Selection of ART drugs should be individualized according to a patient’s specific ART history, the results of drug-resistance assays, and the presence of comorbidities, as well as the individual’s preferences for balancing known and unknown risks and benefits, and of course based on which ART drugs are recommended to best use in preconception and pregnancy. It is recommended to check the latest US Department of Health and Human Services (DHHS) guidelines. In general, those who are already on a fully suppressive regimen when planning pregnancy can stay on their regimen. Key exceptions include regimens that involve medications with a high risk for toxicity or inferior virologic efficacy that are not recommended for use in adults (e.g., didanosine [ddI], indinavir [IDV], nelfinavir [NFV], stavudine [d4T], and treatment-dose RTV). There are some drugs that should not be used in pregnancy because of lower drug levels; these include regimens containing cobisistat (e.g., darunavir/cobicistat [DRV/c], atazanavir/cobicistat [ATV/c], and elvitegravir/cobicistat [EVG/c]). If a patient is on a regimen containing one of these drugs, consider changing the ART regimen. Prior to conception, those trying to get pregnant who are not fully suppressed and who are currently taking ART should be carefully evaluated for adherence and genotypic resistance, with every effort made to achieve full virologic suppression rapidly through adherence interventions or medication changes prior to conception attempts. When treating patients who have previously received ART drugs but who are not currently taking ART drugs, clinicians will need to take previous regimens and the potential for genotypic resistance into consideration.

In general, those who are already on a fully suppressive regimen when they become pregnant (whether planned or unplanned) can stay on the regimen they are taking. Key exceptions include regimens that involve medications with a high risk for toxicity or inferior virologic efficacy that are not recommended for use in adults (e.g., didanosine [ddI], indinavir [IDV], nelfinavir [NFV], stavudine [d4T], and treatment-dose RTV). There are some drugs that should not be used in pregnancy because of lower drug levels; these include regimens containing cobisistat (e.g., darunavir/cobicistat [DRV/c], atazanavir/cobicistat [ATV/c], and elvitegravir/cobicistat [EVG/c]). If on a regimen containing one of these drugs, consider changing the ART regimen. Patients who are not fully suppressed and who are currently taking ART should be carefully evaluated for adherence and genotypic resistance, with every effort made to achieve full virologic suppression rapidly through adherence interventions or medication changes prior to conception attempts being made. When treating patients who have previously received ART drugs but who are not currently taking ART drugs, clinicians will need to take previous regimens and the potential for genotypic resistance into consideration.

Concerns regarding the safe use of dolutegravir before and during pregnancy emerged in 2018 following reports from an observational study carried out in Botswana of a small increased risk of neural tube defects in children born to women living with HIV who were taking dolutegravir in preconception compared with other antiretrovirals. The final study data reported a smaller risk overall. Owing to the high resistance barrier, favourable adverse effect profile, and convenient administration, balanced with the possible but low fetal risk, dolutegravir is considered an appropriate treatment option for people living with HIV who are pregnant or considering pregnancy if they are carefully engaged and involved in decision making about their antiretroviral treatment. If you have a patient who is pregnant, plans to become pregnant, or is not using effective contraception while taking dolutegravir, we advocate for prescribing higher doses of folic acid (e.g., 5 mg/d). For a more detailed discussion on the use of dolutegravir in pregnancy, please read Dolutegravir for pregnant women living with HIV, published in CMAJ in March 2020.

There are currently no data on the risk of birth defects in infants born to women who received Biktarvy or Odefsey before or during pregnancy. Providers should discuss with patients the potential benefits and risks of these combination medications during pregnancy and explain that currently they are not recommended to be used in pregnancy. Given the nuances of risks and benefits, providers should actively engage patients in decisions about their HIV treatment, particularly in the decision to start, continue or switch specific drugs.

While there are various providers in every facility, there are obstetricians in most major cities in Canada who have some expertise in managing HIV in pregnancy. The CHPPG recommends working with your patient to find the obstetrician in your region with the most experience. If there is no expert in your area, or you do not know of any experts in your area, please reach out to the CHPPG team as we may have some recommendations. Please note that at this time, midwives in independent practice cannot manage a pregnancy with HIV as this is outside their scope of practice.

There are various fertility clinics. Work with your patient to determine the best option for them. A standard referral letter with all pertinent information will suffice.

Generally, 0.4-1 mg per day is prescribed 3 months prior to conception. However, in high risk candidates (i.e., prior open neural tube defects [NTDs] in offspring of either parent or personal history of open NTDs in either parent) 5 mg should be prescribed. 1 mg of folic acid should be prescribed to moderate risk candidates. Moderate risk candidates include those with personal or family history of folate-sensitive congenital anomaly other than NTDs, family history of NTDs (first- or second-degree relative), Type I or II diabetes, maternal gastrointestinal malabsorption, medical conditions associated with risk (advanced liver disease, dialysis, alcohol overuse). As many of you know, dolutegravir has been found to be associated with an increased risk of NTDs when taken at the time of conception (<1%, but likely still double as compared to the general population). Dolutegravir has several benefits as an ART drug and the benefits may outweigh the risks in many patients. Biologic mechanistic data suggests that taking a higher dose of folic acid would be best to be started before conception/pregnancy. As such, 5 mg is to be prescribed for those on dolutegravir.

Yes, you can if you wish. If you are not aware of an appropriate provider in your area, please contact a member of the CHPPG team who can provide you with the name of someone in your area.

Discuss with them the various options available, which include the following, and then consider referring them to a fertility clinic for further follow up if appropriate. Options include: Raising foster children or adopting a child; Insemination using a sperm donor/sperm bank; Surrogacy with an egg donor; Co-parenting (a planned, platonic parenting relationship).