7.2.2 First-line ART for pregnant and breastfeeding women and ARV drugs for their infants
Consolidated ARV guidelines, June 2013
The 2010 WHO guidelines on PMTCT (82) recommended a choice of four different regimens for pregnant and breastfeeding women with HIV who required ART for their own health: AZT + 3TC or TDF + 3TC (or FTC) plus either NVP or EFV. Because of concerns about the increased risk of toxicity of NVP among pregnant women with higher CD4 counts (132–134) , the recommended regimens for pregnant women who did not require treatment for their own health and who were receiving triple ARV regimens for PMTCT were AZT + 3TC or TDF + 3TC (or FTC) + EFV as the preferred NNRTI regimens. Alternative regimens were AZT + 3TC plus either LPV/r or ABC, rather than NVP. Although TDF and EFV were recommended, there were limited safety data on their use during pregnancy and breastfeeding.
The 2010 WHO guidelines (82) also recommended four to six weeks of infant NVP (or AZT) as post-exposure prophylaxis for all infants born to mothers who were receiving triple ARV regimens for treatment or prevention. Daily NVP infant prophylaxis throughout breastfeeding was recommended if the mother was not receiving a triple ARV regimen.
In clinical trials, infant prophylaxis has been shown to be especially important for PMTCT when the mother has received limited or no antepartum ARV drugs and when virological suppression has not yet been achieved (135–137). This continues to be a recommended component of PMTCT regimens in resource-rich countries as added protection against exposure to HIV during labour, even when mothers receive ART during pregnancy and when the mother is not breastfeeding (138). The data informing this recommendation have not changed since 2010.