Antiretroviral Therapy and Pregnancy Outcomes

Antiretroviral therapy (ART) has transformed the management of HIV in pregnancy, dramatically reducing vertical transmission and improving maternal health. Over the past two decades, the introduction of potent, well-tolerated drugs and fixed-dose combinations has led to near-universal viral suppression in pregnant women living with HIV. Despite these advances, concerns remain regarding adverse perinatal outcomes such as preterm birth, low birth weight and small for gestational age infants, as well as potential teratogenic effects. Current guidelines recommend early initiation of combination ART (cART), ideally before conception, to optimise both maternal immune status and foetal growth. Research now focuses on the comparative safety of drug classes, the influence of timing of ART initiation and the long-term developmental impact on HIV-exposed but uninfected children. Global implementation of WHO-endorsed regimens has yielded substantial public health benefits, yet regional disparities in drug access and antenatal care uptake continue to shape outcome profiles worldwide.

Research from Nature Portfolio

A comprehensive systematic review and meta-analysis evaluated adverse perinatal outcomes attributable to HIV infection and antiretroviral use in sub-Saharan Africa from 1990 to 2020. The study quantified risk differences for preterm birth, low birth weight and small for gestational age among women receiving no antiretrovirals, monotherapy or antenatal versus preconception cART. It estimated that nearly two million preterm births and over two million low-birthweight infants were attributable to HIV and ARVs, primarily among those without treatment. Importantly, initiation of combination ART before conception was associated with marked reductions in adverse outcomes. These findings underscore the need to expand preconception HIV screening and early treatment initiation to mitigate perinatal morbidity in high-burden settings.

Antiretroviral Therapy and Pregnancy Outcomes publication trend

The graph below shows the total number of articles in antiretroviral therapy and pregnancy outcomes across all publications each year (not limited to Nature Index journals).

Technical terms

Antiretroviral therapy (ART): Treatment regimen using antiretroviral drugs to suppress HIV replication and maintain immune function.

Combination antiretroviral therapy (cART): Use of three or more antiretroviral agents simultaneously to achieve sustained viral suppression.

Nucleoside reverse transcriptase inhibitors (NRTIs): Class of drugs that inhibit HIV reverse transcriptase by mimicking natural nucleosides and terminating viral DNA synthesis.

Pharmacokinetics (PK): Study of how a drug is absorbed, distributed, metabolised and excreted in the body.

Small for gestational age (SGA): Infant weight below the 10th percentile for gestational age, indicating restricted foetal growth.

References

1. Adverse perinatal outcomes attributable to HIV in sub-Saharan Africa from 1990 to 2020: Systematic review and meta-analyses. Communications Medicine (2023).
2. Association of nucleoside reverse transcriptase inhibitors with adverse perinatal outcomes in pregnant women living with HIV: systematic review and meta-analysis. Clinical Microbiology and Infection (2025).
3. Safety and pharmacokinetics of dolutegravir in pregnant mothers with HIV infection and their neonates: A randomised trial (DolPHIN-1 study). PLOS Medicine (2019).