What are the implications of a viral load of 389 copies/mL of Human Immunodeficiency Virus (HIV) during pregnancy?

From the Guidelines

A viral load of 389 copies/mL during pregnancy indicates that HIV is relatively well-controlled but not fully suppressed, and the goal is to achieve an undetectable viral load to prevent mother-to-child transmission. The current viral load is below the threshold of 1,000 copies/mL, above which scheduled cesarean delivery is recommended as an adjunct for prevention of transmission 1. However, this does not guarantee that transmission can be prevented, as transmission has been reported even when maternal HIV-1 RNA levels were below assay quantification 1.

To achieve full viral suppression, the following steps can be taken:

• Continue current antiretroviral therapy (ART) without interruption
• Consider adjusting the medication regimen to achieve full viral suppression, with common pregnancy regimens including dolutegravir or raltegravir with tenofovir/emtricitabine or abacavir/lamivudine
• Increase the frequency of viral load monitoring to every 1-2 months until the viral load becomes undetectable
• Planned cesarean delivery may be recommended if the viral load remains above 1,000 copies/mL near delivery, although this is unlikely to be the case with the current viral load of 389 copies/mL
• The baby will receive antiretroviral prophylaxis after birth, typically with zidovudine for 4-6 weeks

Key considerations include:

• The importance of achieving an undetectable viral load to prevent mother-to-child transmission
• The need for regular viral load monitoring to adjust treatment as needed
• The potential benefits and risks of planned cesarean delivery in reducing transmission risk
• The importance of antiretroviral prophylaxis for the baby after birth to further reduce transmission risk. With appropriate treatment, the risk of transmitting HIV to the baby can be reduced to less than 1% 1.

From the Research

Implications of a Viral Load of 389 copies/mL of HIV during Pregnancy

• A viral load of 389 copies/mL is considered high and increases the risk of mother-to-child transmission of HIV 2, 3.
• According to the study by 2, elective cesarean section is the best delivery mode for pregnant women with viral loads more than 50 copies/ml, but it does not specifically address the implications of a viral load of 389 copies/mL.
• The study by 4 found that during pregnancy, 15.2% of women had a viral load of ≥1000 copies/ml, and 76.9% had a viral load of <50 copies/ml, but it does not provide information on the specific implications of a viral load of 389 copies/mL.
• The management of HIV-infected pregnant women involves initiating antiretroviral therapy (ART) to achieve a maternal serum HIV RNA viral load beneath the laboratory level of detection prior to conceiving, as well as throughout their pregnancy 5.
• Viral load monitoring during pregnancy is crucial to identify women with unsuppressed viral load early in pregnancy and to provide timely intervention to improve viral suppression 6.
• The study by 6 found that women who initiated ART during pregnancy had lower coverage of viral load testing and viral suppression compared to women who initiated ART before pregnancy, highlighting the importance of enhanced adherence counseling during pregnancy.

Risk of Mother-to-Child Transmission

• The risk of mother-to-child transmission of HIV is higher in women with high viral loads 2, 3.
• The study by 3 found that achieving rapid reduction of HIV-1 viral load in HIV-positive pregnant women close to term is essential to prevent mother-to-child transmission.
• The study by 5 found that perinatal HIV transmission can be less than 1% when effective cART, associated with virologic suppression of HIV, is given during the ante-, intra-, and postpartum periods.

Management and Treatment

• The management of HIV-infected pregnant women involves initiating ART to achieve a maternal serum HIV RNA viral load beneath the laboratory level of detection prior to conceiving, as well as throughout their pregnancy 5.
• The study by 2 found that a ritonavir-boosted protease inhibitor combined with two nucleoside reverse transcriptase inhibitors is currently the most widely used regimen.
• The study by 6 found that initiating ART during pregnancy rather than before pregnancy was associated with a lower likelihood of receiving a viral load test during pregnancy, highlighting the importance of enhanced adherence counseling during pregnancy.