U.S. Public Health Service Perinatal Guidelines Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health

U.S. Public Health ServiceU.S. Public Health ServicePerinatal GuidelinesPerinatal Guidelines

Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for

Maternal Health and to Reduce PerinatalHIV-1 Transmission in the United States

April 2009April 2009

April 20092 www.aidsetc.org2

About This PresentationAbout This Presentation

These slides were developed using the April 2009 guidelines. The intended audience is clinicians involved in the care of patients with HIV infection.

Users are cautioned that, because of the rapidly changing field of HIV care, this information could become out of date quickly. Finally, it is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent.

– AETC National Resource Center

http://www.aidsetc.org

April 20093 www.aidsetc.org

Table of ContentsTable of Contents

Topic

Lessons from Clinical Trials Preconception Counseling and Care Management of Pregnant Women with

HIV-Infected Male Partner Antepartum Management Intrapartum Management Postpartum Management Neonatal Postnatal Care

Slide Number

6

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64


IntroductionIntroduction

U.S. recommendations have evolved over 25 years

With universal prenatal HIV counseling and testing, ARV prophylaxis, scheduled cesarean section delivery, and avoidance of breast-feeding, perinatal HIV infection has diminished to <2% in the United States

The guidelines and slides update the July 8, 2008, recommendations

The most recent information is available from the AIDSinfo website: http://aidsinfo.nih.gov


New Information New Information

Includes: Lessons Learned from Clinical Trials of ARV Interventions to

Reduce Perinatal HIV Transmission

Neonatal Postnatal Care

ARV Drug Use in Pregnant HIV-Infected Women (see Tables 1, 2, and 3 in the Perinatal Guidelines)

Safety and Toxicity of ARV Agents in Pregnancy Supplement (see Perinatal Guidelines)

New Ratings for Recommendations (see Perinatal Guidelines)

Lessons from Clinical TrialsLessons from Clinical Trialsof ARV Interventions to Reduceof ARV Interventions to ReducePerinatal HIV TransmissionPerinatal HIV Transmission


ARVs: Mechanisms of ActionARVs: Mechanisms of Action

ARVs reduce perinatal transmission by several mechanisms:

Decreasing maternal viral load Preexposure and postexposure infant prophylaxis

Combined antepartum, intrapartum, and infant ARV prophylaxis is recommended


International Studies: Short-Course International Studies: Short-Course Regimens to Prevent TransmissionRegimens to Prevent Transmission

Combination ARV regimens are more effective than 1-drug therapy

Longer duration of antepartum ARV prophylaxis is more effective than shorter duration

Should start prophylaxis at least by 28 weeks

If no maternal antepartum therapy, administer ARVs during labor and delivery, and to the infant

Less effective than if antepartum ARVs also given


International Studies: Short-Course International Studies: Short-Course Regimens to Prevent Transmission Regimens to Prevent Transmission (2)(2)

If no maternal therapy, give postnatal infant ARV prophylaxis with a minimum of ZDV for 6 weeks

In the United States:

Adding single-dose NVP to standard combination antepartum ARV therapy is not recommended

No additional efficacy; may cause NVP resistance

Breast-feeding is not recommended for HIV-infected women (including those receiving suppressive combination ART) Safe, affordable, and feasible alternatives are available and

culturally acceptable


Transmission and Maternal HIV RNATransmission and Maternal HIV RNA

Risk of perinatal transmission greater with higher maternal HIV RNA viral load (VL)

However, perinatal transmission can occur even at undetectable maternal VL

Plasma VL may not accurately predict transmission risk

VL level should not be a determining factor in deciding whether to start ART for perinatal prophylaxis

ARV prophylaxis to prevent perinatal transmission is recommended for all HIV-infected women

Preconception Counseling andPreconception Counseling andCare for HIV-Infected WomenCare for HIV-Infected Womenof Childbearing Ageof Childbearing Age


RecommendationsRecommendations

Contraception counseling to avoid unintended pregnancy is an essential part of care

Counsel on safe sexual practices, eliminating alcohol, illicit drug use, and smoking

Educate about risk factors for perinatal HIV transmission and strategies for reducing them

Encourage testing and counseling of partners

Counsel on reproductive options that prevent HIV exposure to uninfected partner


Recommendations Recommendations (2)(2)

For women of childbearing potential, consider effectiveness of ARVs as well as teratogenic effects In women who intend to become pregnant, avoid EFV

Attain a stable, maximally suppressed VL prior to conception

Breast-feeding is not recommended in the United States (risk of HIV transmission via breast milk)

Management of the Pregnant Woman with an HIV-Infected Male Partner


Pregnant Woman with an Pregnant Woman with an HIV-Infected Male PartnerHIV-Infected Male Partner

Test for HIV (unless patient declines) 2nd HIV test in 3rd trimester, before 36 weeks if possible

If patient presents in labor: rapid HIV test

If seroconversion is suspected, do HIV RNA and antibody test; repeat test in 4-6 weeks If positive: initiate interventions to reduce perinatal

transmission risk

If negative: counsel to reduce risk of transmission from partner

Antepartum Care Antepartum Care for HIV-Infected Womenfor HIV-Infected Women


Use of ARVs during Pregnancy: Use of ARVs during Pregnancy: General PrinciplesGeneral Principles

Initial evaluation should include: Assessment of HIV disease status Recommendations on ART or assessment of current

ARV regimen

Recommend ARV therapy/prophylaxis to ALL pregnant HIV-infected women

Discuss known benefits and potential risks ofARVs during pregnancy


General PrinciplesGeneral Principles (2)(2)

If HIV RNA is detectable, do resistance testing before starting/modifying therapy

Individualize ART

Emphasize the importance of adherence to treatment and prophylaxis

Assure coordination of comprehensive services


HIV-Infected Pregnant Women HIV-Infected Pregnant Women Currently on ARTCurrently on ART

Continue ART, if possible; avoid treatment interruption

Avoid EFV in the 1st trimester: switch to an alternative ARV, if possible

Order ARV resistance tests if detectable viremia If on NVP with suppressed VL and tolerating it,

continue NVP Include ZDV in regimen, unless contraindicated


ARV NaiveARV Naive

If patient meets criteria for initiation of ART, start standard potent combination therapy For a patient who requires ART for her own health,

start as soon as possible, including in 1st trimester

Consult data on specific ARVs in pregnancy

If patient does not require treatment for her own health: 3-drug combination ARV regimen for perinatal prophylaxis May delay until after 1st trimester

ZDV monotherapy for prophylaxis not recommended, but may be considered if VL <1,000 copies/mL


ARV Naive ARV Naive (2)(2)

Perform resistance testing before selection of ARVs

Include ZDV in ARV regimen when feasible

NVP: can be initiated for pregnant women with CD4 counts of <250 cells/µL

If CD4 cell count is >250 cells/µL, initiate NVP only if benefit outweighs risk (increased risk of hepatic toxicity)

Avoid EFV in 1st trimester


Women Not Currently on ARVs with Women Not Currently on ARVs with History of Prophylaxis or TreatmentHistory of Prophylaxis or Treatment

Obtain history of prior ARV regimens and results of resistance testing

Perform drug resistance testing before starting ARVs

Results may not be accurate; interpret with caution

Select ARVs based on ARV history and resistance testing; monitor virologic response closely

Avoid drugs that may harm the fetus or mother (eg, EFV, d4T + ddI)

If poor virologic response, repeat resistance testing and consult experts


Special Considerations for ARV UseSpecial Considerations for ARV Useby Pregnant Women and Infantsby Pregnant Women and Infants

Pregnancy may alter ARV absorption, distribution, and metabolism

ARV dosing and toxicity risk may be affected

Some PIs may require altered dosing

Limited data to guide treatment in pregnant women

Report all cases of ARV drug exposure to Antiretroviral Pregnancy Registry


Special Considerations for ARV Use Special Considerations for ARV Use (2)(2)

Potential adverse effects during pregnancy: EFV: Avoid during 1st trimester of pregnancy;

possible risk of neural tube defects TDF: Concern for possible fetal bone effects;

monitor for renal toxicity in pregnancy Combination of d4T + ddI: increased risk of lactic

acidosis and hepatic steatosis


Special ConsiderationsSpecial Considerations for ARV Use for ARV Use (3)(3)

Use with caution during pregnancy: NVP: Increased risk of hepatotoxicity; do not initiate in women with

CD4 counts of >250 cells/µL unless benefits clearly outweigh risks

Screen for hyperglycemia: Standard glucose loading test at 24-28 weeksConsider earlier screening if on chronic PI-based therapy

Risk of lactic acidosis/hepatic steatosis owing to NRTIs: Monitor hepatic enzymes, electrolytes monthly in 3rd

trimester; assess often for new symptoms


Types of ARV RegimensTypes of ARV Regimens

NNRTI based

(1 NNRTI + 2 NRTI backbone)

PI based

(1 or 2 PIs + 2 NRTI backbone)

NRTI based

(3 NRTIs: inferior virologic efficacy; consider if NNRTI- or PI-based regimen is not appropriate)


Current ARV MedicationsNRTI Abacavir (ABC) Didanosine (ddI) Emtricitabine (FTC) Lamivudine (3TC) Stavudine (d4T) Tenofovir (TDF) Zidovudine (AZT, ZDV)

NNRTI Efavirenz (EFV) Delavirdine (DLV) Etravirine (ETR) Nevirapine (NVP)

PI Atazanavir (ATV) Darunavir (DRV) Fosamprenavir (FPV) Indinavir (IDV) Lopinavir (LPV) Nelfinavir (NFV) Ritonavir (RTV) Saquinavir (SQV) Tipranavir (TPV)

Entry Inhibitor Enfuvirtide (ENF, T-20) Maraviroc (MVC)

Integrase Inhibitor Raltegravir (RAL)


Components of ART: Components of ART: Working Group CategoriesWorking Group Categories

Recommended

Alternative

Use in Special Circumstances

Insufficient Data to Recommend Use

Not Recommended


ARV Recommendations: NRTIsARV Recommendations: NRTIs

Recommended Concerns in Pregnancy

3TC Extensive studies in pregnancy

ZDV Extensive studies in pregnancy

Alternative

ABC Risk of hypersensitivity reaction; test for HLA-B*5701 before starting; do not use if positive for HLA-B*5701

ddI Lactic acidosis, sometimes fatal, with ddI + d4T

FTCSlightly lower levels in 3rd trimester; no clear

need to increase dosage

d4T Same as ddI

• Class concerns for NRTIs: lactic acidosis, mitochondrial toxicity


ARV Recommendations: NRTIs ARV Recommendations: NRTIs (2)(2)


Concerns in Pregnancy

TDF Limited studies in pregnant women; concern for possible fetal bone effects; monitor for renal toxicity during pregnancy

• Class concerns for NRTIs: lactic acidosis, mitochondrial toxicity


ARV Recommendations: NNRTIsARV Recommendations: NNRTIs

Recommended Concerns in Pregnancy

NVPIncreased risk of potentially fatal liver toxicity if initiated at CD4 counts of >250/µL


EFV

FDA pregnancy class D; case reports of neural tube defects in humans with 1st trimester exposure

• Can be considered after 1st trimester• If continued postpartum, ensure adequate

contraception (concerns include drug interactions with hormonal contraceptives; risk of teratogenicity in fetus if woman becomes pregnant while taking EFV)

• Class concerns for NNRTIs: rash, hypersensitivity, hepatic toxicity


ARV Recommendations: NNRTIs ARV Recommendations: NNRTIs (2)(2)



ETR Insufficient data

Not RecommendedDLV Teratogenic in animals

• Class concerns for NNRTIs: rash, hypersensitivity, hepatic toxicity


ARV Recommendations: PIsARV Recommendations: PIs

Recommended Concerns in PregnancyLPV/r* Optimal dosing of tablet formulation during

pregnancy is uncertain

AlternativeATV/r* Optimal dosing during pregnancy is uncertain

IDV/r* May exacerbate hyperbilirubinemia in neonate

NFV May require increased dosage in 3rd trimester

SQV/r* Limited data on hard-gel and tablet formulations

• Class concerns for PIs: hyperglycemia, diabetes, question of increased risk of preterm delivery

* r = low-dose ritonavir


ARV Recommendations: PIs ARV Recommendations: PIs (2)(2)

Insufficient Data to Recommend Use Concerns in Pregnancy

DRV/r* No experience in pregnancy

FPV/r* Limited experience in pregnancy

TPV/r* No experience in pregnancy

* r = low-dose ritonavir


ARV Recommendations: Entry InhibitorsARV Recommendations: Entry Inhibitors



ENF Minimal data in pregnancy

MVC No experience in pregnancy


ARV Recommendations: Integrase InhibitorsARV Recommendations: Integrase Inhibitors



RAL No experience in pregnancy


HIV/HBV CoinfectionHIV/HBV Coinfection

Screen for HBsAg

Interferons not recommended during pregnancy

If chronic HBV/HIV, and treatment required for either, use 3-drug regimen

Include TDF + 3TC or FTC in ARV regimen

Entecavir should not be used without fully suppressive anti-HIV ARV regimen (risk of ARV resistance)


HIV/HBV CoinfectionHIV/HBV Coinfection (2)(2)

Postpartum, if treatment of HBV but not HIV indicated, consult with expert

Risk of HBV flare with discontinuation of HBV-active ARVs

Options include:

Stop ARVs and start pegylated interferon-alfa

Continue the 3-drug ARV regimen



If HBV/HIV coinfected and treatment not required for either, consult with expert

Options include:

Antepartum 3-drug regimen including TDF + 3TC or FTC; discontinue postpartum (monitor closely for HBV flare)

Antepartum 3-drug regimen without TDF + 3TC or FTC; discontinue postpartum



Check transaminase levels 2 weeks after ARV initiation, at least monthly thereafter

Infants: give HBIG and begin HBV vaccination series within 12 hours of birth


HIV/HCV CoinfectionHIV/HCV Coinfection Screen for HCV

Interferons not recommended during pregnancy

Ribavirin contraindicated during pregnancy(teratogenic)

Coinfection increases risk of perinatal HCV transmission, and perhaps of HIV transmission

Consider combination ART for all HCV/HIVpregnant women


HIV/HCV CoinfectionHIV/HCV Coinfection (2)(2)

Check transaminase levels 2 weeks after ART initiation, at least monthly thereafter

Mode of delivery based on considerations related to HIV infection alone

Evaluate infants by HCV RNA testing (at 2-6 months) and/or HCV antibody testing (after age 15 months)


Stopping ART during PregnancyStopping ART during Pregnancy

Avoid interruption of ART, if possible

If discontinuation required, stop and reinitiateall drugs at the same time, except: If on NNRTI, if possible stop NNRTI first, continue others

for approximately 7 days NNRTIs have long half-life; optimal interval between stopping

NNRTI and other ARV drugs not known

If restarting NVP after interruption of >2 weeks,restart with standard 2-week dosage escalation


Failure of Viral SuppressionFailure of Viral Suppression

Assess resistance, adherence, dosing, and problems with absorption

Consider modification of ARV regimen

Consult with an expert

Scheduled cesarean delivery recommended if HIV RNA >1,000 copies/mL near time of delivery


Monitoring Woman and FetusMonitoring Woman and Fetus

Monitor CD4 cell count at initial visit and every 3 months thereafter

Monitor plasma HIV RNA levels to assess rapid and sustained lowering

At initial visit 2-6 weeks after starting/changing ARV regimen Monthly until RNA levels undetectable Every 2 months during pregnancy At 34-36 weeks for decision on mode of delivery


Monitoring Woman and FetusMonitoring Woman and Fetus (2)(2)

Perform resistance testing for women with suboptimal VL suppression or rebound

Monitor for ARV drug complications

Ultrasound recommendations:

1st trimester – confirmation of gestational age and potential timing for cesarean delivery, if needed

2nd trimester – assess fetal anatomy for women oncombination ARVs (especially EFV) during 1st trimester


ART and Pregnancy OutcomeART and Pregnancy Outcome

Conflicting data: Are ARVs associated with adverse outcomes, especially preterm delivery? – Most U.S. data do not demonstrate increased risk

Conflicting data: Does in utero ARV exposure cause mitochondrial dysfunction in neonates?– If so, appears to occur very rarely

HIV-infected women should receive combination ART according to current guidelines


ARV Resistance in PregnancyARV Resistance in Pregnancy

Resistance to ARVs may:

Decrease efficacy of perinatal prophylaxis

Limit future maternal treatment options

Limit treatment options in infected infants


ARV Resistance Testing during PregnancyARV Resistance Testing during Pregnancy

Recommended for:

Women not currently on ARVs – before starting treatment or prophylaxis

Women experiencing virologic failure or suboptimal VL suppression

To maximize prevention of perinatal transmission, empiric ART can be started before test results are available, with adjustments made after results are known


Management of ARV Resistance Management of ARV Resistance during Pregnancyduring Pregnancy

Women with ZDV resistance should still receive IV ZDV during labor, along with their ARV regimen

Their infants should receive oral ZDV for 6 weeks

Often, only wild-type virus is transmitted

ZDV crosses placenta readily, with high levels in fetus

Reduces genital HIV VL

Consult pediatric HIV specialist

Discontinue d4T in women taking ZDV


Incidence of Resistance with Incidence of Resistance with Prophylactic RegimensProphylactic Regimens

Single-dose NVP added to an ongoing ART regimen not recommended

No additional efficacy

May result in NVP drug resistance


Prevention of ARV Drug ResistancePrevention of ARV Drug Resistance

Select ARVs according to ART history and resistancetest results

Maximally suppress viral replication

Counsel patient about adherence

If stopping NVP / NNRTI-containing regimen, consider continuing NRTIs for 7 days after stopping NNRTI NNRTIs have very long half-lives

Need to “cover” period of persisting NNRTI exposure

Optimal time to continue NRTIs is not known

Intrapartum Care Intrapartum Care for HIV-Infected Womenfor HIV-Infected Women


Intrapartum ARV Therapy/ProphylaxisIntrapartum ARV Therapy/Prophylaxis

IV ZDV recommended for all HIV-positive women during labor

Continue other ARVs orally on schedule, as possible

When administering ZDV, discontinue d4T

If suboptimal VL suppression on ARV, single-dose intrapartum maternal + infant NVP not recommended

Cesarean delivery if VL >1,000 copies/mL


Intrapartum ARV Therapy/Prophylaxis Intrapartum ARV Therapy/Prophylaxis (2)(2)

If no antepartum ARV therapy to mother, administerIV ZDV during labor and continue 6 weeks of infant ZDV

Unknown whether additional ARVs during labor and to neonate further reduces perinatal transmission

Some would add single-dose intrapartum maternal + infant NVP, with oral 3TC to mother + 7 days of ZDV/3TC to mother


Intrapartum ARV Therapy/Prophylaxis Intrapartum ARV Therapy/Prophylaxis (3)(3)

If woman’s HIV status unknown, administer rapid HIV antibody test

If test result is positive, give IV ZDV and initiate infant ZDV

Confirmatory HIV test done postpartum

If positive, give infant 6 weeks of ZDV

If negative, stop infant ZDV


HIV Transmission and Cesarean DeliveryHIV Transmission and Cesarean Delivery

Schedule at 38 weeks to reduce risk of transmission: For women with HIV RNA levels >1,000 copies/mL

(whether on ARVs or not) near time of delivery For women with unknown HIV RNA levels Benefits of C/S not clear after rupture of membranes

or onset of labor: base decision on clinical factors Benefits of C/S unclear for women with HIV RNA

levels <1,000 copies/mL

Scheduled C/S may not further reduce risk of transmission


Maternal Risks by Mode of DeliveryMaternal Risks by Mode of Delivery

Counsel women about potential risks and benefits of cesarean vs vaginal delivery

C/S associated with greater risk of complications Compared with vaginal delivery in HIV-infected women

Compared with C/S in HIV-uninfected women

Scheduled C/S less risky than emergent C/S

Complications do not outweigh benefits of reduced HIV transmission for those at increased risk

Prophylactic narrow spectrum antibiotic generally recommended at time of C/S


Other Intrapartum Management IssuesOther Intrapartum Management Issues

Avoid artificial rupture of membranes or invasive monitoring unless obstetrically indicated and duration is expected to be short

Use forceps or vacuum extractor only in select circumstances

Avoid use of Methergine for postpartum hemorrhage in women receiving PIs, EFV, or DLV Risk of exaggerated vasoconstrictive response

Use if no other alternative, at low dosage and for short duration

Postpartum Management Postpartum Management for HIV-Infected Womenfor HIV-Infected Women


Postpartum Follow-UpPostpartum Follow-Up Coordinate medical services between obstetric and

HIV specialists

ART:

Continuing or stopping depends on CD4 nadir, clinical symptoms, disease stage, and other factors

If nadir CD4 <350 cells/µL or symptomatic, encourage continuing the regimen

If started ART with nadir of CD4 >350 cells/µL, consult the provider on whether to continue therapy

If no indication for therapy, stop ARVs after delivery

Adherence may be challenging in postpartum period


Postpartum Follow-Up Postpartum Follow-Up (2)(2)

Women with positive rapid HIV test result in labor Confirmation of HIV infection

Counseling and comprehensive medical assessment

Assessment of need for ART

Supportive services to be assured prior to discharge

Breast-feeding not recommended (risk of HIV transmission via breast milk)


Postpartum Follow-UpPostpartum Follow-Up (3)(3)

Contraceptive counseling is critical

Condom use important for prevention of HIV and STD transmission

Unintended pregnancy rate is high with condom use alone

Drug interactions between oral contraceptives and many PIs and NNRTIs

For women who are certain they do not wish future childbearing: thorough counseling and discussion about permanent contraceptive methods

Neonatal Postnatal CareNeonatal Postnatal Care


Infants Born to Mothers with Unknown Infants Born to Mothers with Unknown HIV Infection StatusHIV Infection Status

Rapid HIV antibody testing of mother or infant recommended If positive:

Initiate ARV prophylaxis for infant immediately

Perform confirmatory test (eg, Western blot)

Positive infant antibody test cannot distinguish maternal from infant infection – requires HIV virologic test

If confirmatory test is negative (in mother or infant), discontinue ARV prophylaxis


Infant ARV ProphylaxisInfant ARV Prophylaxis

6-week ZDV chemoprophylaxis advised for all HIV-exposed neonates

Should be initiated within 6-12 hours of delivery

If concerns about adherence or toxicity, may consider reducing infant prophylaxis from 6 to 4 weeks

Dosage is different for premature infants; consultwith pediatric HIV specialist


Infant ARV ProphylaxisInfant ARV Prophylaxis (2)(2)

Combination therapy: ZDV + additional ARVs

Additional efficacy in prevention of infant infection not proven

Consult with a pediatric HIV specialist if considering additional ARVs in situations of increased transmission risk


Infant ARV ProphylaxisInfant ARV Prophylaxis (3)(3)

Use of additional drugs will depend on: Maternal HIV RNA level near delivery

Mode of delivery

Gestational age at delivery

Availability of drug formulation

Dosing information for neonates (known for few ARVs)

Risks of toxicity in neonates are unclear Limited data on most ARVs


Initial Management of the Initial Management of the HIV-Exposed NeonateHIV-Exposed Neonate

Monitoring ARV effects CBC and differential before starting ZDV

Follow-up of hematologic monitoring varies by baseline results, clinical factors

If hematologic abnormalities identified, consult pediatric HIV specialist

LFTs may be required for infants exposed tocombination ARV therapy in utero or after birth

Serum lactate: recommended if infant develops severe clinical symptoms of unknown etiology If severely abnormal (>5 mmol/L), discontinue ARV prophylaxis

and consult pediatric HIV specialist


Initial Management of the Initial Management of the HIV-Exposed Neonate HIV-Exposed Neonate (2)(2)

Begin PCP prophylaxis (TMP-SMX) at 6 weeks,after completion of ZDV regimen, unless HIVhas been ruled out

Diagnosis of HIV infection in neonates: virologictests (HIV DNA or RNA) Age 14-21 days, 1-2 months, and 4-6 months Some experts test at birth


Long-Term Follow-Up of Long-Term Follow-Up of ARV-Exposed InfantsARV-Exposed Infants

Children with significant organ system abnormalities of unknown etiology: evaluate for mitochondrialdysfunction

Other possible early and late effects of in utero ARV exposure are not fully known

Follow-up should continue into adulthood

Should include yearly physical examination

For adolescent females, should include gynecologicevaluation with Pap tests


Guidelines InformationGuidelines Information

U.S. Public Health Service Perinatal Guidelines

Working Group meets monthly, reviews clinical trials

results, and updates the guidelines

The published text is posted on www.aidsinfo.nih.gov


This presentation was prepared by Susa Coffey, MD; Rebecca Fry, MSN, APN; Elaine Gross, RN, MS; Supriya Modey, MPH, MBBS; for the AETC National Resource Center in July 2008, and revised in April 2009

See the AETC National Resource Center website for the most current version of this presentation:

http://www.aidsetc.org

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U.S. Public Health Service Perinatal Guidelines Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health