Updated
Dec. 30, 2021
Reviewed
Dec. 30, 2021

Recommendations for Use of Antiretroviral Drugs During Pregnancy

Table 4. What to Start: Initial Antiretroviral Regimens During Pregnancy for People Who Are Antiretroviral-Naive

Recommendations for initial antiretroviral therapy (ART) therapy during pregnancy are intended for people who have never received ART or antiretroviral (ARV) drugs for prophylaxis (i.e., people who are ARV-naive) and who show no evidence of significant resistance to regimen components (see Pregnant People with HIV Who Have Never Received Antiretroviral Drugs and Table 5).

In general, the Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission (the Panel) recommends that people who are already on fully suppressive ARV regimens when pregnancy occurs should continue to use those regimens, unless they are receiving an ARV drug or ARV regimen that is not recommended for use in adults or concerns exist about safety and inferior efficacy during pregnancy (see Table 5 and Pregnant People with HIV Who Are Currently Receiving Antiretroviral Therapy). Clinicians may need to consider additional factors when initiating ART in patients who previously received ART or ARV drugs for prophylaxis (see Pregnant People with HIV Who Have Previously Received Antiretroviral Treatment or Prophylaxis but Are Not Currently Receiving Any Antiretroviral Medications and Table 5).

Regimens are listed alphabetically within each drug class and recommendation category, so the order does not indicate a ranking of preference. In addition, except where noted below, the Panel makes no recommendation of one agent or regimen over another within each category (Preferred or Alternative). The table also indicates antiretroviral drugs or regimens that are available in fixed-dose combination (FDC) tablets. Patients and providers should make shared decisions about which ARV drugs to use during pregnancy after discussing the known and potential risks to pregnant people and their fetuses (see Appendix C: Antiretroviral Counseling Guide for Health Care Providers and Recommendations for Use of Antiretroviral Drugs During Pregnancy).

Note: For more information about the use of specific drugs and dosing in pregnancy, see Table 5, the individual drug sections in Appendix B, and Table 11.

Table 4. What to Start: Initial Combination Regimens for Antiretroviral-Naive Pregnant Women
Preferred Initial Regimens in Pregnancy

Drugs or drug combinations are designated as Preferred for therapy during pregnancy when clinical trial data in adults have demonstrated efficacy and durability with acceptable toxicity and ease of use, and pregnancy-specific PK data are available to guide dosing. In addition, the available data must suggest a favorable risk-benefit balance for the drug or drug combination compared with other ARV drug options; the assessment of risks and benefits should incorporate maternal, pregnancy, fetal, and infant outcomes. Some Preferred drugs or regimens may have minimal toxicity or teratogenicity risks that are offset by other advantages for people with HIV who are pregnant or who are trying to conceive. Therefore, it is important to read all the information on each drug in the Perinatal Guidelines before administering any of these medications to patients (see Appendix B: Supplement: Safety and Toxicity of Individual Antiretroviral Agents in Pregnancy).

Preferred Dual-NRTI Backbones

ABC/3TC

Available as an FDC. Can be administered once daily. ABC should not be used in patients who test positive for HLA-B*5701 because of the risk of developing a hypersensitivity reaction. ABC/3TC administered with ATV/r or EFV is not recommended if pretreatment HIV RNA is >100,000 copies/mL.

TAF/FTC

or

TAF plus 3TC

TAF/FTC is available as an FDC. Either coformulated TAF/FTC or separate doses of TAF and 3TC can be administered once daily. When combined with DTG, the efficacy and toxicity of TAF/FTC and TDF/FTC for treatment of pregnant patients are similar, but TAF/FTC is associated with fewer adverse birth outcomes and slightly higher gestational weight gain.

TDF/FTC

or

TDF/3TC

TDF/FTC is available as an FDC. Either coformulated TDF/FTC or separate doses of TDF and 3TC can be administered once daily. TDF has potential renal toxicity; thus, TDF-based, dual-NRTI combinations should be used with caution in patients with renal insufficiency.

Preferred INSTI Regimens

DTG/ABC/3TC (FDC)

or

DTG plus a Preferred Dual-NRTI Backbonea

Administered once daily. The use of DTG/ABC/3TC requires HLA-B*5701 testing before starting therapy because this FDC contains ABC. INSTI-based regimens may be particularly useful when drug interactions or the potential for preterm delivery with a PI-based regimen are a concern. In nonpregnant adults, DTG is associated with lower rates of INSTI resistance than RAL; like RAL, DTG has been shown to rapidly decrease viral load in ARV-naive pregnant women who present to care later in pregnancy. DTG is the only Preferred agent recommended for the treatment of acute HIV infection during pregnancy. Either DTG or RAL is the Preferred agent for patients who present to care late in pregnancy. However, DTG is the only Preferred drug for pregnant patients with acute HIV (see Acute HIV Infection). Specific timing and/or fasting recommendations apply if DTG is taken with calcium or iron (e.g., in prenatal vitamins; see Table 11). The use of DTG at conception has been associated with a small increase in the risk of NTDs, but this was not seen when DTG was started during pregnancy. However, in the most recent data from Botswana, there was no longer a significant difference in NTDs with the use of DTG-containing compared to non-DTG containing ARV regimens at conception. This information should be discussed with patients to ensure informed decision-making. For more information, see Recommendations for Use of Antiretroviral Drugs During Pregnancy, Table 5, Teratogenicity, and Appendix C: Antiretroviral Counseling Guide for Health Care Providers.

RAL plus a Preferred Dual-NRTI Backbone

PK data are available for RAL in pregnancy when using the twice-daily formulation (400 mg twice daily), but data are not available for the once-daily 1,200 mg (2 × 600 mg) extended-release formulation “raltegravir HD.” Twice-daily dosing is required in pregnancy. RAL has been shown to produce rapid viral load decline to undetectable levels in women who present for initial therapy late in pregnancy and thus is a Preferred ARV option in this setting. However, RAL is an Alternative ARV for persons diagnosed with acute HIV during pregnancy (see Acute HIV Infection). INSTI-based regimens may be particularly useful when drug interactions or the potential for preterm delivery with PI-based regimens are a concern. Specific timing and/or fasting recommendations apply if RAL is taken with calcium or iron (e.g., in prenatal vitamins; see Table 11).

Preferred PI Regimens

ATV/r plus a Preferred Dual-NRTI Backbone

Once-daily administration. Extensive experience with use in pregnancy. Maternal hyperbilirubinemia; no clinically significant neonatal hyperbilirubinemia or kernicterus reported, but neonatal bilirubin monitoring is recommended. Cannot be administered with PPIs. Specific timing recommended for dosing with H2 blockers (see Table 11).

DRV/r plus a Preferred Dual-NRTI Backbone

Must be used twice daily in pregnancy.

Alternative Initial Regimens in Pregnancy

Drugs or drug combinations are designated as Alternative options for therapy during pregnancy when clinical trial data in adults show efficacy, and the data in pregnant individuals are generally favorable, but limited. Most Alternative drugs or regimens are associated with more PK, dosing, tolerability, formulation, administration, or interaction concerns than those in the Preferred category, but they are acceptable for use in pregnancy. Some Alternative drugs or regimens may have known toxicity or teratogenicity risks that are offset by other advantages for people with HIV who are pregnant or who are trying to conceive. Therefore, it is important to read all the information on each drug in the Perinatal Guidelines before administering any of these medications to patients (see Appendix B: Supplement: Safety and Toxicity of Individual Antiretroviral Agents in Pregnancy).

Alternative Dual-NRTI Backbones

ZDV/3TC

Available as an FDC. Although not recommended for initial therapy in nonpregnant adults, ZDV/3TC is the NRTI combination with most experience for use in pregnancy. It has the disadvantages of requiring twice-daily administration and having the potential for hematologic toxicities and other toxicities.

Alternative NNRTI Regimens

EFV/TDF/FTC (FDC)

or

EFV/TDF/3TC (FDC)

or

EFV plus a Preferred Dual-NRTI Backbone

Birth defects have been reported in primate studies of EFV, but no evidence has been found of an increased risk of birth defects in human studies and extensive experience in pregnancy; cautionary text remains in the package insert (see Teratogenicity, Efavirenz, and Table 11). These regimens are useful for patients who require treatment with drugs that have significant interactions with Preferred agents or who need the convenience of a coformulated, single-tablet, once-daily regimen and are not eligible for DTG or RPV. Screening for antenatal and postpartum depression is recommended. Higher rate of adverse events than some Preferred drugs.

RPV/TDF/FTC (FDC)

or

RPV/TAF/FTC (FDC)

RPV (oral) plus a Preferred Dual-NRTI Backbone

RPV is not recommended in patients with pretreatment HIV RNA >100,000 copies/mL or CD4 counts <200 cells/mm3. Do not use with PPIs. PK data are available for pregnant individuals, but there is relatively little experience with use in pregnancy. PK data suggest lower drug levels and risk of viral rebound in the second and third trimesters; if used, consider monitoring viral load more frequently. Should be taken with food. Available in a coformulated, single-tablet, once-daily regimen.

Insufficient Data in Pregnancy to Recommend for Initial Regimens in People Who Are ART-Naive

These drugs are approved for use in adults but lack adequate pregnancy-specific PK or safety data.

BIC/TAF/FTC (FDC)

Limited data on the use of BIC in pregnancy.

DOR

No data on the use of DOR in pregnancy.

IBA

No data on the use of IBA in pregnancy.

Not Recommended for Initial ART or Use in Pregnancy

These drugs and drug combinations are recommended for use in adults but are not recommended for use during pregnancy because of limited data about use in pregnancy and/or concerns about maternal or fetal safety or PK changes or inferior efficacy, including viral breakthroughs in the second and third trimester (see Table 5 and Table 11).

Note: When a pregnant person presents to care while virally suppressed on one of these drugs or drug combinations, providers should consider whether to continue their current regimen or switch to a recommended ARV regimen (see Pregnant People with HIV Who Are Currently Receiving Antiretroviral Therapy and Table 5).

ATV/c

Limited data exist on the use of ATV with COBI in pregnancy. Substantial reductions in trough levels of ATV in the second and third trimesters have been reported when taken with COBI.

DRV/c (FDC)

or

DRV/c/FTC/TAF (FDC)

Limited data exist on the use of DRV with COBI in pregnancy. Inadequate levels of both DRV and COBI in second and third trimester, as well as viral breakthroughs, have been reported.

EVG/c/FTC/TAF (FDC)

or

EVG/c/FTC/TDF (FDC)

Limited data exist on the use of EVG with COBI (see above). Inadequate levels of both EVG and COBI in the second and third trimester, as well as viral breakthroughs, have been reported. Specific timing and/or fasting recommendations apply, especially if taken with calcium or iron (e.g., in prenatal vitamins; see Table 11).

Long-acting injectable CAB plus RPV (co-packaged formulation)

Limited data on the use of CAB plus RPV in pregnancy. Not recommended for initial treatment for ARV naive adults or adolescents (pregnant or nonpregnant). Due to the long half-life of injectable CAB and RPV, drug levels may persist up to 12 months after the last dose.

Not Recommended for Initial ART in Pregnancy and Not Recommended, Except in Special Circumstances, for Treatment-Experienced People in Pregnancy

These drugs are not recommended for use in pregnant people who have never received ART. With the exception of NVP and LPV/r, data about the PKs, safety, and efficacy of these drugs during pregnancy are limited.

Some of these drugs also are categorized as not recommended except in special circumstances during pregnancy because the Panel recognizes that circumstances may exist in which patients who are ART-experienced may need to initiate or continue these drugs during pregnancy to reach or maintain viral suppression (see Table 5).

ETR

Not recommended for use in nonpregnant ART-naive populations. Data about the use of ETR in pregnancy are limited.

FTR

Not recommended for use in nonpregnant ART-naive populations. Data about the use of FTR in pregnancy are limited.

LPV/r plus a Preferred Dual-NRTI Backbone

Abundant experience and established PKs in pregnancy. Has been associated with an increased risk of preterm delivery (see Antiretroviral Drug Regimens and Maternal and Neonatal Outcomes). More nausea than with Preferred or Alternative agents. If LPV/r is used, it should be dosed twice daily in pregnancy; data suggest that once-daily LPV/r will not achieve sufficient plasma concentrations. Some experts recommend an increased dose of LPV/r in the second and third trimesters (see Table 11 and Lopinavir/Ritonavir).

MVC

Not recommended for use in nonpregnant ART-naive populations. MVC requires tropism testing before use. Available PK data suggest that using the standard adult dose is appropriate for pregnant patients, although data about use in pregnancy are limited.

NVP

Not recommended because of the potential for adverse events, complex lead-in dosing, and low barrier to resistance. NVP should be used with caution when initiating ART in women with CD4 counts >250 cells/mm3. Use NVP and ABC together with caution; both can cause hypersensitivity reactions in the first few weeks after initiation.

T-20

Not recommended for use in nonpregnant ART-naive populations.

Note: The following drugs and drug combinations (not listed above) should not be used during pregnancy; women who become pregnant while taking these medications 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, two-drug ARV regimens, 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.

Key: 3TC = lamivudine; ABC = abacavir; ART = antiretroviral therapy; ARV = antiretroviral; ATV = atazanavir; ATV/c = atazanavir/cobicistat; ATV/r = atazanavir/ritonavir; BIC = bictegravir; CD4 = CD4 T lymphocyte cell; CAB = cabotegravir; COBI = cobicistat; 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/r = lopinavir/ritonavir; MVC = maraviroc; NFV = nelfinavir; NNRTI = non-nucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; NTD = neural tube defect; NVP = nevirapine; the Panel = the Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission; PI = protease inhibitor; PK = pharmacokinetic; PPI = proton pump inhibitor; 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

Recommendations for Use of Antiretroviral Drugs During Pregnancy

Table 4. What to Start: Initial Antiretroviral Regimens During Pregnancy for People Who Are Antiretroviral-Naive

Table 4. What to Start: Initial Combination Regimens for Antiretroviral-Naive Pregnant Women
Preferred Initial Regimens in Pregnancy

Drugs or drug combinations are designated as Preferred for therapy during pregnancy when clinical trial data in adults have demonstrated efficacy and durability with acceptable toxicity and ease of use, and pregnancy-specific PK data are available to guide dosing. In addition, the available data must suggest a favorable risk-benefit balance for the drug or drug combination compared with other ARV drug options; the assessment of risks and benefits should incorporate maternal, pregnancy, fetal, and infant outcomes. Some Preferred drugs or regimens may have minimal toxicity or teratogenicity risks that are offset by other advantages for people with HIV who are pregnant or who are trying to conceive. Therefore, it is important to read all the information on each drug in the Perinatal Guidelines before administering any of these medications to patients (see Appendix B: Supplement: Safety and Toxicity of Individual Antiretroviral Agents in Pregnancy).

Preferred Dual-NRTI Backbones

ABC/3TC

Available as an FDC. Can be administered once daily. ABC should not be used in patients who test positive for HLA-B*5701 because of the risk of developing a hypersensitivity reaction. ABC/3TC administered with ATV/r or EFV is not recommended if pretreatment HIV RNA is >100,000 copies/mL.

TAF/FTC

or

TAF plus 3TC

TAF/FTC is available as an FDC. Either coformulated TAF/FTC or separate doses of TAF and 3TC can be administered once daily. When combined with DTG, the efficacy and toxicity of TAF/FTC and TDF/FTC for treatment of pregnant patients are similar, but TAF/FTC is associated with fewer adverse birth outcomes and slightly higher gestational weight gain.

TDF/FTC

or

TDF/3TC

TDF/FTC is available as an FDC. Either coformulated TDF/FTC or separate doses of TDF and 3TC can be administered once daily. TDF has potential renal toxicity; thus, TDF-based, dual-NRTI combinations should be used with caution in patients with renal insufficiency.

Preferred INSTI Regimens

DTG/ABC/3TC (FDC)

or

DTG plus a Preferred Dual-NRTI Backbonea

Administered once daily. The use of DTG/ABC/3TC requires HLA-B*5701 testing before starting therapy because this FDC contains ABC. INSTI-based regimens may be particularly useful when drug interactions or the potential for preterm delivery with a PI-based regimen are a concern. In nonpregnant adults, DTG is associated with lower rates of INSTI resistance than RAL; like RAL, DTG has been shown to rapidly decrease viral load in ARV-naive pregnant women who present to care later in pregnancy. DTG is the only Preferred agent recommended for the treatment of acute HIV infection during pregnancy. Either DTG or RAL is the Preferred agent for patients who present to care late in pregnancy. However, DTG is the only Preferred drug for pregnant patients with acute HIV (see Acute HIV Infection). Specific timing and/or fasting recommendations apply if DTG is taken with calcium or iron (e.g., in prenatal vitamins; see Table 11). The use of DTG at conception has been associated with a small increase in the risk of NTDs, but this was not seen when DTG was started during pregnancy. However, in the most recent data from Botswana, there was no longer a significant difference in NTDs with the use of DTG-containing compared to non-DTG containing ARV regimens at conception. This information should be discussed with patients to ensure informed decision-making. For more information, see Recommendations for Use of Antiretroviral Drugs During Pregnancy, Table 5, Teratogenicity, and Appendix C: Antiretroviral Counseling Guide for Health Care Providers.

RAL plus a Preferred Dual-NRTI Backbone

PK data are available for RAL in pregnancy when using the twice-daily formulation (400 mg twice daily), but data are not available for the once-daily 1,200 mg (2 × 600 mg) extended-release formulation “raltegravir HD.” Twice-daily dosing is required in pregnancy. RAL has been shown to produce rapid viral load decline to undetectable levels in women who present for initial therapy late in pregnancy and thus is a Preferred ARV option in this setting. However, RAL is an Alternative ARV for persons diagnosed with acute HIV during pregnancy (see Acute HIV Infection). INSTI-based regimens may be particularly useful when drug interactions or the potential for preterm delivery with PI-based regimens are a concern. Specific timing and/or fasting recommendations apply if RAL is taken with calcium or iron (e.g., in prenatal vitamins; see Table 11).

Preferred PI Regimens

ATV/r plus a Preferred Dual-NRTI Backbone

Once-daily administration. Extensive experience with use in pregnancy. Maternal hyperbilirubinemia; no clinically significant neonatal hyperbilirubinemia or kernicterus reported, but neonatal bilirubin monitoring is recommended. Cannot be administered with PPIs. Specific timing recommended for dosing with H2 blockers (see Table 11).

DRV/r plus a Preferred Dual-NRTI Backbone

Must be used twice daily in pregnancy.

Alternative Initial Regimens in Pregnancy

Drugs or drug combinations are designated as Alternative options for therapy during pregnancy when clinical trial data in adults show efficacy, and the data in pregnant individuals are generally favorable, but limited. Most Alternative drugs or regimens are associated with more PK, dosing, tolerability, formulation, administration, or interaction concerns than those in the Preferred category, but they are acceptable for use in pregnancy. Some Alternative drugs or regimens may have known toxicity or teratogenicity risks that are offset by other advantages for people with HIV who are pregnant or who are trying to conceive. Therefore, it is important to read all the information on each drug in the Perinatal Guidelines before administering any of these medications to patients (see Appendix B: Supplement: Safety and Toxicity of Individual Antiretroviral Agents in Pregnancy).

Alternative Dual-NRTI Backbones

ZDV/3TC

Available as an FDC. Although not recommended for initial therapy in nonpregnant adults, ZDV/3TC is the NRTI combination with most experience for use in pregnancy. It has the disadvantages of requiring twice-daily administration and having the potential for hematologic toxicities and other toxicities.

Alternative NNRTI Regimens

EFV/TDF/FTC (FDC)

or

EFV/TDF/3TC (FDC)

or

EFV plus a Preferred Dual-NRTI Backbone

Birth defects have been reported in primate studies of EFV, but no evidence has been found of an increased risk of birth defects in human studies and extensive experience in pregnancy; cautionary text remains in the package insert (see Teratogenicity, Efavirenz, and Table 11). These regimens are useful for patients who require treatment with drugs that have significant interactions with Preferred agents or who need the convenience of a coformulated, single-tablet, once-daily regimen and are not eligible for DTG or RPV. Screening for antenatal and postpartum depression is recommended. Higher rate of adverse events than some Preferred drugs.

RPV/TDF/FTC (FDC)

or

RPV/TAF/FTC (FDC)

RPV (oral) plus a Preferred Dual-NRTI Backbone

RPV is not recommended in patients with pretreatment HIV RNA >100,000 copies/mL or CD4 counts <200 cells/mm3. Do not use with PPIs. PK data are available for pregnant individuals, but there is relatively little experience with use in pregnancy. PK data suggest lower drug levels and risk of viral rebound in the second and third trimesters; if used, consider monitoring viral load more frequently. Should be taken with food. Available in a coformulated, single-tablet, once-daily regimen.

Insufficient Data in Pregnancy to Recommend for Initial Regimens in People Who Are ART-Naive

These drugs are approved for use in adults but lack adequate pregnancy-specific PK or safety data.

BIC/TAF/FTC (FDC)

Limited data on the use of BIC in pregnancy.

DOR

No data on the use of DOR in pregnancy.

IBA

No data on the use of IBA in pregnancy.

Not Recommended for Initial ART or Use in Pregnancy

These drugs and drug combinations are recommended for use in adults but are not recommended for use during pregnancy because of limited data about use in pregnancy and/or concerns about maternal or fetal safety or PK changes or inferior efficacy, including viral breakthroughs in the second and third trimester (see Table 5 and Table 11).

Note: When a pregnant person presents to care while virally suppressed on one of these drugs or drug combinations, providers should consider whether to continue their current regimen or switch to a recommended ARV regimen (see Pregnant People with HIV Who Are Currently Receiving Antiretroviral Therapy and Table 5).

ATV/c

Limited data exist on the use of ATV with COBI in pregnancy. Substantial reductions in trough levels of ATV in the second and third trimesters have been reported when taken with COBI.

DRV/c (FDC)

or

DRV/c/FTC/TAF (FDC)

Limited data exist on the use of DRV with COBI in pregnancy. Inadequate levels of both DRV and COBI in second and third trimester, as well as viral breakthroughs, have been reported.

EVG/c/FTC/TAF (FDC)

or

EVG/c/FTC/TDF (FDC)

Limited data exist on the use of EVG with COBI (see above). Inadequate levels of both EVG and COBI in the second and third trimester, as well as viral breakthroughs, have been reported. Specific timing and/or fasting recommendations apply, especially if taken with calcium or iron (e.g., in prenatal vitamins; see Table 11).

Long-acting injectable CAB plus RPV (co-packaged formulation)

Limited data on the use of CAB plus RPV in pregnancy. Not recommended for initial treatment for ARV naive adults or adolescents (pregnant or nonpregnant). Due to the long half-life of injectable CAB and RPV, drug levels may persist up to 12 months after the last dose.

Not Recommended for Initial ART in Pregnancy and Not Recommended, Except in Special Circumstances, for Treatment-Experienced People in Pregnancy

These drugs are not recommended for use in pregnant people who have never received ART. With the exception of NVP and LPV/r, data about the PKs, safety, and efficacy of these drugs during pregnancy are limited.

Some of these drugs also are categorized as not recommended except in special circumstances during pregnancy because the Panel recognizes that circumstances may exist in which patients who are ART-experienced may need to initiate or continue these drugs during pregnancy to reach or maintain viral suppression (see Table 5).

ETR

Not recommended for use in nonpregnant ART-naive populations. Data about the use of ETR in pregnancy are limited.

FTR

Not recommended for use in nonpregnant ART-naive populations. Data about the use of FTR in pregnancy are limited.

LPV/r plus a Preferred Dual-NRTI Backbone

Abundant experience and established PKs in pregnancy. Has been associated with an increased risk of preterm delivery (see Antiretroviral Drug Regimens and Maternal and Neonatal Outcomes). More nausea than with Preferred or Alternative agents. If LPV/r is used, it should be dosed twice daily in pregnancy; data suggest that once-daily LPV/r will not achieve sufficient plasma concentrations. Some experts recommend an increased dose of LPV/r in the second and third trimesters (see Table 11 and Lopinavir/Ritonavir).

MVC

Not recommended for use in nonpregnant ART-naive populations. MVC requires tropism testing before use. Available PK data suggest that using the standard adult dose is appropriate for pregnant patients, although data about use in pregnancy are limited.

NVP

Not recommended because of the potential for adverse events, complex lead-in dosing, and low barrier to resistance. NVP should be used with caution when initiating ART in women with CD4 counts >250 cells/mm3. Use NVP and ABC together with caution; both can cause hypersensitivity reactions in the first few weeks after initiation.

T-20

Not recommended for use in nonpregnant ART-naive populations.

Note: The following drugs and drug combinations (not listed above) should not be used during pregnancy; women who become pregnant while taking these medications 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, two-drug ARV regimens, 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.

Key: 3TC = lamivudine; ABC = abacavir; ART = antiretroviral therapy; ARV = antiretroviral; ATV = atazanavir; ATV/c = atazanavir/cobicistat; ATV/r = atazanavir/ritonavir; BIC = bictegravir; CD4 = CD4 T lymphocyte cell; CAB = cabotegravir; COBI = cobicistat; 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/r = lopinavir/ritonavir; MVC = maraviroc; NFV = nelfinavir; NNRTI = non-nucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; NTD = neural tube defect; NVP = nevirapine; the Panel = the Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission; PI = protease inhibitor; PK = pharmacokinetic; PPI = proton pump inhibitor; 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

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