7.1.2 When to start ART in pregnant and breastfeeding women

Consolidated ARV guidelines, June 2013


ARV drugs are used for pregnant and breastfeeding women with HIV primarily for the mother’s health and to prevent the exposed child from becoming infected. It may also offer benefits for preventing the sexual transmission of HIV. The 2010 WHO PMTCT guidelines (82) recommended lifelong ART for women eligible for treatment (based on the 2010 eligibility criteria of CD4 counts ≤350 cells/mm3 or presence of WHO clinical stage 3 or 4 disease) and ARV prophylaxis for PMTCT for women with HIV not eligible for treatment.

For those not eligible for treatment, two prophylaxis regimens were recommended: “Option A”, AZT for the mother during pregnancy, single-dose NVP (sd-NVP) plus AZT and 3TC for the mother at delivery and continued for a week postpartum; and “Option B”, triple ARV drugs for the mother during pregnancy and throughout breastfeeding.

Prophylaxis was recommended to start as early as 14 weeks of gestation, and both prophylaxis options included four to six weeks of peripartum NVP or AZT for the infant, regardless of whether the mother was breastfeeding. Countries were advised to choose a national approach for their ARV option for PMTCT based on operational considerations.

To accelerate the rapid global scaling up of ART and PMTCT in resource-limited settings, ensure equitable access to ART for pregnant women and achieve the global goal of eliminating new paediatric infections and keeping mothers alive (83) , recommendations need to be further simplified, standardized and harmonized.

In 2011, Malawi implemented a new approach of lifelong ART for all pregnant and breastfeeding women with HIV regardless of CD4 count or clinical status, commonly referred to as “Option B+” (84–86). WHO issued a programmatic update in April 2012 (87) outlining some of the operational advantages of Option B and the emerging strategy of Option B+.

These 2013 guidelines recommend ART (one simplified triple regimen) for all pregnant and breastfeeding women with HIV during the period of risk of mother-to-child HIV transmission and continuing lifelong ART either for all women or for the women meeting eligibility criteria for their own health. Option A is no longer recommended.