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ART in Pregnancy
ART Selection in Pregnancy

Released: July 23, 2026

Carolyn Chu
Carolyn Chu, MD, MSc, FAAFP, AAHIVS
Activity Information

Activity

Key Takeaways
  • Interventions such as rapid ART, long-acting ART, and novel dual-therapy combinations have profoundly changed how we think about starting and supporting HIV treatment for people living with HIV.
  • For people re-engaging in care, we must assess for the possibility of HIV drug resistance when constructing effective treatment regimens.

Case Study: What Would You Do?
You are asked to develop treatment recommendations for a patient who is currently 28 weeks pregnant. Although she was initially diagnosed with HIV in 2016, she reports “not really being focused on my meds” except during her prior pregnancies because of work and other priorities. At the initial prenatal visit, which occurred at 18 weeks gestational age, she was reinitiated on bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF), and HIV-1 RNA drawn at that visit was approximately 15,000 copies/mL. Although another viral load was ordered to be drawn at 20-22 weeks (along with a genotype), early follow-up testing wasn’t completed and the patient missed a few second trimester appointments. Last week, a repeat HIV-1 RNA was drawn and it has come back at approximately 32,000 copies/mL; genotype results are still pending.

What antiretroviral therapy (ART) options would you consider offering this person?

ART Adherence is Both a Clinical and Personal Decision
Clinical guidelines universally recommend lifelong therapy to durably suppress HIV viral load and restore immune function, reduce HIV-associated morbidity and mortality, improve quality of life, and prevent transmission. However, the decision to initiate and remain on treatment requires person-centered decision-making within a supportive care environment.

People with HIV may be exposed to misinformation or disinformation, and stigma remains pervasive. Healthcare professionals (HCPs) must be able to communicate the benefits of early, sustained treatment and address concerns that could affect uptake and medication adherence. Of importance, multiple intersecting structural factors continue to influence HIV care delivery and treatment persistence. These include lack of housing and/or stable employment, insurance barriers, transportation challenges, limited HCP access, and competing priorities.

The individual in our case may benefit from information and tailored counseling about the importance of treatment adherence, especially during the last trimester of pregnancy. Her comments indicate that she could also be finding it difficult to balance daily oral ART with other essential priorities right now. Therefore, finding out more about her specific structural barriers, day-to-day challenges, and connecting her with a case manager, social worker, and/or dedicated adherence support resources could relieve some of this burden and facilitate more consistent engagement in HIV care.

Real-world Success Requires a Humanistic Approach
Over the last decade, advances in ART, such as second-generation integrase inhibitors, rapid ART initiation, innovative dual-therapy approaches, and long-acting (LA) injectable medications, have propelled HIV care forward. However, real-world implementation requires a humanistic approach and continued efforts to mitigate health disparities at both the individual and community levels. As HCPs across increasingly diverse settings adopt new standards of care to follow evolving guidelines, a few areas of ongoing clinical uncertainty remain, as illustrated by our patient case:

Rapid ART Reinitiation
The majority of literature on rapid ART focuses on people with newly diagnosed HIV infection, although rapid ART reinitiation is another essential component of the care continuum. Indeed, a recent cost–consequence analysis describes the economic and public health impacts associated with improved ART reinitiation among people who had been disengaged from care.

To construct effective “rapid restart” combinations, clinical decision-making needs to be informed by additional factors, namely consideration of HIV drug resistance. To comprehensively assess drug resistance, HCPs should first gather relevant history, such as:

  1. What prior treatments has the person received and how long has it been since they discontinued therapy? This is especially important for people previously on a LA injectable regimen.
  2. Did prolonged periods of intermittent medication adherence ever occur or were antiretrovirals discontinued all at once?
  3. Prior to treatment discontinuation, did the last regimen lead to virologic suppression? 

For treatment-experienced individuals experiencing virologic failure, like the individual in our case study, we should carefully consider whether HIV resistance mutations may be present. Although resistance to BIC/FTC/TAF is rare, this individual’s history of suboptimal treatment adherence may increase the risk of developing resistance-associated mutations.

ART in Pregnant People
Timely and sustained virologic suppression is especially important in pregnancy, as maternal HIV viral load is the most important factor determining the likelihood of perinatal transmission. Guidelines affirm that ART should be started as early as possible during pregnancy, or ideally before conception.

For pregnant people with newly diagnosed HIV, ART should be initiated for all even before baseline resistance testing results are available:current first-line rapid ART combinations are also recommended as safe and effective in pregnancy.

Unfortunately, pregnancy-associated physiologic changes and other factors can significantly impact oral medication adherence. There is a critical gap in treatment options for pregnant people who are unable to tolerate oral ART, particularly in scenarios involving a narrow timeframe for achieving virologic suppression before delivery. It is possible that the individual in our case scenario is experiencing virologic failure due to an inability to tolerate daily oral medication (leading to missed doses of BIC/FTC/TAF on most days), and possibly also HIV drug resistance. If consistent use of oral ART will be a challenge for the remainder of this pregnancy, she may be a good candidate for LA ART (specifically LA injectable cabotegravir with rilpivirine) if there are no concerns for cabotegravir or rilpivirine resistance.

Multiple case reports and conference proceedings describing LA ART in pregnancy have now been published, with several highlighting steep and rapid viral load decay. Although these may still be considered “edge cases” by some, the potential impact of preventing perinatal transmission and operative deliveries, as well as increased touchpoints after delivery to reduce postpartum disengagement from care, cannot be overstated.

Findings from recent clinical trials such as LATITUDE and low-barrier care models further support the promise of early consideration and transition to LA ART for persons with adherence challenges, and emerging evidence suggests this practice is also safe and highly effective in pregnancy.

Moving forward with the individual in our case scenario, her individualized ART regimen will depend on several factors. First, she must be assessed for HIV drug resistance to determine which specific combinations are likely to be feasible and effective options. Then, specific challenges regarding consistent medication use and appointment attendance should be explored and addressed as best as possible. Finally, the optimal ART regimen should be decided with her input so that personal factors and priorities can be taken into consideration and conversations about other care plan considerations, including labor/delivery preparations and the postpartum period, can occur.

Your Thoughts
What ART regimen would you suggest for this individual? What interventions would you recommend to enhance and sustain her engagement in HIV care? Leave a comment to join the discussion!