Initiation of Antiretroviral Therapy Prior to Pregnancy Considered Safe

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ART initiation prior to conception was associated with a risk of preterm delivery.
ART initiation prior to conception was associated with a risk of preterm delivery.

Among women who initiate antiretroviral therapy (ART) prior to conception, the therapeutic benefits of improved maternal health and prevention of mother-to-child transmission likely outweigh the associated risks for preterm delivery and low-birthweight infants, according to the results of a systematic review and meta-analysis published in The Lancet HIV.

To evaluate pregnancy outcomes associated with ART initiation prior to conception, researchers evaluated randomized studies, quasi-randomized studies, and prospective cohort studies that evaluated the timing of ART initiation in pregnant women. A total of 11 studies (n=19,189 mother-infant pairs) were included in the analysis, and risk ratios for pregnancy outcomes were calculated using pooled data.

Compared with women who initiated ART after conception, those who initiated ART before conception had an increased risk for preterm delivery (risk ratio [RR] 1.20; 95% CI, 1.01-1.44) based on the pooled results from 10 studies. Significant between-study heterogeneity was reported for these results (I2 77%; P <.001). The researchers attributed the heterogeneity in part to the differences between studies performed in low- and middle-income countries (RR 1.41; 95% CI, 1.22-1.63) compared with those performed in high-income countries (RR 0.89; 95% CI, 0.54-1.47).

Initiation of ART before conception was also associated with very-preterm delivery (RR 1.53) and low-birthweight infants (RR 1.30) compared with initiation of ART after conception. Both of these measures were based on the outcomes of 2 studies.

No significant differences between groups were reported in risk for very low birth weight, small for gestational age, severe small for gestational age, stillbirth, and congenital anomalies. The data for neonatal mortality were limited.

The study concluded that, “the benefits of ART for prevention of mother-to-child transmission of HIV and for maternal health clearly outweigh any risks identified so far, and there is no question that ART should be initiated in all pregnant women and continued thereafter.” They noted, however, that, “further research is needed to define these risks better and determine how to optimize ART to allow safe, healthy pregnancies for women with HIV and good health outcomes for both mother and child.”


Uthman OA, Nachega JB, Anderson J, et al. Timing of initiation of antiretroviral therapy and adverse pregnancy outcomes: a systematic review and meta-analysis. Lancet HIV. 2017;4(1):e21-e30.

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