Antiretroviral Therapy and Adverse Pregnancy Outcome: The Elephant in the Room?

(See the major article by Li et al on pages 1057–64.) Combination antiretroviral therapy (ART) during pregnancy has resulted in a remarkable shift in the pediatric human immunodeficiency virus (HIV) epidemic, opening the opportunity for global elimination of new pediatric HIV infections. In 2013, the World Health Organization (WHO) recommended all pregnant and breastfeeding women with HIV infection should initiate ART, continued at least for the duration of mother-to-child transmission (MTCT) risk, with the option of continuing ART lifelong regardless of clinical or immune status in high HIV prevalence settings (“Option B+”) [1]. Due to programmatic simplicity, many countries have adopted the Option B+ approach [2]. Additionally, ART started before conception and continued throughout pregnancy results in extremely low MTCT rates [3–6]. Given the Strategic Timing of Antiretroviral Therapy (START) trial results, demonstrating a 53% reduction in AIDS, other serious illness or death with immediate therapy at CD4 lymphocyte cell count above 500 cells/µL compared to deferring treatment until CD4 drops below 350 cells/µL, immediate lifelong treatment will likely be recommended by WHO for all HIV-infected individuals, including pregnant women [7, 8].