to a dual NRTI backbone as the preferred treatment options during pregnancy. However, ritonavir-boosted darunavir is now recommended only as an alternative option in certain patients (e.g., women who have received long-acting injectable cabotegravir for pre-exposure prophylaxis).
The other major change to the recommended ART regimens is the addition of bictegravir as an alternative treatment for women who are pregnant or trying to conceive. Previously, bictegravir was not recommended in pregnant women due to insufficient data. However, small studies and data from the Antiretroviral Pregnancy Registry now suggest that bictegravir is safe during pregnancy and maintains viral suppression.
Women and girls accounted for 44% of all new HIV infections globally in 2023, with most infections occurring in sub-Saharan Africa. Approximately 1.2 million women with HIV were pregnant in 2023, of whom an estimated 84% received ART.
Summary
Definition
History and exam
Key diagnostic factors
- increased risk of maternal HIV infection
- increased risk of perinatal HIV transmission
Other diagnostic factors
- oral candidiasis
- increasing dyspnea
- weight loss
- fever
- malaise
- lymphadenopathy
- maculopapular blanching rash
Risk factors
- needle-sharing with injection drug use
- unprotected receptive penile-vaginal intercourse
- unprotected receptive anal intercourse
- percutaneous needle stick
- sexually transmitted infections (STIs) and bacterial vaginosis
- high maternal viral load (perinatal transmission)
- absence of prenatal maternal antiretroviral therapy (perinatal transmission)
- breast-feeding in mothers without viral suppression (perinatal transmission)
- violence against women and girls
- receptive oral intercourse
- insertive oral intercourse
- multiple sexual partners
- low maternal CD4 count (perinatal transmission)
Diagnostic tests
1st tests to order
- maternal HIV-1/HIV-2 antigen/antibody enzyme-linked immunosorbent assay (ELISA)
- maternal HIV-1/HIV-2 antibody differentiation immunoassay
- neonatal HIV DNA or RNA polymerase chain reaction (PCR)
Tests to consider
- HIV-1 western blot
- HIV-1 indirect immunofluorescence assay (IFA)
- HIV-1 nucleic acid test (NAT)
- CD4 count
- plasma HIV RNA levels (viral load)
- renal function tests
- liver function tests (LFTs)
- drug resistance tests
- complete blood count
- glucose screening
- fetal ultrasound
- tests for coinfections
Treatment algorithm
HIV-1-infected pregnant women: <38 weeks not in labor (regardless of HIV RNA level)
HIV-1-infected pregnant women with HIV-1 RNA levels >1000 copies/mL: at 38 weeks or in labor
HIV-1-infected pregnant women with HIV-1 RNA levels ≤1000 copies/mL: at 38 weeks or in labor
infants born to HIV-infected mothers
Contributors
Authors
Rachel K. Scott, MD, MPH, FACOG
Associate Professor of Obstetrics and Gynecology
Georgetown University School of Medicine
Scientific Director of Women’s Health Research
MedStar Health Research Institute
Associate Chair for Research
MedStar Washington Hospital Center Department of Women’s and Infants’ Services
Washington
DC
Disclosures
RKS declares that she has participated in an advisory meeting for ViiV Healthcare and has received research funding from ViiV, managed by MedStar Health Institute.
Acknowledgements
Dr Rachel K. Scott would like to gratefully acknowledge Dr Isaac Delke, Dr Christina Bailey, and Dr Mettassebia Kano, the previous contributors to this topic.
Disclosures
ID, CB, and MK declare that they have no competing interests.
Peer reviewers
Aisha Sethi, MD
Assistant Professor of Medicine
Associate Residency Program Director
University of Chicago
Chicago
IL
Disclosures
AS declares that she has no competing interests.
Graham P. Taylor, MBChB, FRCP, FHEA
Reader in Communicable Diseases
Faculty of Medicine
Imperial College
London
UK
Disclosures
GPT has been reimbursed by various pharmaceutical companies for attending conferences, lecturing, and consulting, and has been chief investigator of investigator-initiated industry-funded research on HIV and pregnancy.
Differentials
- Infectious mononucleosis
- Toxoplasmosis
- Viral hepatitis
More DifferentialsGuidelines
- Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States
- Care of pregnant women living with HIV and interventions to reduce perinatal transmission
More GuidelinesPatient information
HIV infection in pregnancy
More Patient information
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