Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States

The postpartum period provides an opportunity to review and optimize a patient’s health care. Comprehensive medical care and supportive services are particularly important for people with HIV and their families, who often face multiple medical and social challenges. Components of comprehensive care include the following services, as needed:

• Primary care, gynecologic/obstetric care, and HIV specialty care;
• Pediatric and pediatric HIV specialty care for the infant;
• Sexual and reproductive health services, including contraception;
• Mental health services;
• Substance use prevention and treatment;
• Supportive services;
• Coordination of care through case management for the patient, their child (or children), and other family members; and
• Prevention of secondary transmission for partners with differing HIV status, including counseling on the use of condoms, antiretroviral therapy (ART) to maintain virologic suppression in the partner with HIV (i.e., treatment as prevention), and the potential use of pre-exposure prophylaxis (PrEP) by the partner without HIV (see Pre-exposure Prophylaxis [PrEP] to Prevent HIV During Periconception, Antepartum, and Postpartum Periods).

Supportive services should be tailored to the individual’s needs and can include screening for intimate partner violence; case management; childcare; respite care; assistance with basic needs, such as housing, food, and transportation; peer counseling; and legal and advocacy services. Ideally, these services should begin before pregnancy and continue throughout pregnancy and the postpartum period.

During the postpartum period, immediate linkage to care, comprehensive medical assessment, counseling, and follow-up are required for all people with HIV and particularly for those who have a new positive HIV test during labor or at delivery. This is important because intrapartum diagnosis of HIV has been negatively associated with HIV care outcomes in the postpartum period.^1,2 The American College of Obstetricians and Gynecologists recommends that all people have contact with their obstetrician-gynecologists within 3 weeks postpartum and that postpartum care be provided as an ongoing process based on an individual’s needs rather than as a single postpartum visit.³ People with HIV, particularly those who struggle with ART adherence, should have a follow-up appointment with the health care provider who manages their HIV care—whether that is an obstetrician or an HIV health care provider—within 2 to 4 weeks of postpartum hospital discharge. People who have difficulty attending in-person appointments should consider telemedicine visits.⁴

When care is not co-located or not within the same health care system, a case manager’s role for care coordination becomes even more crucial. People who are receiving case management are more likely to have viral suppression and be retained in care.⁵ Alternative models of HIV care delivery—such as HIV-adapted group prenatal care—have been associated with higher retention in HIV care for women in the postpartum period.⁶ Ensuring continuity of ART between the antepartum and postpartum periods is especially critical. People with HIV newly diagnosed in the intrapartum period should receive ART, and presumptive HIV therapy should be initiated immediately for the newborn before hospital discharge. Special hospital programs may need to be established to support dispensing ART to birthing parents before discharge.

Transgender and gender-diverse people who were assigned female sex at birth may require additional support and linkage to care during the postpartum period (see Perinatal HIV Prevention for Transgender and Gender-Diverse People Assigned Female at Birth).^7-9

Postpartum Antiretroviral Therapy

ART should be continued postpartum. Decisions about changes to an ART regimen after delivery should be made after discussion between the individual and their HIV care provider, ideally before delivery. When providing counseling about postpartum ART, health care providers should consider the person’s desire for future planned pregnancies or the potential for unplanned pregnancies in the context of the person’s anticipated ART regimen, choice of contraceptive, and the potential for any drug–drug interactions during the postpartum period that were not an issue during pregnancy (see Prepregnancy Counseling and Care for Persons of Childbearing Age with HIV and Appendix C: Antiretroviral Counseling Guide for Health Care Providers). Some ART regimens that are recommended for nonpregnant adults may not be recommended for use during pregnancy or for people who are trying to conceive (see the Adult and Adolescent Antiretroviral Guidelines). See Recommendations for Use of Antiretroviral Drugs During Pregnancy, Table 4. Antepartum Screenings and Assessments for Pregnant People with HIV, Table 5. HIV-Related Laboratory Monitoring Schedule for Pregnant People with HIV, Teratogenicity, and Antiretroviral Drug Regimens and Pregnancy Outcomes for additional information and specific recommendations regarding regimens for use during pregnancy and when trying to conceive.

ART is currently recommended for all individuals with HIV to reduce the risk of disease progression and to prevent secondary transmission of HIV.¹⁰ The Strategic Timing of AntiRetroviral Treatment (START)¹¹ and TEMPRANO trials¹² were randomized clinical trials that demonstrated that early ART can reduce the risk of disease progression, even in individuals with CD4 T lymphocyte cell counts >500 cells/mm³, and the HIV Prevention Trials Network (HPTN) 052 randomized clinical trial demonstrated that effective ART can reduce the risk of sexual transmission of HIV to a partner without HIV by 100%.¹³ People with HIV who take ART as prescribed and achieve and maintain an undetectable viral load have effectively no risk of transmitting HIV through sex (i.e., Undetectable = Untransmittable).¹⁴

Helping people with HIV understand the need for lifelong ART is a priority during postpartum care. Several studies have demonstrated significant decreases in ART adherence postpartum.^15-19 During the postpartum period, people may have difficulty with medical appointment follow-up—including appointment adherence—which can affect ART adherence. Systematic monitoring of retention in HIV care is recommended for all individuals with HIV, but special attention is warranted during the postpartum period.

Adherence to ART and Postpartum Depression

Symptoms of depression have been associated with lower ART adherence and viral suppression during pregnancy and the postpartum period.²⁰ Furthermore, postpartum depression is common among people with HIV.^2,21-24 The U.S. Preventive Services Task Force recommends screening all postpartum people for postpartum depression²⁵ using a validated tool (e.g., the Edinburgh Postnatal Depression Scale); such screening is especially important for people with HIV who appear to be at increased risk for postpartum depression and poor ART adherence during the postpartum period. Enquiring about intimate partner violence, food or housing insecurity, and substance use is also important, as these factors have been associated with worsening depressive symptoms.²⁶ People should be counseled that postpartum physical and psychological changes (and the stresses and demands of caring for a new baby) may make adherence more difficult and that additional support may be needed during this period.^5,27-30

Poor adherence has been shown to be associated with virologic failure, development of antiretroviral (ARV) drug resistance, and decreased long-term effectiveness of ART.^31-33 In people who achieve viral suppression by the time of delivery, postpartum ART simplification to once-daily, coformulated regimens—which are often the preferred initial regimens for nonpregnant adults—could promote adherence during this challenging time. Efforts to maintain adequate adherence during the postpartum period may ensure effectiveness of therapy (see Adherence to the Continuum of Care in the Adult and Adolescent Antiretroviral Guidelines). For people who are continuing ART and who received increased protease inhibitor doses during pregnancy, available data suggest that doses can be reduced to standard doses immediately after delivery. In addition, such behavioral interventions as peer support and text messaging may help improve retention in HIV care postpartum.³⁴

Secondary Sexual Transmission and Contraception

The postpartum period is a critical time for addressing safer sex practices to reduce secondary transmission of HIV to partners,³⁵ and clinicians should begin discussing these practices with the patient during the prenatal period. Topics for discussion during counseling on prevention of secondary transmission to the partner without HIV should include condom use, ART for the partner with HIV to maintain viral suppression below the limit of detection, and the potential use of PrEP by the partner without HIV. With full, sustained viral suppression (undetectable viral load) in the person with HIV—with or without reliable PrEP use by the partner—there is no risk of sexual transmission (see Reproductive Options for Couples When One or Both Partners Have HIV and National Institutes of Health’s Treatment as Prevention guidance for more information).

Comprehensive prepregnancy counseling and contraception should be integrated into all health care visits, with special attention given to these topics during routine prenatal and postpartum visits. Lack of breastfeeding is associated with earlier return of fertility. Ovulation returns as early as 6 weeks postpartum, and it can occur earlier in some people—even before resumption of menses—putting them at risk of pregnancy soon after delivery.³⁶ HIV does not preclude the use of any contraceptive method (see Table 3. Drug Interactions Between Antiretroviral Agents and Hormonal Contraceptives). The contraceptive plans for people with HIV should not differ from those for people without HIV; however, because of the significantly higher prevalence of unplanned pregnancy in people with HIV,³⁷ establishing contraceptive plans early, using shared decision-making, is important. If a long-acting reversible contraceptive (LARC)—such as an injectable, implant, or intrauterine device (IUD)—is desired by the patient, it should be inserted before postpartum hospital discharge or during the routine postpartum visit. If LARC insertion is planned for the postpartum visit and the patient desires a contraceptive method in the interim, intramuscular depot medroxyprogesterone acetate is an option that can be given before postpartum hospital discharge. People should be advised to avoid interpregnancy intervals shorter than 6 months.^3,38,39

The potential for drug–drug interactions between several ARV drugs and hormonal contraceptives is discussed in Prepregnancy Counseling and Care for Persons of Childbearing Age with HIV and Table 3. Drug Interactions Between Antiretroviral Agents and Hormonal Contraceptives. A systematic review conducted for the World Health Organization summarized the research on hormonal contraception, IUD use, and risk of HIV infection and concluded that women with HIV can use all forms of contraception.^40,41 This is consistent with Centers for Disease Control and Prevention recommendations advocating access to a broad range of effective contraceptive methods, including combined hormonal contraceptives, progestin-only pills, depot medroxyprogesterone acetate, and implants.⁴²

Infant Feeding

People with HIV should receive evidence-based counseling to support shared decision-making about infant feeding options prior to and during pregnancy (see Infant Feeding Counseling for Individuals with HIV in the United States. Counseling and plans for infant feeding should be reviewed again after delivery.

Lactation Inhibition

For people who do not breastfeed, symptoms related to breast engorgement can be very unpleasant in the days following labor and delivery. Supportive measures—such as using acetaminophen or ibuprofen for pain control, alternating hot and cold compresses on the breasts, or wearing a tight-fitting bra—can help relieve symptoms related to breast engorgement.³ Although pharmacologic options for lactation inhibition generally are not used in the United States, recent data suggest cabergoline may be appropriate for some people.^43,44 Cabergoline is a dopamine agonist/ergot derivative that reduces the production of prolactin; however, it is not approved by the U.S. Food and Drug Administration for lactation inhibition.^45,46 Cabergoline is contraindicated for women with hypertension—including pregnancy-induced hypertension, preeclampsia, or eclampsia—or liver disease and for women being treated with antipsychotics or those who have a history of puerperal psychosis.⁴⁷ Bromocriptine, another dopamine agonist, is no longer used for lactation inhibition because of serious cardiovascular and neurologic complications associated with its use.⁴⁸

References

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