Management of HIV in Pregnancy
All pregnant women with HIV should be treated with antiretroviral therapy (ART) regardless of their immunologic or virologic status to prevent perinatal transmission and improve maternal health. 1
Antiretroviral Therapy Approach
Initial Assessment
- Confirm HIV diagnosis with appropriate testing
- Assess CD4 count and HIV viral load
- Perform HIV resistance testing before starting therapy
- Screen for other infections including syphilis, hepatitis B, hepatitis C, and group B streptococcus
ART Regimen Selection
Start ART immediately upon diagnosis regardless of gestational age
- Do not delay treatment even in first trimester
- Early ART initiation is associated with higher rates of viral suppression at delivery 2
Preferred regimens:
For women already on ART who become pregnant:
- Continue current HAART regimen if effective
- Discontinue drugs with teratogenic potential
- Do not stop ART during first trimester 1
Monitoring During Pregnancy
- Monitor viral load regularly throughout pregnancy
- Goal: Achieve viral suppression (<40 copies/ml) by delivery
- Women on ART for 21-35 weeks have significantly lower risk of detectable viral load at delivery compared to those on ART for ≤12 weeks 2
- Monitor for ART side effects: hyperglycemia, lactic acidosis, hepatitis, cutaneous rash 3
Delivery Planning
Mode of Delivery
- Offer scheduled cesarean section at 38 weeks to reduce risk of perinatal HIV transmission 1
- Cesarean section is particularly beneficial for women with:
- HIV RNA levels >1000 copies/mL
- Unknown viral load status
- Poor adherence to ART
Intrapartum Management
- Continue HAART regimen during labor and delivery 1
- Administer intravenous zidovudine during labor for women with:
- HIV RNA >1000 copies/mL
- Unknown viral load
- Poor adherence to ART
Postpartum Care
Maternal Management
- For women who don't meet criteria for treatment outside of pregnancy:
- Consider discontinuing therapy after delivery
- When stopping therapy containing drugs with long half-lives (e.g., nevirapine), continue the nucleoside analogue components for 3-7 days after stopping nevirapine 1
Infant Management
- Provide antiretroviral prophylaxis to all HIV-exposed infants
- Begin prophylaxis as soon as possible after birth, ideally within 12 hours 1
- Perform HIV virologic testing on exposed infants
- Any positive virologic test should be repeated to confirm diagnosis 1
Breastfeeding
- HIV-infected women in the United States should not breastfeed to eliminate risk of postnatal transmission 1
- Provide support services for appropriate breast milk substitutes
Special Considerations
Multidisciplinary Care
- Involve specialists experienced in treating pregnant women with HIV 1
- Coordinate care between HIV specialists, obstetricians, and pediatric providers
- Notify pediatric care providers of impending birth of HIV-exposed infant 1
Disclosure and Confidentiality
- Include HIV status in confidential medical records of mother and infant
- Counsel regarding potential negative effects (discrimination, domestic violence)
- Provide referrals to appropriate psychological, social, and legal services
Common Pitfalls to Avoid
- Delaying ART initiation - Start therapy immediately upon diagnosis regardless of gestational age
- Stopping ART during first trimester - Interruption of therapy increases risk of viral rebound
- Failing to include zidovudine in regimens when possible
- Late entry to prenatal care - Early ANC attendance facilitates prompt ART initiation 2
- Not planning for postpartum infant prophylaxis - Arrange before delivery
By following these guidelines, the risk of perinatal HIV transmission can be reduced to less than 1% 4.