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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Table 5. Situation-Specific Recommendations for Use of Antiretroviral Drugs in Pregnant People and Nonpregnant People Who Are Trying to Conceive
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
aDo 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, TAF plus FTC, and TDF plus 3TC are Preferred dual-NRTI backbones, and ZDV plus 3TC is an Alternative dual-NRTI backbone for ARV regimens.

d The long-acting injectable formulations of CAB and RPV are available only as a co-packaged product. Co-administration of CAB plus RPV is a complete two-drug ART regimen for nonpregnant adults with HIV RNA levels <50 copies/mL for at least 3 months, on a stable ARV regimen, with no history of treatment failure, and no known or suspected resistance to CAB or RPV. Oral lead-in dosing with CAB and RPV for at least 28 days is used to assess tolerability before starting monthly long-acting IM injections. CAB plus RPV (oral or injectable) should not be administered with NRTIs or other ARV drugs. Oral and injectable CAB and injectable RPV are not recommended for use in pregnancy. The Panel recommends that people who conceive while taking long-acting injectable CAB plus RPV switch to an oral regimen recommended for use in pregnancy; timing of the switch must take into account the long half-life of the long-acting injectable formulations with persistence of the drug for up to 12 months. With the current dosing schedule of monthly injections, change to an oral regimen should occur within 4 weeks of the last CAB and RPV IM doses.1 Dosing recommendations, including guidance for switching to an oral regimen, can be found in the prescribing information2,3 and the Adult and Adolescent Antiretroviral Guidelines.

e 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 concerns about switching exist, 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; higher doses of ATV are required if coadministered with TDF or antacids, and twice-daily dosing is required for DRV, in the second and third trimesters.

f 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.

g Although these drugs are not recommended for initial treatment in ART-naive pregnant people, in special circumstances ART-experienced people may need to continue or initiate ETR, NVP, MVC, and T-20 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.

h When using FDC tablets, refer to Table 11 and the drug sections in Appendix B for information about the dosing and safety of individual components of the FDC tablet during pregnancy.

i 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.

j Two-drug oral ARV regimens are not recommended for use in pregnancy due to lack of available data about use in pregnancy. However, pregnant persons who present to care on an oral DTG/3TC or DTG/RPV regimen with successfully maintained virologic suppression can continue it with more frequent viral load monitoring, every 1–2 months throughout pregnancy, because the component drugs are recommended for use in pregnancy.

The following drugs and drug combinations, which are not listed above, should not be used during pregnancy: If a person becomes pregnant while taking any of these medications, they 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; CAB = cabotegravir; d4T = stavudine; ddI = didanosine; DOR = doravirine; DRV = darunavir; DRV/c = darunavir/cobicistat; DRV/r = darunavir/ritonavir; DTG = dolutegravir; EFV = efavirenz; ETR = etravirine; 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; IM = intramuscular; IM CAB and RPV = long-acting intramuscular formulations of cabotegravir and rilpivirine; INSTI = integrase strand transfer inhibitor; 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
CABd
Oral (lead-in)
Long-acting (IM)
Not recommended Insufficient data Not recommended Not recommended Insufficient data
EVG/ce 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/ce Not recommended Continue with frequent viral load monitoring or consider switching Not recommended Not recommended Not recommended
DRV/ce 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
RPV
Oralf
Alternative Continue Alternative Alternative Alternative
RPV
Long-acting (IM)d
Not recommended Insufficient data Not recommended Not recommended Insufficient data
DOR Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data
ETRg Not recommended Continue Not recommended, except in special circumstances Not recommended, except in special circumstances Not recommended, except in special circumstances
NVPg Not recommended Continue Not recommended, except in special circumstances Not recommended, except in special circumstances Not recommended, except in special circumstances
NRTI Drugsc,h
ABCi 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
TAF Preferred Continue Preferred  Preferred Preferred 
Entry, Attachment, and Fusion Inhibitor Drugs
IBA Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data
MVCg Not recommended Continue Not recommended, except in special circumstances Not recommended, except in special circumstances Not recommended, except in special circumstances
T-20g 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 and Co-administered (FDC) Regimensd,e,h
The individual drug component that is most responsible for the overall recommendation is indicated in parentheses.
ABC/DTG/3TCi 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/TDFf 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/TDFe 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/TAFe 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/TAFe 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 Continue with frequent viral load monitoringf Not recommended Not recommended Not recommended
IM CAB and RPVd
As a complete regimen
Not recommended Insufficient data Not recommended Not recommended Insufficient data