Antiretroviral Regimens Recommended for HIV-1 Treatment in Drug-Naive Pregnant Women

TABLE 59-6. Antiretroviral Regimens Recommended for HIV-1 Treatment in Drug-Naive Pregnant Women

Regimen	Combination Treatment	Possible Advantages	Possible Disadvantages	Drug Interaction	Impact
Protease inhibitor-based HAART regimen (NNRTI- and FI-sparing)	Lopinavir/ritonavir + lamivudine + (zidovudine or stavudine^a) (Atazanavir or fosamprenavir or fosamprenavir/ritonavir or indinavir/ritonavir or lopinavir/ritonavir or nelfinavir or saquinavir/ritonavir) + (lamivudine or emtricitabine) + (zidovudine or stavudine^a or abacavir)	Efficacy documented Resistance requires multiple mutations Spares NNRTI and FI side effects Targets HIV at two steps of viral replication (RT and PI)	Some regimens are difficult to use, especially long term Long-term side effects often include lipodystrophy, hyperlipidemia, and insulin resistance	Mild to severe inhibition of cytochrome P₄₅₀ pathway—ritonavir is most potent, but this can be exploited to boost levels of other PIs	Preserves NNRTIs and FIs for use in treatment failure Resistance primes for cross-resistance with other PIs
Non-nucleoside reverse transcriptase inhibitor-based HAART regimen (PI- and FI-sparing)	Efavirenz + lamivudine + (zidovudine or tenofovir DF or stavudine^a) Efavirenz + emtricitabine + (zidovudine or tenofovir DF or stavudine^a) Efavirenz + (lamivudine or emtricitabine) + (didanosine or abacavir) Nevirapine + (lamivudine or emtricitabine) + (zidovudine or stavudine* or didanosine or abacavir)	Virological and immunological efficacy well-documented Spares PI and FI side effects Easier use, including long-term, compared with PIs	Those with CD4⁺ counts > 250/mm³ have increased risk of symptomatic nevirapine hepatotoxicity Efavirenz should be avoided in the first trimester Resistance conferred by single or limited number of mutations	Fewer drug interactions compared with PIs	Preserves PIs and FIs for use in treatment failure Resistance usually leads to cross-resistance across entire NNRTI class
Triple nucleoside reverse transcriptase inhibitor regimen (NNRTI-, PI-, and FI-sparing)	Abacavir + lamivudine + zidovudine (or stavudine^a)	Generally easier use and greater adherence compared with PIs Spares NNRTI, PI, and FI side effects	Only when an NNRTI- or a PI-based regimen cannotor should not be used as first-line therapy Efficacy inferior to efavirenz-based regimen	No cytochrome P₄₅₀ interaction	Preserves NNRTI, PI, and FI classes for use in treatment failure

NNRTI = non-nucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; PI = protease inhibitor; HAART = highly active antiretroviral treatment; FI = fusion inhibitor; HIV = human immunodefiency virus.
Lopinavir and ritonavir is formulated as Kaletra, and zidovudine and lamivudine are formulated as Combivir.
^aHigher incidence of lipoatrophy, hyperlipidemia, and mitochondrial toxicities reported with stavudine than with other NRTIs.
Modified from the U.S. Public Health Services (2004a, 2003) from http://AIDSinfo.nih.gov; accessedMarch 23, 2004.

TABLE 59-6. Antiretroviral Regimens Recommended for HIV-1 Treatment in Drug-Naive Pregnant Women

Regimen	Combination Treatment	Possible Advantages	Possible Disadvantages	Drug Interaction	Impact
Protease inhibitor-based HAART regimen (NNRTI- and FI-sparing)	Lopinavir/ritonavir + lamivudine + (zidovudine or stavudine^a) (Atazanavir or fosamprenavir or fosamprenavir/ritonavir or indinavir/ritonavir or lopinavir/ritonavir or nelfinavir or saquinavir/ritonavir) + (lamivudine or emtricitabine) + (zidovudine or stavudine^a or abacavir)	Efficacy documented Resistance requires multiple mutations Spares NNRTI and FI side effects Targets HIV at two steps of viral replication (RT and PI)	Some regimens are difficult to use, especially long term Long-term side effects often include lipodystrophy, hyperlipidemia, and insulin resistance	Mild to severe inhibition of cytochrome P₄₅₀ pathway—ritonavir is most potent, but this can be exploited to boost levels of other PIs	Preserves NNRTIs and FIs for use in treatment failure Resistance primes for cross-resistance with other PIs
Non-nucleoside reverse transcriptase inhibitor-based HAART regimen (PI- and FI-sparing)	Efavirenz + lamivudine + (zidovudine or tenofovir DF or stavudine^a) Efavirenz + emtricitabine + (zidovudine or tenofovir DF or stavudine^a) Efavirenz + (lamivudine or emtricitabine) + (didanosine or abacavir) Nevirapine + (lamivudine or emtricitabine) + (zidovudine or stavudine* or didanosine or abacavir)	Virological and immunological efficacy well-documented Spares PI and FI side effects Easier use, including long-term, compared with PIs	Those with CD4⁺ counts > 250/mm³ have increased risk of symptomatic nevirapine hepatotoxicity Efavirenz should be avoided in the first trimester Resistance conferred by single or limited number of mutations	Fewer drug interactions compared with PIs	Preserves PIs and FIs for use in treatment failure Resistance usually leads to cross-resistance across entire NNRTI class
Triple nucleoside reverse transcriptase inhibitor regimen (NNRTI-, PI-, and FI-sparing)	Abacavir + lamivudine + zidovudine (or stavudine^a)	Generally easier use and greater adherence compared with PIs Spares NNRTI, PI, and FI side effects	Only when an NNRTI- or a PI-based regimen cannotor should not be used as first-line therapy Efficacy inferior to efavirenz-based regimen	No cytochrome P₄₅₀ interaction	Preserves NNRTI, PI, and FI classes for use in treatment failure

NNRTI = non-nucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; PI = protease inhibitor; HAART = highly active antiretroviral treatment; FI = fusion inhibitor; HIV = human immunodefiency virus.
Lopinavir and ritonavir is formulated as Kaletra, and zidovudine and lamivudine are formulated as Combivir.
^aHigher incidence of lipoatrophy, hyperlipidemia, and mitochondrial toxicities reported with stavudine than with other NRTIs.
Modified from the U.S. Public Health Services (2004a, 2003) from http://AIDSinfo.nih.gov; accessedMarch 23, 2004.