The patient was a 36-year-old gravida 8 para 2 woman who presented for prenatal care at 7 weeks’ gestation with an unplanned but desired pregnancy. Between 1996 and her presentation to our clinic, she had been intermittently adherent to several sequentially administered combination antiretroviral regimens. During that time, the patient was exposed to most nucleoside analogues, at least one non-nucleoside reverse transcriptase inhibitor and at least two protease inhibitors. At presentation she was receiving lamivudine, abacavir, and lopinavir/ritonavir, and had a viral load of 29 712 copies/ml and a CD4 T-cell count of 323 cells/ml. Genotypic resistance testing revealed multidrug resistance (reverse transcriptase: M41L, L74V, K103N, M184V, and T215Y; protease: L10F, L33F, I54V, L63P, A71V, V82A, I84V). A phenotypic resistance test confirmed high-level resistance to most drugs (Fig. 1).

The patient was admitted to the hospital for directly observed therapy at week 33. Her regimen was changed to lamivudine, abacavir, tenofovir, lopinavir/ritonavir, and enfuvirtide. Labor was induced at 37 weeks’ gestation using oxytocin. The maternal plasma HIV-1-RNA level was undetectable just before the delivery (Fig. 1). Intravenous zidovudine was administered during her labor. The infant received nevirapine, lamivudine, lopinavir/ritonavir, and zidovudine after delivery. The