Decisions regarding maternal ART should made based upon the timing of presentation for care and maternal indications for therapy. Women who are already receiving ART at the time of conception should continue on the same regimen, unless it includes EFV, in which case NVP or a PI should be substituted. Section 2.5.5 presents additional information about ART toxicity during pregnancy.

Per Protocol 2.3, newly identified HIV-positive pregnant women with maternal indications for ART (that is, either clinical symptoms or CD4 below 350 cells/mm³) should immediately start combination therapy with three antiretroviral drugs. The preferred—and most widely available—regimen is AZT, 3TC, and NVP. AZT has the longest track record for use by pregnant women and is a preferred component for all regimens.

Women presenting in pregnancy who are not already receiving ART and who do not have maternal indications for therapy (i.e., CD4 above 350 cells/mm³) may be started on therapy at the 28^th week of gestation for pMTCT. Triple therapy with AZT, 3TC, and a PI is preferred.

HIV-positive women who present after the 28^th week of gestation should be started on treatment as soon as possible, even before the results of CD4 testing are available; liver function tests (LFTs) should be closely monitored. Women who present in labor and have not yet received ART should receive single-dose NVP.^108,109 In addition, based on reports of developed NVP resistance, any woman who received any NVP for pMTCT is now also given one week of AZT and 3TC.¹¹⁰ The ZL protocol recommends the continuation of AZT and 3TC for two weeks after the postpartum cessation of NVP.

The management of HIV-exposed infants is presented in Protocol 2.4. All HIV-exposed infants are given AZT syrup for one week. If the mother did not receive ART prior to the 34^th week of gestation, the infant should also receive single-dose NVP; AZT should be continued for a total of six weeks of therapy. If the mother is suspected of having resistant virus, alternative drug combinations may be considered for the infant. Infant protocol is determined by the available information about the mother’s prior exposure to antiretrovirals, viral load, and presence or absence of resistance mutations.