What is the recommended management for a pregnant patient with a reactive Human Immunodeficiency Virus (HIV) test?

Management of HIV-Reactive Pregnant Patient

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

Immediate Confirmation and Referral

• Confirm the diagnosis with a supplemental test (Western blot) before making final treatment decisions, though prophylactic interventions may need to begin based on preliminary reactive results 3
• Immediately refer to providers experienced in HIV care during pregnancy for co-management between HIV specialists and obstetricians 1, 2
• A reactive rapid test must be confirmed, but necessary peripartum interventions to reduce transmission risk may need to be initiated before confirmatory results are available, particularly if discovered at labor and delivery 3

Antiretroviral Therapy Initiation

Start or continue HAART immediately with a 3-drug regimen that includes zidovudine (ZDV) whenever possible, as ZDV remains the cornerstone of perinatal prevention 2

Preferred Regimens:

• Dual nucleoside reverse transcriptase inhibitors (NRTIs) plus an integrase strand transfer inhibitor (INSTI) or ritonavir-boosted protease inhibitor 4
• INSTIs are first-line agents as they achieve more rapid viral load reduction 5
• Zidovudine should be included in the regimen when possible 2

Critical Drug Avoidance:

• Never use efavirenz - documented teratogenic potential causing neural tube defects 2
• Never combine stavudine (d4T) plus didanosine (ddI) - increased risk of lactic acidosis and hepatic steatosis in pregnant women 6, 2
• If the woman is already on HAART containing efavirenz when pregnancy is discovered, discontinue immediately and replace 2

First Trimester Considerations:

• Do not stop antiretrovirals in the first trimester if the woman requires treatment for her own health (CD4 <350/mm³ or AIDS-defining illness), despite theoretical teratogenicity concerns 2
• If discontinuation is absolutely necessary, stop all drugs simultaneously to prevent resistance, except for long half-life drugs like nevirapine—continue nucleoside analogues for 3-7 days after stopping the NNRTI 2

Monitoring Throughout Pregnancy

• Measure viral load at baseline, 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 with combination therapy 2
• Assess fetal growth and wellbeing during third trimester with serial ultrasounds 2

Delivery Planning Based on Viral Load

For Viral Load >1000 copies/mL or Unknown:

• Offer scheduled cesarean section at 38 weeks gestation - reduces transmission by approximately 50% 3, 2
• Administer intravenous zidovudine during labor as part of the PACTG 076 protocol, even if mother is on oral HAART 2
• Continue HAART throughout labor and delivery—do not interrupt the regimen 2

For Viral Load <1000 copies/mL (Virologically Suppressed):

• Vaginal delivery is reasonable as the additional benefit of cesarean section is unclear in this population 2
• Continue HAART throughout labor and delivery 2
• Administer intravenous zidovudine during labor 2

Infant Management

Administer zidovudine prophylaxis to the newborn starting within 6-12 hours of birth, continuing for 6 weeks at 4 mg/kg twice daily 2, 7

Infant Prophylaxis Regimen Depends on Maternal Viral Suppression:

• Low-risk infants (mother virologically suppressed): 6 weeks of zidovudine alone 7
• High-risk infants (maternal viral load >1000 copies/mL, inadequate prenatal care, or no maternal treatment): Consider combination prophylaxis with additional agents 7

Infant Monitoring:

• Obtain baseline complete blood count before starting ZDV and repeat after completing 6-week regimen (at 12 weeks if abnormal) - 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 according to current standards, with repeat testing after completion of prophylaxis if initial tests are negative 2

Feeding Recommendations

Instruct mothers not to breastfeed in settings where safe formula alternatives are available, as this eliminates postnatal transmission risk 3, 2, 8

Postpartum Management

• Coordinate care between obstetricians and HIV specialists to ensure continuity of antiretroviral treatment 1, 2
• 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

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 2
• Document antiretroviral exposure in the child's permanent medical record 2

Common Pitfalls to Avoid

• Never delay treatment initiation while waiting for confirmatory testing if clinical suspicion is high 3
• Never use monotherapy or dual therapy - current recommendations require highly active combination therapy with 3 drugs for pregnant women with ongoing viral replication (HIV RNA >1000 copies/mL) 3
• Never stop antiretrovirals during labor - continue throughout delivery 2
• The goal is maternal viral load beneath laboratory level of detection prior to and throughout pregnancy, which can reduce perinatal transmission to less than 1-2% 4, 9, 5