**4.5. Procedures for monitoring ART during pregnancy**

**AR Main toxicity Other toxicities**

60 Trends in Basic and Therapeutic Options in HIV Infection - Towards a Functional Cure

Abacavir Hypersensitivity reaction Gastrointestinal Tenofovir - Gastrointestinal, Renal

Indinavir Metabolic, hyperbilirubinemia, kidney stones Gastrointestinal Atanazavir Hyperbilirubinemia, rash Gastrointestinal

**4.3. Opportunity for ART initiation in pregnancy**

Nevirapine Rash, Hepatotoxicity

**Table 3.** Antiretroviral agent toxicity

(Grade B recommendation).

**4.4. Choice of drugs to start ART**

recommendation).

recommendation).

PI (except for Atanazavir)

as follows:

C).

AZT Anemia - Neutropenia Gastrointestinal-headache-rash d4T Polyneuropathy, lipoatrophy, lactic acidosis Pancreatitis, hepatic steatosis 3TC - Gastrointestinal-headache ddl Pancreatitis, polyneuropathy Gastrointestinal, Hyperuricemia

Efavirenz CNS: Vertigo, Psychosis Rash, hepatotoxicity, dyslipidemia

Lipodystrophy, dyslipidemia, diabetes Liver toxicity, gastrointestinal, osteonecrosis

Several cohort studies show that the late initiation of ART is associated both with higher VT as well as with longer duration of VT. The latter is based on the fact that when therapy duration was 9.5 weeks, VT was significantly higher than when therapy duration was 16 weeks (*P* < 0.001) [21]. Conversely, in a study conducted at the United Kingdom and Ireland VT was significantly higher among patients with a delayed initiation of therapy (25 + 6 vs. 30 + 1 weeks, <0.001; level of evidence: 2++) [2, 14]. Conditions of ART initiation during pregnancy are listed

**•** A pregnant woman without prior therapy should initiate ART from 20 weeks of gestation

**•** When VL is higher than 100,000 copies/ml, ART should be initiated by week 14 (Grade B

**•** If the pregnant woman has clinical or immunological criteria for ART initiation, or if seroconversion occurs during gestation, ART must be initiated immediately (Grade B

**•** A low frequency of VT (5%) has been observed during the second trimester of pregnancy. Thirty-four percent of VT occurs during the antepartum and 66% occurs during delivery [2, 7, 10, 12]. However, placental transmission may occur from 13 weeks (Level 2++ evidence

Triple ART or HAART (highly active antiretroviral therapy) is the preferred choice. The use of zidovudine (AZT) in association with lamivudine (3TC) 600 and 300 mg per day, respec‐ tively, is recommended for the prevention of HIV vertical transmission. A preparation Efficacy of ART is measured through the decrease of viral load. ART is effective if the decrease is near 1 log of VL 2 weeks after the initiation of therapy and 1.5 log at 4 weeks. Achieving a decrease of 2 logs between 28 and 34 weeks of gestation is also considered effective [19]. The viral load should be assessed upon the first control visit. Viral load should be controlled 2 and 4 weeks after the initiation of therapy or after a change in therapy. Subsequently, VL should be controlled on a monthly basis until becoming undetectable. At gestation weeks 34-36, a VL assessment should be performed to define the route of delivery, eventual additional ART, and to plan ART for the newborn (Grade D recommendation).

In patients starting ART before week 24, a VL every 2 months (8 weeks) and at week 34 is recommended (Grade D recommendation).

Several clinical guidelines propose such management based on expert recommendations (Level 4 evidence) [15-17, 19-21].
