Which ARVs to use in pregnancy

As with all treatment decisions there are no hard and fast rules.

AZT is the only drug licensed for use in pregnancy. There is much experience with its use it is likely that it will be recommended as part of a combination.

The second nuke is likely to be 3TC as there is also much experience with this drug in pregnancy.

The third drug will be either a protease inhibitor (there is most experience with nelfinavir) or a non-nuke such as nevirapine (there are some cases where this drug would not be appropriate).

ARVs not recommended for use in pregnancy

Efavirenz is not recommended in pregnancy because of the possible risk to the baby’s development. The caution is strongest during the first trimester (12 weeks). If a woman finds that she is pregnant and using efavirenz, she will need to have some extra tests. After the first trimester there is no point in switching efavirenz.

Nevirapine is not recommended for women with CD4 counts above 250 cells/mm³ (not just during pregnancy) because of risk of liver toxicity. It is very safe for women with CD4 counts below 250 cells/mm³.

There is a strong warning against using d4T and ddI together. There have been several reports of fatal side effects in pregnant women using these drugs together.