Pregnant women with HIV infection must receive standard clinical, immunologic, and virologic evaluation. Recommendations for initiation and choice of antiretroviral therapy should be based on the same parameters used for persons who are not pregnant, although the known and unknown risks and benefits of such therapy during pregnancy must be considered and discussed.

The three-part zidovudine (ZDV) chemoprophylaxis regimen, initiated after the first trimester, should be recommended for all pregnant women with HIV infection regardless of antenatal HIV RNA copy number to reduce the risk for perinatal transmission.

The combination of ZDV chemoprophylaxis with additional antiretroviral drugs for treatment of HIV infection is recommended for infected women whose clinical, immunologic or virologic status requires treatment or who have HIV RNA over 1,000 compies/mL regardless of clinical or immunologic status.

Women who are in the first trimester of pregnancy may consider delaying initiation of therapy until after 10-12 weeks' gestation.

HIV-1-infected women receiving antiretroviral therapy in whom pregnancy is identified after the first trimester should continue therapy. ZDV should be a component of the antenatal antiretroviral treatment regimen after the first trimester whenever possible, although this may not always be feasible.

For women receiving antiretroviral therapy in whom pregnancy is recognized during the first trimester, the woman should be counseled regarding the benefits and potential risks of antiretroviral administration during this period, and continuation of therapy should be considered. If therapy is discontinued during the first trimester, all drugs should be stopped and reintroduced simultaneously to avoid the development of resistance.

Regardless of the antepartum antiretroviral regimen, ZDV administration is recommended during the intrapartum period and for the newborn. Recommendations for resistance testing in HIV-infected pregnant women are the same as for non-pregnant patients: acute HIV infection and virologic failure or suboptimal viral suppression after initiation of antiretroviral therapy.

Several effective regimens are available (Table 4). These include: 1) single dose nevirapine at the onset of labor followed by a single dose of nevirapine for the newborn at age 48 hours; 2) oral ZDV and 3TC during labor, followed by one week of oral ZDV/3TC for the newborn; 3) intrapartum intravenous ZDV followed by 6 weeks of ZDV for the newborn; and 4) the 2-dose nevirapine regimen combined with intrapartum intravenous ZDV and 6 week ZDV for the newborn.

In the immediate postpartum period, the woman should have appropriate assessments (e.g., CD4+ count and HIV-1 RNA copy number) to determine whether antiretroviral therapy is recommended for her own health.

The 6-week neonatal ZDV component of the ZDV chemoprophylactic regimen should be discussed with the mother and offered for the newborn.

ZDV should be initiated as soon as possible after delivery-preferably within 12-24 hours of birth.

Some clinicians may choose to use ZDV in combination with other antiretroviral drugs, particularly if the mother is known or suspected to have ZDV-resistant virus. However, the efficacy of this approach for prevention of transmission is unknown, and appropriate dosing regimens for neonates are incompletely defined.

In the immediate postpartum period, the woman should undergo appropriate assessment (e.g., CD4+ count and HIV-1 RNA copy number) to determine if antiretroviral therapy is required for her own health. The infant should undergo early diagnostic testing so that if HIV-infected, treatment can be initiated as soon as possible.