Treatment algorithm
Your Organizational Guidance
ebpracticenet urges you to prioritize the following organizational guidance:
Richtlijn zorg voor patiënten met hiv in de eerste lijnPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2023GPC sur la prise en charge des patients vivant avec le VIHPublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2023Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
pregnant women: <38 weeks not in labor (regardless of HIV RNA level)
antiretroviral therapy (ART): preferred 2-NRTI backbone
Women with HIV who are receiving ART should continue their ART during pregnancy provided that it is safe, effective in suppressing viral replication, and well tolerated. Women who are not currently taking ART should be started on a regimen as soon as HIV is a feasible diagnosis, regardless of CD4 count or viral load; earlier viral suppression is associated with a lower risk of perinatal transmission.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Antiretroviral regimens are complex and a specialist should be consulted for guidance on the best combination to use. The options listed here are examples only and are based on current US guidance for pregnant women (and those trying to conceive).[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full Other regimens may be recommended in special circumstances and specific situations; local guidelines should be consulted.
Two nucleoside reverse transcriptase inhibitors are recommended as the backbone of combination regimens.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Primary options
emtricitabine/tenofovir disoproxil
OR
emtricitabine/tenofovir alafenamide
OR
lamivudine/tenofovir disoproxil
OR
lamivudine
and
tenofovir alafenamide
Secondary options
abacavir/lamivudine
More abacavir/lamivudineAbacavir/lamivudine should not be used in patients with HLA-B* 5701 because of the risk of hypersensitivity reaction. It is also not recommended with atazanavir/ritonavir or efavirenz if pretreatment HIV RNA is >100,000 copies/mL.
OR
lamivudine/zidovudine
More lamivudine/zidovudineLamivudine/zidovudine has increased potential for hematologic and other toxicities.
antiretroviral therapy (ART): INSTI or PI or NNRTI
Treatment recommended for ALL patients in selected patient group
Antiretroviral regimens are complex and a specialist should be consulted for guidance on the best combination to use. The options listed here are examples only and are based on current US guidance for pregnant women.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full Other regimens may be recommended in special circumstances and specific situations; local guidelines should be consulted.
An integrase strand transfer inhibitor (INSTI) is the preferred agent to add to the 2-NRTI backbone. Protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) may also be used; however, there are no preferred PIs or NNRTIs in treatment-naive pregnant women.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Primary options
INSTI-based regimen
bictegravir/emtricitabine/tenofovir alafenamide
More bictegravir/emtricitabine/tenofovir alafenamideBictegravir is only available commercially as a combination formulation with a 2-NRTI backbone of emtricitabine/tenofovir alafenamide.
OR
INSTI-based regimen
dolutegravir
Secondary options
INSTI-based regimen
raltegravir
OR
PI-based regimen
darunavir
and
ritonavir
OR
PI-based regimen
atazanavir
More atazanavirAtazanavir has been associated with benign indirect maternal hyperbilirubinemia.
and
ritonavir
OR
NNRTI-based regimen
efavirenz
More efavirenzPreviously, efavirenz was only recommended after 8 weeks’ gestation; however, it is commonly used in the first trimester and current guidelines support this.
OR
NNRTI-based regimen
rilpivirine
pregnant women with HIV RNA levels >1000 copies/mL: at 38 weeks or in labor
cesarean delivery
A scheduled cesarean delivery at 38 weeks' gestation is recommended for pregnant women with HIV and who have HIV-1 RNA levels >1000 copies/mL or unknown viral load near the time of delivery (within 4 weeks of delivery), in order to reduce the risk of perinatal transmission.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full Individualized birth plans to extend pregnancies beyond 38 weeks and to avoid the need for cesarean delivery may be considered in women with HIV RNA >1000 copies/mL or unknown viral load who have started intrapartum antiretroviral therapy (ART).[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
In nonvirally suppressed patients who present in labor prior to their scheduled cesarean delivery date, an emergency cesarean delivery should be performed. In patients who present with rupture of membranes, there are insufficient data to address the question of how long after the onset of labor or rupture of membranes the benefit of cesarean delivery to prevention of perinatal transmission is lost.
Urgent consideration with a perinatal HIV specialist is recommended.
zidovudine plus continue antiretroviral therapy (ART)
Treatment recommended for ALL patients in selected patient group
Intravenous zidovudine should be started at least 3 hours before scheduled delivery in women with HIV RNA >1000 copies/mL or unknown viral load near delivery (within 4 weeks of delivery). It is also recommended if there is a known or suspected lack of adherence to ART since the last HIV RNA result, or the patient tests positive during labor.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Women should also continue taking their antepartum ART on schedule during labor and before scheduled delivery.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Primary options
zidovudine: 2 mg/kg intravenously as a loading dose, followed by 1 mg/kg/hour infusion until cord clamp
pregnant women with HIV RNA levels ≤1000 copies/mL: at 38 weeks or in labor
await normal vaginal delivery plus continue antiretroviral therapy (ART)
Scheduled cesarean delivery is not routinely recommended for women on ART who have HIV RNA levels ≤1000 copies/mL because of the low rate of perinatal transmission in these patients, as well as limited or no known evidence of benefit and an increased risk of infection, surgical trauma, hospital deaths, and prolonged hospitalization associated with cesarean delivery.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full [15]Kourtis AP, Ellington S, Pazol K, et al. Complications of cesarean deliveries among HIV-infected women in the United States. AIDS. 2014 Nov 13;28(17):2609-18. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4509679 http://www.ncbi.nlm.nih.gov/pubmed/25574961?tool=bestpractice.com [96]American College of Obstetricians and Gynecologists. ACOG committee opinion no. 751: Labor and delivery management of women with human immunodeficiency virus infection. Sep 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/09/labor-and-delivery-management-of-women-with-human-immunodeficiency-virus-infection
If scheduled cesarean delivery or induction is indicated in these patients, it should be performed at the standard time for obstetric indications.
Women should also continue taking their antepartum ART on schedule during labor and before delivery, regardless of route of delivery.
zidovudine
Treatment recommended for SOME patients in selected patient group
Intravenous zidovudine may be considered in women with HIV RNA between 50 and ≤1000 copies/mL within 4 weeks of delivery; however, there are inadequate data to determine whether this provides additional protection against perinatal transmission in this group. It is also recommended if there is a known or suspected lack of adherence to antiretroviral therapy (ART) since the last HIV RNA result, or the patient tests positive during labor. It is not recommended in women receiving ART with HIV RNA ≤50 copies/mL during late pregnancy and near delivery, provided there are no concerns about adherence to ART.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Primary options
zidovudine: 2 mg/kg intravenously as a loading dose, followed by 1 mg/kg/hour infusion until cord clamp
infant with in utero or intrapartum HIV exposure
initial postnatal antiretroviral prophylaxis
All infants who have been perinatally exposed to HIV should receive postnatal antiretroviral prophylaxis in the immediate neonatal period to reduce the risk of perinatal transmission. Antiretroviral prophylaxis should be started as close to the time of delivery as possible, and preferably within 6 hours of birth.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Choice of antiretroviral regimen for infants with in utero or intrapartum exposure to HIV is based on the predicted risk for transmission as determined by the mother’s HIV RNA levels.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Infants at high risk of HIV acquisition (i.e., born to a pregnant woman with HIV RNA ≥50 copies/mL in the 4 weeks prior to delivery): a three-drug regimen consisting of zidovudine plus lamivudine plus either nevirapine (treatment dose) or raltegravir is recommended, administered from birth for 2-6 weeks. This serves as presumptive HIV therapy or enhanced prophylaxis. If the HIV test at birth is negative and the duration of prophylaxis is <6 weeks, zidovudine monotherapy should be continued to complete a 6-week course.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Infants at low risk of HIV acquisition (i.e., born to a pregnant woman with HIV RNA <50 copies/mL from 20 weeks’ gestation through to delivery, ideally documented by at least 2 consecutive tests at least 4 weeks apart but can be based on clinical judgment): zidovudine monotherapy for 2 weeks is recommended.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Infants who do not meet the criteria above should receive antiretroviral regimens and durations based on case-specific factors related to the level and timing of viremia during pregnancy.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full Consult your local guidance for more information.
Antiretroviral regimens are complex and a pediatric HIV specialist should be consulted for guidance on the best combination to use and doses. The options listed here are examples only and are based on current US guidance.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Primary options
Infants at high risk of HIV acquisition
zidovudine
More zidovudineIf the HIV test at birth is negative and the duration of prophylaxis is <6 weeks, zidovudine monotherapy should be continued to complete a 6-week course.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
-- AND --
lamivudine
-- AND --
nevirapine
or
raltegravir
OR
Infants at low risk of HIV acquisition
zidovudine
counseling on infant feeding options
Treatment recommended for ALL patients in selected patient group
US guidelines recommend that patients should receive patient-centered, evidence-based counseling to support shared decision-making about infant feeding, including breastfeeding. Counseling should include information about available feeding options, including formula feeding, use of banked donor milk, or breastfeeding.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Several studies in low‐resource settings with exclusive breastfeeding in women with HIV demonstrated next to no perinatal HIV transmission with maternal viral suppression on antiretroviral therapy (ART).[38]Shapiro RL, Hughes MD, Ogwu A, et al. Antiretroviral regimens in pregnancy and breast-feeding in Botswana. N Engl J Med. 2010 Jun 17;362(24):2282-94. http://www.ncbi.nlm.nih.gov/pubmed/20554983?tool=bestpractice.com [97]Flynn PM, Taha TE, Cababasay M, et al. Prevention of HIV-1 transmission through breastfeeding: efficacy and safety of maternal antiretroviral therapy versus infant nevirapine prophylaxis for duration of breastfeeding in HIV-1-infected women with high CD4 cell count (IMPAACT PROMISE): a randomized, open-label, clinical trial. J Acquir Immune Defic Syndr. 2018 Apr 1;77(4):383-92. https://journals.lww.com/jaids/Fulltext/2018/04010/Prevention_of_HIV_1_Transmission_Through.6.aspx http://www.ncbi.nlm.nih.gov/pubmed/29239901?tool=bestpractice.com [98]Luoga E, Vanobberghen F, Bircher R, et al. Brief report: no HIV transmission from virally suppressed mothers during breastfeeding in rural Tanzania. J Acquir Immune Defic Syndr. 2018 Sep 1;79(1):e17-e20. https://journals.lww.com/jaids/Fulltext/2018/09010/Brief_Report__No_HIV_Transmission_From_Virally.15.aspx http://www.ncbi.nlm.nih.gov/pubmed/29781882?tool=bestpractice.com However, while suppressive ART significantly reduces the risk of perinatal HIV transmission through breastfeeding, it does not completely eliminate the risk (estimated to be 3/1000).[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Replacement feeding is recommended to eliminate the risk of HIV transmission via breastfeeding when people with HIV are not on ART, and/or do not have a suppressed viral load during pregnancy (at a minimum throughout the third trimester), and at delivery. However, patients who are on ART with a sustained undetectable viral load should be supported if they choose to breastfeed. If the breastfeeding parent has a detectable viral load, replacement feeding should be initiated and breastfeeding temporarily stopped or discontinued while viral load is rechecked and causes for the viremia are investigated. If the repeat viral load is undetectable, breastfeeding may resume. If the repeat viral load is detectable, options may include initiating or modifying infant antiretroviral prophylaxis, permanently discontinuing breastfeeding, and considering the need for infant HIV testing. Most experts recommend permanently discontinuing breastfeeding if HIV RNA is ≥200 copies/mL.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Measures that minimize risk of HIV transmission (e.g., exclusive breastfeeding for the first 6 months, gradual weaning, immediate treatment of maternal mastitis and infant thrush, infant monitoring) are recommended in women who choose to breastfeed.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
The American Academy of Pediatrics (AAP) supports a harm reduction approach to support people on ART with sustained viral suppression <50 copies/mL, but recommends counseling people against breastfeeding if they are not on ART or are on ART without viral suppression.[99]Abuogi L, Noble L, Smith C, et al. Infant feeding for persons living with and at risk for HIV in the United States: clinical report. Pediatrics. 2024 Jun 1;153(6):e2024066843. https://publications.aap.org/pediatrics/article/153/6/e2024066843/197305/Infant-Feeding-for-Persons-Living-With-and-at-Risk http://www.ncbi.nlm.nih.gov/pubmed/38766700?tool=bestpractice.com
extended antiretroviral prophylaxis
Treatment recommended for SOME patients in selected patient group
Extended antiretroviral prophylaxis during breastfeeding should ensure continuous prophylaxis through the entire postnatal period. Infants should be transitioned to extended prophylaxis only after completion of initial postnatal prophylaxis with zidovudine.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
HIV RNA levels of the breastfeeding parent should be monitored periodically during breastfeeding.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Choice of antiretroviral regimen in infants with exposure to HIV during the breastfeeding period is based on the current or anticipated virologic status of the breastfeeding parent.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Infants at low risk of HIV acquisition during breastfeeding (i.e., breastfeeding parent is receiving ART with HIV RNA <50 copies/mL for at least 3 months prior to delivery and there are no concerns about ART adherence): there is no consensus about management in these patients. Nevirapine or lamivudine are the recommended options. However, some experts do not recommend extended prophylaxis in these patients.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Infants currently at low risk of HIV acquisition during breastfeeding but with concerns for future risk (i.e., concerns about lack of ART adherence or loss of virologic suppression for other reasons during breastfeeding): nevirapine or lamivudine should be considered.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Extended prophylaxis should continue until either 6 weeks after the last exposure to breast milk, or 6 weeks after concerns about the breastfeeding parent’s virologic suppression have resolved, whichever comes first. It may be reasonable to discontinue prophylaxis earlier if the concerns for viremia in the breastfeeding parent have resolved.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Nevirapine or lamivudine can be given from birth (replacing zidovudine) to provide initial postnatal prophylaxis and extended prophylaxis during breastfeeding.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full Consult your local guidelines for more information.
Antiretroviral regimens are complex and a pediatric HIV specialist should be consulted for guidance on the best combination to use and doses. The options listed here are examples only and are based on current US guidance.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Primary options
nevirapine
OR
lamivudine
stop breastfeeding and start presumptive antiretroviral therapy (ART)
Treatment recommended for SOME patients in selected patient group
HIV RNA levels of the breastfeeding parent should be monitored periodically during breastfeeding. If the breastfeeding parent experiences new viremia during breastfeeding, breastfeeding should be temporarily stopped or discontinued, replacement feeding initiated, and an HIV test performed in the infant. Permanent discontinuation is recommended by most experts when HIV RNA is ≥200 copies/mL, but some support resuming breastfeeding once virologic suppression is achieved again.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
The choice of antiretroviral regimen depends on the level of maternal viremia.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
HIV RNA ≥200 copies/mL: in infants age <4 weeks, zidovudine plus lamivudine plus nevirapine (treatment dose) or raltegravir for 2-6 weeks is recommended. In infants age ≥4 weeks, a three-drug regimen consisting of zidovudine plus lamivudine plus dolutegravir for 2-6 weeks is recommended. This serves as presumptive HIV therapy or enhanced prophylaxis. If the HIV test is negative and the duration of prophylaxis is <6 weeks, zidovudine monotherapy can be continued to complete a 6-week course.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
HIV RNA <200 copies/mL: there is no consensus about management in these patients. Some experts recommend a three-drug regimen (as for those with HIV RNA ≥200 copies/mL), while others recommend a single-drug regimen with either nevirapine or lamivudine. Others recommend management based on repeat HIV RNA testing of the breastfeeding parent. Consult with an expert is recommended.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Infants of mothers with a new diagnosis of HIV during breastfeeding should be managed as per the recommendations for infants at high risk of in utero or intrapartum HIV acquisition, along with replacement feeding.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Antiretroviral regimens are complex and a pediatric HIV specialist should be consulted for guidance on the best combination to use and doses. The options listed here are examples only and are based on current US guidance.[7]Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jun 2025 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new?view=full
Primary options
Maternal HIV RNA ≥200 copies/mL: infant <4 weeks of age
zidovudine
-- AND --
lamivudine
-- AND --
nevirapine
or
raltegravir
OR
Maternal HIV RNA ≥200 copies/mL: infant ≥4 weeks of age
zidovudine
and
lamivudine
and
dolutegravir
OR
Maternal HIV RNA <200 copies/mL
nevirapine
OR
Maternal HIV RNA <200 copies/mL
lamivudine
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
Use of this content is subject to our disclaimer