Table 5. Situation-Specific Recommendations for Use of Antiretroviral Drugs in Pregnant People and Nonpregnant People Who Are Trying to Conceive

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ART Regimen Component ART for Pregnant People Who Have Never Received ARV Drugs and Who Are Initiating ART for the First Time Continuing ART for People Who Become Pregnant on a Fully Suppressive, Well-Tolerated Regimen ART for Pregnant People Who Have Received ARV Drugs in the Past and Who Are Restarting ARTa New ART Regimen for Pregnant People Whose Current Regimen Is Not Well Tolerated and/or Is Not Fully Suppressivea ART for Nonpregnant People Who Are Trying to Conceivea,b
a Do not initiate ARV regimens with components that have documented resistance or suspected resistance based on prior ARV exposure.

b This guidance is intended for people who are pregnant or trying to conceive. These recommendations are not intended for all people with HIV who might become pregnant.

c ABC plus 3TC, TDF plus FTC, and TDF plus 3TC are Preferred dual-NRTI backbones, and ZDV plus 3TC and TAF plus FTC are Alternative dual-NRTI backbones for ARV regimens.

d DRV/c, EVG/c, and ATV/c are not recommended for use in pregnancy because of PK changes that pose a risk for low drug levels and viral rebound in the second and third trimesters. However, in cases where virologically suppressed pregnant people present to care on regimens that include these drugs, these drug combinations can be continued with frequent viral load monitoring or can be switched to a recommended or alternative agent. If there are concerns about switching, see Pregnant People with HIV Who Are Currently Receiving Antiretroviral Therapy. If the cobicistat pharmacologic booster is replaced with ritonavir for ATV and DRV, attention to dosing in pregnancy is critical, with higher doses of ATV required if coadministered with TDF or antacids, and twice-daily dosing required for DRV, in the second and third trimesters.

e Although PK data indicate that RPV plasma concentration is reduced during the second and third trimesters, the reduction is less than the reductions seen with use of EVG/c or DRV/c. Higher-than-standard doses of RPV have not been studied, so data are insufficient to recommend a dose change in pregnancy. With standard dosing, viral load should be monitored more frequently.

f Although these drugs are not recommended for initial treatment in ART-naive pregnant people, there may be special circumstances in which ART-experienced people may need to continue or initiate ETR, NVP, MVC, and T-20 in order to maintain or achieve viral suppression. Safety and efficacy data are limited about the use of ETR, MVC, and T 20 in pregnancy. NVP is not recommended for ART-naive people, because it has a greater potential for adverse events than other NNRTIs, complex lead-in dosing, and a low barrier to resistance; however, if a pregnant person presents to care on a well-tolerated, NVP-containing regimen, it is likely that NVP will be safe and effective during pregnancy. See Table 4 and Nevirapine for more information.

g When using FDC tablets, refer to Table 8 and the drug sections in Appendix B for information about the dosing and safety of individual components of the FDC tablet during pregnancy.

h Testing for HLA-B*5701 identifies patients who are at risk of developing hypersensitivity reactions while taking ABC; testing should be performed, and a patient should be documented as negative before initiating ABC.

i Available data about the use of TAF in pregnancy support continuing it in pregnant people who are virally suppressed, although data are insufficient to recommend it when initiating ART in pregnancy.

j Two-drug ARV regimens are not recommended for use in pregnancy.

The following drugs and drug combinations (that are not listed above) should not be used during pregnancy: if a person becomes pregnant while taking any of these medications, she should switch to a recommended regimen: d4T, ddI, FPV, FPV/r, IDV, IDV/r, NFV, RTV (as the sole PI), SQV, SQV/r, TPV, TPV/r, or a three-NRTI ARV regimen (e.g., ABC/ZDV/3TC). See Archived Drugs in the Perinatal Guidelines and What Not to Use in the Adult and Adolescent Antiretroviral Guidelines for individual ARV drugs, ARV combinations, and ARV regimens that are not recommended or that should not be used in adults. Refer to the table above and Table 4 for ARV regimens that are recommended for use in pregnancy.

Key: 3TC = lamivudine; ABC = abacavir; ART = antiretroviral therapy; ARV = antiretroviral; ATV = atazanavir; ATV/c = atazanavir/cobicistat; ATV/r = atazanavir/ritonavir; BIC = bictegravir; d4T = stavudine; ddI = didanosine; DOR = doravirine; DRV = darunavir; DRV/c = darunavir/cobicistat; DRV/r = darunavir/ritonavir; DTG = dolutegravir; EFV = efavirenz; ETR = etravirine; EVG = elvitegravir; EVG/c = elvitegravir/cobicistat; FDC = fixed-dose combination; FPV = fosamprenavir; FPV/r = fosamprenavir/ritonavir; FTC = emtricitabine; FTR = fostemsavir; IBA = ibalizumab; IDV = indinavir; IDV/r = indinavir/ritonavir; INSTI = integrase strand transfer inhibitor; LPV = lopinavir; LPV/r = lopinavir/ritonavir; MVC = maraviroc; NFV = nelfinavir; NNRTI = non-nucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; NVP = nevirapine; PI = protease inhibitor; PK = pharmacokinetic; RAL = raltegravir; RPV = rilpivirine; RTV = ritonavir; SQV = saquinavir; SQV/r = saquinavir/ritonavir; T 20 = enfuvirtide; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate; TPV = tipranavir; TPV/r = tipranavir/ritonavir; ZDV = zidovudine
Integrase Strand Transfer Inhibitor (INSTI) Drugs
Used in combination with a dual-nucleoside reverse transcriptase inhibitor (NRTI) backbonec
DTG
 
Preferred Continue Preferred Preferred Preferred
RAL Preferred Continue Preferred Preferred Preferred
BIC Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data
EVG/cd Not recommended Continue with frequent viral load monitoring or consider switching Not recommended Not recommended Not recommended
Protease Inhibitor (PI) Drugs
Used in combination with a dual-NRTI backbonec
ATV/r Preferred Continue Preferred Preferred Preferred
DRV/r Preferred Continue Preferred Preferred Preferred
LPV/r Not recommended, except in special circumstances Continue Not recommended, except in special circumstances Not recommended, except in special circumstances Not recommended, except in special circumstances
ATV/cd Not recommended Continue with frequent viral load monitoring or consider switching Not recommended Not recommended Not recommended
DRV/cd Not recommended Continue with frequent viral load monitoring or consider switching Not recommended Not recommended Not recommended
Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) Drugs
Used in combination with a dual-NRTI backbonec
EFV Alternative Continue Alternative Alternative Alternative
RPVe Alternative Continue Alternative Alternative Alternative
DOR Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data
ETRf Not recommended Continue Not recommended, except in special circumstances Not recommended, except in special circumstances Not recommended, except in special circumstances
NVPf Not recommended Continue Not recommended, except in special circumstances Not recommended, except in special circumstances Not recommended, except in special circumstances
NRTI Drugsc,g
ABCh Preferred Continue Preferred Preferred Preferred
FTC Preferred Continue Preferred Preferred Preferred
3TC Preferred Continue Preferred Preferred Preferred
TDF Preferred Continue Preferred Preferred Preferred
ZDV Alternative Continue Alternative Alternative Alternative
TAFi Alternative  Continue Alternative  Alternative  Alternative 
Entry, Attachment, and Fusion Inhibitor Drugs
IBA Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data
MVCf Not recommended Continue Not recommended, except in special circumstances Not recommended, except in special circumstances Not recommended, except in special circumstances
T-20f Not recommended Continue Not recommended, except in special circumstances Not recommended, except in special circumstances Not recommended, except in special circumstances
FTR Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data
Fixed-Dose Combination (FDC) Regimensd,g
The individual drug component that is most responsible for the overall recommendation is indicated in parentheses.
ABC/DTG/3TCh Preferred Continue Preferred Preferred Preferred
EFV/FTC/TDF Alternative (EFV) Continue Alternative (EFV) Alternative (EFV) Alternative (EFV)
EFV/3TC/TDF Alternative (EFV) Continue Alternative (EFV) Alternative (EFV) Alternative (EFV)
FTC/RPV/TDFe Alternative (RPV) Continue (RPV) Alternative (RPV) Alternative (RPV) Alternative (RPV)
BIC/FTC/TAF Insufficient data (BIC) Insufficient data (BIC) Insufficient data (BIC) Insufficient data (BIC) Insufficient data (BIC)
DOR/3TC/TDF Insufficient data (DOR) Insufficient data (DOR) Insufficient data (DOR) Insufficient data (DOR) Insufficient data (DOR)
FTC/RPV/TAF Alternative Continue Alternative Alternative Alternative
EVG/c/FTC/TDFd Not recommended (EVG/c) Continue with frequent viral load monitoring or consider switching (EVG/c) Not recommended (EVG/c) Not recommended (EVG/c) Not recommended (EVG/c)
EVG/c/FTC/TAFd Not recommended (EVG/c) Continue with frequent viral load monitoring or consider switching (EVG/c)  Not recommended (EVG/c) Not recommended (EVG/c) Not recommended (EVG/c)
DRV/c/FTC/TAFd Not recommended (DRV/c) Continue with frequent viral load monitoring or consider switching (DRV/c)  Not recommended (DRV/c) Not recommended (DRV/c) Not recommended (DRV/c)
DTG/3TC
As a complete regimenj
Not recommended Not recommended; switch, or add additional agents Not recommended Not recommended Not recommended
DTG/RPV
As a complete regimenj
Not recommended Not recommended; switch, or add additional agentse Not recommended Not recommended Not recommended