What is the management of HIV (Human Immunodeficiency Virus) in an 8-week pregnant individual?

Management of HIV in Pregnancy at 8 Weeks

Immediate Antiretroviral Therapy Initiation

All HIV-infected pregnant women at 8 weeks gestation should receive combination antiretroviral therapy (HAART) with at least 3 drugs immediately, regardless of CD4 count or viral load, to prevent mother-to-child transmission and maintain maternal health. 1, 2

• Start a 3-drug regimen that includes zidovudine (ZDV) whenever possible, as ZDV remains the cornerstone of perinatal prevention 2
• For women already on HAART when pregnancy is discovered at 8 weeks, continue the current regimen unless it contains teratogenic agents 2
• If the woman requires treatment for her own health (CD4 <350/mm³ or AIDS-defining illness), antiretroviral drugs should not be stopped during the first trimester despite theoretical teratogenicity concerns 2
• For women with HIV RNA >1000 copies/mL, combination HAART is mandatory; for those with <1000 copies/mL, either HAART or the 3-part zidovudine regimen can be used 1, 2

Critical First Trimester Drug Restrictions at 8 Weeks

Immediately discontinue efavirenz if currently prescribed, as it causes neural tube defects when used during the first trimester. 2

• Avoid the combination of stavudine (d4T) plus didanosine (ddI) due to increased risk of lactic acidosis and hepatic steatosis in pregnant women 2
• If discontinuation of all antiretrovirals is deemed necessary in the first trimester, stop all drugs simultaneously to prevent resistance, except when using drugs with long half-lives like nevirapine—in which case continue nucleoside analogues for 3-7 days after stopping the NNRTI 2
• Integrase inhibitors (INSTIs) are first-line recommended agents as they lead to more rapid HIV viral load reduction and have demonstrated safety in pregnancy 3, 4

Monitoring Protocol Throughout Pregnancy

Measure viral load at baseline (8 weeks), monthly initially, then at 34-36 weeks gestation to guide delivery planning. 2

• Monitor CD4 counts to assess maternal immune status and need for opportunistic infection prophylaxis 2
• Perform level II ultrasound for detailed fetal anatomic assessment, particularly if using combination therapy 2
• Assess fetal growth and wellbeing during the third trimester with serial ultrasounds 2
• The maternal HIV viral load is the strongest predictor of perinatal transmission, making suppressive antiretroviral treatment the principal means to eliminate transmission 3

Delivery Management

Offer scheduled cesarean section at 38 weeks gestation to women with viral loads >1000 copies/mL or unknown viral load, as this reduces transmission by approximately 50%. 1, 2

• Continue HAART throughout labor and delivery—do not interrupt the regimen 2
• Administer intravenous zidovudine during labor as part of the PACTG 076 protocol at 2 mg/kg over 1 hour followed by continuous infusion of 1 mg/kg/hr until delivery, even if the mother is on oral HAART 1, 2, 5
• For women with undetectable or very low viral loads (<1000 copies/mL) on HAART, vaginal delivery is reasonable as the additional benefit of cesarean section is unclear in this population 2
• Elective cesarean delivery performed before onset of labor and rupture of membranes was associated with transmission rates of 1.8% in randomized trials 1

Postpartum Management

Coordinate care between obstetricians and HIV specialists to ensure continuity of antiretroviral treatment immediately after delivery. 2, 6

• For women who do not meet criteria for treatment in non-pregnant individuals (CD4 >350/mm³, no AIDS-defining illness), consider discontinuing therapy after delivery with all drugs stopped simultaneously 2
• Exception for nevirapine-containing regimens: Continue dual nucleoside analogues for 3-7 days after stopping nevirapine to reduce resistance risk 2
• Screen for postpartum depression, which interferes with adherence and is associated with virologic failure and resistance development 2
• Instruct mothers not to breastfeed in settings where safe formula alternatives are available, as breastfeeding may increase transmission by 10%-20% 1, 2, 7

Neonatal Prophylaxis and Testing

Administer zidovudine prophylaxis to the newborn starting within 6-12 hours of birth at 2 mg/kg orally every 6 hours, continuing for 6 weeks. 2, 5

• For neonates unable to receive oral dosing, administer zidovudine intravenously at 1.5 mg/kg infused over 30 minutes every 6 hours 5
• Obtain baseline complete blood count before starting ZDV and repeat after completing the 6-week regimen (at 12 weeks of age if abnormal), as anemia is the primary complication 2
• Start Pneumocystis carinii pneumonia (PCP) prophylaxis at 6 weeks of age after completing ZDV prophylaxis 2
• Perform HIV virologic testing with PCR for HIV DNA or RNA; sensitivity improves from 50% at birth to >90% at 2-4 weeks of age 1
• Test high-risk infants at birth (mothers who seroconverted during pregnancy or were untreated), then repeat at >1 and >4 months of age 1
• Confirm absence of HIV infection with a negative HIV antibody assay at 12-18 months of age, as maternal IgG crosses the placenta and can remain positive until 18 months 1

Long-Term Follow-Up

Maintain long-term follow-up of HIV-exposed infants into adulthood due to theoretical concerns about carcinogenicity of nucleoside analogues. 2

• Include yearly physical examinations for all antiretroviral-exposed children, with gynecologic evaluation and Pap smears for adolescent females 2
• Document antiretroviral exposure in the child's permanent medical record, particularly for uninfected children 2
• With appropriate combination antiretroviral therapy, HIV-infected mothers can achieve virologic suppression to undetectable levels and yield a perinatal transmission rate of less than 2% 3