The safety of highly active antiretroviral therapy for the HIV-positive pregnant mother and her baby: is 'the more the merrier'?

Highly active antiretroviral therapy (HAART) is frequently indicated for pregnant women both for maternal health and for prevention of mother-to-child HIV transmission, which can be reduced to <1%. Prospective data and large cohort studies have not found any evidence that antiretroviral therapy significantly increases the risk of congenital malformation. Nucleoside analogue reverse transcriptase inhibitors (NRTIs) are, to varying degrees, toxic to mitochondria, and molecular and clinical evidence of mitochondrial toxicity has been reported, albeit rarely, in NRTI-exposed but HIV-uninfected children. However, with NRTI-based fully suppressive antiretroviral therapy this effect was not seen. Although conflicting observational data have been reported, an increased risk of pre-term delivery with HAART compared with zidovudine monotherapy remains a concern.