How should a pregnant woman with newly diagnosed HIV infection be managed?

Management of New Onset HIV During Pregnancy

All pregnant women with newly diagnosed HIV infection must immediately start combination antiretroviral therapy (ART) 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 Antiretroviral Therapy Initiation

• Start combination ART immediately upon diagnosis with a 3-drug regimen that includes a backbone of two nucleoside reverse transcriptase inhibitors (NRTIs) plus a third agent 2
• Dolutegravir-based regimens (an integrase inhibitor) combined with emtricitabine and tenofovir alafenamide are now preferred first-line therapy when started during pregnancy, as they provide more rapid viral load reduction and have demonstrated safety and efficacy through 50 weeks postpartum 3, 4
• Alternative dolutegravir-based regimen: dolutegravir, emtricitabine, and tenofovir disoproxil fumarate 3
• Do not delay treatment—perinatal HIV transmission can be reduced to <1% with appropriate therapy 1, 5

Critical Drug Selection Considerations

Avoid these medications during pregnancy:

• Efavirenz is contraindicated due to documented teratogenic potential causing neural tube defects; if a woman presents already taking efavirenz, switch immediately 2
• Avoid stavudine (d4T) plus didanosine (ddI) combination due to increased risk of lactic acidosis and hepatic steatosis in pregnant women 2
• Do not use nevirapine in women with CD4 counts >250/mm³ due to severe hepatotoxicity risk 6

Monitoring Throughout Pregnancy

• Measure HIV viral load at baseline, then monthly initially, and again at 34-36 weeks gestation to guide delivery planning 2
• Monitor CD4 counts to assess maternal immune status and determine need for opportunistic infection prophylaxis 1, 2
• Perform detailed fetal anatomic ultrasound (level II) to assess for any structural abnormalities, particularly if using combination therapy 2
• Assess fetal growth and wellbeing during third trimester with serial ultrasounds 2
• Monitor liver function tests closely, especially during the first several months of treatment 7

Intrapartum Management

Continue all antiretroviral medications throughout labor and delivery—do not interrupt the regimen 2

Delivery Mode Decision Algorithm:

• If viral load <150 copies/mL at 34-36 weeks: Vaginal delivery is recommended if no obstetric contraindications exist 8
• If viral load >1000 copies/mL or unknown: Offer scheduled cesarean section at 38 weeks gestation, as this reduces transmission by approximately 50% 1, 6
• If viral load 150-1000 copies/mL: Consider cesarean section at 38 weeks, as the additional benefit of cesarean in this range requires clinical judgment 8
• Administer intravenous zidovudine during labor as part of standard protocol, even if the mother is on oral combination ART 2

Postpartum Maternal Management

• Continue antiretroviral therapy after delivery to maintain maternal health—pregnancy is not an adequate reason to defer or discontinue HIV treatment 1
• Coordinate care between obstetricians and HIV specialists to ensure continuity of treatment 2, 5
• For women who do not meet criteria for lifelong treatment (CD4 >350/mm³, no AIDS-defining illness), discuss whether to continue therapy, though current practice favors continuation 2
• Screen for postpartum depression, which significantly impairs 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 this eliminates postnatal transmission risk 1, 5

Newborn Management

Administer antiretroviral postexposure prophylaxis to the infant:

• Start zidovudine prophylaxis within 6-12 hours of birth, continuing for 6 weeks at 4 mg/kg twice daily 2, 5
• For high-risk infants (maternal viral load >1000 copies/mL or no maternal treatment), consider 3-drug infant prophylaxis 8
• Obtain baseline complete blood count before starting zidovudine and repeat after completing the 6-week regimen, as anemia is the primary complication 2

Diagnostic testing for the infant:

• Perform HIV virologic testing (PCR for HIV DNA or RNA) at birth for high-risk infants, then at 2-4 weeks, 1-2 months, and 4-6 months of age 1
• Any positive virologic test must be immediately repeated to confirm diagnosis 1
• Start Pneumocystis carinii pneumonia (PCP) prophylaxis at 6 weeks of age after completing zidovudine prophylaxis 2
• Infection is definitively ruled out with negative PCR results after 1 month and 4 months of age, plus negative HIV antibody at 12-18 months 1

Counseling and Support Services

• Provide comprehensive HIV prevention counseling including discussion of perinatal transmission risks and ways to reduce them 1
• Assess for potential negative effects including discrimination, domestic violence, and psychological difficulties 1
• Refer to appropriate psychological, social, and legal services as needed 1
• Educate about the importance of strict adherence to prevent drug resistance 9
• Inform about reproductive options with nondirective counseling 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 2
• Document antiretroviral exposure in the child's permanent medical record 2
• Encourage testing of any other children born after the mother became infected 1

Common Pitfalls to Avoid

• Never delay ART initiation while waiting for resistance testing or specialist consultation—start immediately with a recommended first-line regimen 2, 5
• Do not discontinue all antiretrovirals during first trimester due to theoretical teratogenicity concerns if the woman requires treatment for her own health (CD4 <350/mm³) 2
• If discontinuation is absolutely necessary, stop all drugs simultaneously to prevent resistance, except with long half-life drugs like nevirapine—continue nucleoside analogues for 3-7 days after stopping the NNRTI 2
• Do not use single or dual therapy—always use combination ART with at least 3 drugs 1, 2
• Ensure coordination between HIV specialists and obstetricians, as management can be complicated by multiple drug interactions, side effects, and need for careful monitoring 1