REVIEW
Management of HIV infection
in pregnancy
Lauren Bull
Abdul W Khan
Simon Barton
Abstract
Advances in the management of HIV positive patients combined with up
to date research, collaborative guidelines and routine antenatal screening
has meant that the transmission of HIV-1 from mother to child is now a
rare occurrence in the UK. Globally women equally share the burden of
HIV associated morbidity and mortality with men, however in the devel-
oped world, women represent a minority of those with new HIV infection.
The clinical intricacies associated with the management of pregnancy and
childbirth necessitates specialist care across multidisciplinary teams, thus
ensuring optimal outcomes for mothers and their babies. The global
target of eliminating mother to child transmission MTCT requires a
major and sustained effort to improve access to testing, antiretroviral
therapy and expert multidisciplinary care. The following article highlights
the latest research and guidelines applicable to HIV positive expectant
mothers in the UK.
Keywords antiretrovirals; breastfeeding; epidemiology; hepatitis co-
infection; HIV; point-of-care testing; pre-labour caesarean section;
pregnancy
Introduction
Globally, approximately 35 million people are infected with HIV
and almost half of them are women. The overwhelming majority
of women living with HIV are in resource poor countries. In the
UK, there has been a concerted effort to increase HIV testing
uptake both in traditional settings such as Genitourinary Medi-
cine clinics and antenatal clinics and novel settings such as Dean
Street Express a walk in service which provides rapid results for
all sexual infections, as well as making HIV testing part of routine
investigations in settings such as Accident & Emergency and
general practice. Additionally, the widespread availability of
point of care tests (POCT) for HIV enable rapid identification of
Lauren Bull MSc MRCP is a Specialist Registrar in Genitourinary Medicine
and HIV at Chelsea and Westminster Hospital, London, UK. Conflicts of
interest: I have received funding from Gilead and Janssen to attend
conferences.
Abdul W Khan MSc MBBS is an Associate Specialist in Genitourinary
Medicine and HIV at Chelsea and Westminster Hospital, London, UK.
Conflicts of interest: none declared.
Simon Barton BSc MD FRCOG FRCP is a Consultant Physician in HIV and
Genitourinary Medicine at Chelsea and Westminster Hospital, and
Adjunct Professor at Imperial College, London, UK. Conflicts of interest:
Received honoraria and travel funding from ViiV and Gilead for
delivering educational lectures at conferences. Trustee of St Stephens
AIDS Trust a registered Charity.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:10
persons carrying the virus enabling appropriate clinical decisions
to be made. The aim of these testing campaigns is to reduce the
proportion of people (approximately one quarter) who are un-
aware of their HIV status. A third of all new HIV diagnoses are
defined as late presenters ie they have a CD4 count of below 200
cells/ml at the time of diagnosis which has a negative effect on
clinical outcomes. The majority of women who are unaware of
their status are from sub-Saharan Africa. With the HIV epidemic
maturing, there are now cases of women who acquired HIV
vertically themselves now becoming mothers.
Natural history
HIV 1 is responsible for the majority of HIV infections worldwide
whilst HIV 2 is generally confined to West Africa and has a much
lower virulence and transmission.
After infection, viral replication and integration results in a
gradual loss of the CD4 lymphocyte count causing immune
deficiency, indicated by a cell count less than 350 cells/mm3.
This can make a patient vulnerable to a variety of opportunistic
infections or subsequently a risk of developing AIDS. The time
taken to develop AIDS from seroconversion is very variable,
ranging from months to more than a decade. The development of
anti-retroviral drugs has transformed the management of HIV. In
fact the initial effects were so impressive it led to the term highly
active antiretroviral therapy (HAART) to come into existence.
Now that these effects are widely accepted it is more commonly,
and herein referred to as antiretroviral therapy (ART). By
enabling restoration of immune function and in doing so
increasing life expectancy, ART also renders viral loads unde-
tectable and thus reduces infectivity.
Mother to child transmission (MTCT)
In 2011, the WHO unveiled a campaign “No child born with HIV”
outlining the goals and plans to decrease worldwide MTCT rates.
In the UK, in 2011, the estimated HIV prevalence of HIV infection
amongst women giving birth was 2.2 per 1000 women The ma-
jority of these women are from sub-Saharan Africa The rate of
HIV MTCT has significantly decreased from 25.6% in 1993 to an
estimated 0.57% in 2007e2011. The risk of transmission is
highly dependent on the viral load (VL). At a viral load of
>100,000 copies/ml there is a 40% risk of transmission. This
falls to 1% at 1000 copies/ml and less than 1% at undetectable
VL (<50 copies/ml). Management also considers the mode of
delivery, appropriate and timely intervention of post exposure
prophylaxis (PEP) for the infant and avoidance of breast feeding.
It must be noted that in the UK, over half of pregnant women
with HIV present late for antenatal care. Late presentation and
later booking has adverse consequences for both mother and
child, with a small proportion of HIV positive women remaining
undiagnosed at the point of delivery. Obtaining the best possible
outcome for all HIV positive women including late presenters
requires a dedicated and flexible team of specialist midwifes,
obstetricians and HIV physicians.
Methods of MTCT
There are three established ways of MTCT:
 In utero transmission is a less common mode of trans-
mission as an intact placenta acts as a very effective barrier
to the transfer of HIV. Placental transfer of virus can
273 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW
happen with an extremely high viral load which is com-
mon in seroconversion illness where transmission rates
can be as high as 30%, advanced late stage disease with
very low CD4 and in the presence of opportunistic in-
fections which can up regulate the viral load. In normal
circumstances a viral load of above 100,000 copies/ml is
high enough to facilitate in utero transmission with a risk
of about 2%. The placental barrier can be compromised
with severe systemic infections like milliary tuberculosis,
falciparum malaria and secondary syphilis where inflam-
matory endarteritis can distort the integrity of the placenta.
Con-comittant use of crack and cocaine can also impair
placental function and may increase the risk of MTCT.
 MTCT at the point of delivery is the commonest mode of
transmission, and can occur as a result of high viral load at
delivery, prolonged rupture of membranes, prematurity,
vaginal laceration, vaginal ulceration due to herpes sim-
plex infection or syphilitic ulcers, episiotomy, invasive
fetal monitoring and instrumental delivery.
 Post-partum MTCT is almost exclusively due to breast
feeding and accounts for up to 40% of transmissions in
undiagnosed women. There are reports that for some
women there may be a lot of stigma around being unable
to breastfeed. This is especially among communities in
parts of Africa and migrants living in the UK from these
areas, where it may be viewed as a disclosure of their HIV
status to friends, families and even partners.
Antenatal management
Antenatal testing
Prior to 2005, the majority of women diagnosed with HIV ante-
natally were not aware of their diagnosis however the majority
are now already aware, many diagnosed in a previous preg-
nancy. The UK introduced routine ‘opt out’ antenatal HIV testing
in 1999; the uptake in 2008 was 92e95%. Testing is performed at
booking (12e14 weeks) and no further HIV tests are routinely
offered. However the National Screening Committee has
emphasised that any woman declining the initial test should be
reoffered screening at 28 weeks’ gestation. Additionally, given
the risk of seroconversion during pregnancy as outlined above,
any woman considered to be at ongoing risk should be reoffered
screening particularly if presenting with symptoms consistent
with seroconversion.
Robust policies should exist in every antenatal unit offering
HIV tests, with clear records of uptake and the reasons for
declining a test. Reasons for declining should be further explored
through a meeting with a dedicated HIV midwife and the
obstetrician in charge, with repeat offering of the test. All rele-
vant healthcare staff should have the skills and knowledge to
deal with these situations comfortably and receive regular
training, peer support and audit in their units. Additionally,
training in the use of point of care tests (POCT) should be
considered. Given the advances in HIV management, counselling
prior to testing should not be seen as the daunting task it once
was. It is based around a discussion of risk and the likely
outcome of the result and is always performed with the notion
that it is better to know the result and act on it accordingly.
Serology tests are taken routinely as part of screening with no
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:10
counselling. POCT’s have a window period of 6 weeks, i.e. in-
forms us of the patient’s status 6 weeks before and have a false
reactive rate of less than 1%. Any reactive result undergoes a
confirmatory test of a different type of POT to confirm the results.
Screening of HIV positive pregnant women
The British HIV Association (BHIVA) guidelines recommend STI
screening on a yearly basis in HIV positive individuals. Women
need to be educated about preventing onward HIV transmission
and STI’s. Any pregnant woman at risk should also be screened
for other sexual infections that could potentially be transmitted
to the unborn child including chlamydia, syphilis, hepatitis,
gonorrhoea and herpes. Screening for STI’s should be performed
twice during pregnancy, once in the first trimester and again in
the third trimester. Test of cure should be performed following
treatment for any bacterial STI’s.
Recurrent herpes simplex (HSV) type 2 infection is common in
HIV positive women and all women should have type specific
HSV serology if they have no previous diagnosis of genital herpes
and present with symptoms of genital ulcers. HSV recurrence will
increase the local HIV replication and may play a role in MTCT
especially when vaginal delivery is anticipated. Prophylactic
treatment with aciclovir 400 mg TDS should be offered from 32
weeks especially where vaginal delivery is planned. Appropriate
partner notification should be performed. HIV positive women
with primary genital HSV in the last trimester should be managed
as per HIV negative women. There is currently no evidence to
support HIV positive women who are HSV antibody positive but
with no history of genital ulceration to have aciclovir
prophylaxis.
Vaccinations: whooping cough vaccine and vitamin D should be
offered to women regardless of their HIV status.
ART in pregnancy
Antiretroviral drugs have been used extensively in HIV positive
women in order to control virus levels and thus reduce MTCT.
The repertoire of antiretroviral agents is expanding and there is
better understanding about the mode of action, toxicity and in-
teractions of these agents. Very little data have arisen from ani-
mal studies for these drugs and most of the experience of use in
pregnancy comes from observational studies, pregnancy drug
registry and yellow card reporting.
Up until the late 1990’s the standard of care for HIV positive
pregnant women was to take Zidovudine, a nucleoside analogue
inhibitor, orally in the second trimester, followed by an intra-
venous infusion during labour and then given orally to new
born for first six weeks. This was called the 076 protocol after
the major study that proved its efficacy. This reduced the MTCT
from 27.7% to 7.9%; importantly women did not breast feed.
The 076 protocol in conjunction with a bloodless planned lower
segment caesarean section further reduced the risk of MTCT to
2%. In the late 1990s, introduction of triple combination anti-
retroviral or ART changed clinical practice. ART’s ability to
lower plasma viral load to undetectable levels improves survival
and reduces morbidity. All children born to mothers who had
exposure to antiretrovirals in the UK are followed up for any
future potential adverse effects and are placed on the pregnancy
registry.
274 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW
Timing and type of ART and transmission
A high viral load is the most important risk factor for MTCT;
mothers with a viral load of less than 50 copies/ml (undetect-
able) and who do not breast feed have a 0.5% chance of trans-
mitting the virus. Some women will require initiation of ART
whilst pregnant for their own health, i.e. a CD4 <350, others will
conceive whilst already on ART and others will only require to
start ART to minimise MTCT.
Maternal baseline viral load is an important factor to take into
consideration when deciding the time to initiate treatment in
pregnant women. All women should commence ART by 24 weeks
of pregnancy. A longer duration of ART is associated with reduced
MTCT and rates of MTCT are lower in women who became
pregnant on ART, compared to those who start ART during
pregnancy; each week of ART reduces the odds of transmission by
8%. It is important to start ARV earlier than 20e24 weeks when
the base line viral load is high, the CD 4 count is low, in the
presence of co-morbidities like hepatitis B/C infection or recurrent
genital HSV, and in high risk obstetrics patients such as those with
a history of premature delivery. ART should be started as soon as
possible if the viral load is higher than 100,000 and in some
special circumstances, for example seroconversion illness.
Studies have shown the different types of ART used do not
influence the rate of MTCT. There are increasing amount of data
to guide the use of ARV during pregnancy however there have
been many newer agents developed in recent years for which
such data is not yet available. As a general rule, if a woman
conceives on an effective ART regime she should continue on
this, one exception is a patient on protease inhibitor mono-
therapy as this requires intensification with additional anti ret-
rovirals to maintain viral suppression. See Table 1 for an outline
of the major classes of antiretroviral therapy.
Antiretroviral toxicity
The fetus is most vulnerable to toxic drug effects in the first 12
weeks of gestation. Previous guidelines had advised that efavir-
enz should not be used in pregnancy. However, systematic re-
view and meta-analysis indicates that there is no additional
teratogenicity with efavirenz compared to other drugs; indeed it
can be both continued and commenced in pregnancy. Zidovu-
dine, lamivudine and ritonavir have been shown to have
congenital malformation rates within the expected range. Simi-
larly, an excess in congenital malformations has been excluded
with abacavir, tenofovir, emtricitabine, lopinavir, atazanavir
nevirapine. Newer agents such as raltegravir, etravirine, mar-
aviroc, rilpivirine, elvitegravir and dolutegravir do not have
sufficient reported outcomes of first trimester exposure to
exclude such risk. Ongoing surveillance of all children exposed to
ART is through the RCOG/NSPH and the international Anti-
retroviral Pregnancy Registry.
There is no evidence to suggest that the pharmacokinetics of
most ARV are altered in pregnancy if used at adult license doses.
Antenatal ultrasound and invasive procedures
Fetal ultrasound imaging should be performed as per national
guidelines regardless of maternal HIV status. Prenatal diagnostic
testing should not be performed until HIV status of the woman has
been determined and ideally deferred until viral load is suppressed.
Most invasive procedures should be avoided in HIV positive
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:10
pregnant women if possible given the small chance of bleeding and
thus of HIV transmission; however this risk has to be weighed
against the benefit of performing the procedure. The French Pae-
diatric HIV Infection Study Group observed a relative risk of HIV
transmission of 1.9 with antenatal procedures including amnio-
centesis, cerclage, laser therapy and amnioscopy. However, this
study was conducted between 1985 and 1993 and only a minority
had received zidovudine. Current guidelines recommend that if the
procedure cannot be delayed until viral suppression is achieved, an
ART regimen including raltegravir (associated with rapid viral load
suppression) should be given along with single dose of nevirapine
2e4 hours prior to the procedure.
Hepatitis co-infection: hepatitis B and/or C co-infection is rela-
tively common within the HIV positive cohort in the UK, although
less so in pregnant women. HIV can have deleterious impact on
hepatitis with lower rates of spontaneous clearance and faster rate
of progression to cirrhosis. It is recommended that any abnormal
liver function tests are investigated with hepatitis co-infection in
mind and that co-infected patient are co-managed by clinicians
with expertise in treating both conditions. Particular attention
must be paid to antiviral agents used for treatment of hepatitis B
and C. Patients need to have close monitoring of liver function
tests if starting HIV antiviral therapy due to the risk of hepato-
toxicity or immune reconstitution inflammatory syndrome. For
both infections, in the absence of obstetric complications, vaginal
delivery can be anticipated if HIV viral load is suppressed on ART.
Management of labour
Mode of delivery (Figure 1)
Historically a planned elective caesarean section was the method
of choice for delivery in HIV positive women. However effective
control of viral load with ART has led to more and more women
having vaginal deliveries. For women taking ART, a decision
regarding mode of delivery should be made after review of viral
load at 36 weeks.
BHIVA guidelines state that a planned vaginal delivery is
recommended for women on ART with an undetectable viral
load in the absence of obstetric complications. In these women,
obstetric management should follow the same guidelines as for
the uninfected population. Published cohort data from the UK
and other European countries have shown MTCT rates of <0.5%
in women with plasma viral load <50 cpml taking ART, irre-
spective of mode of delivery.
In circumstances when the viral load is greater than 400
copies/ml at 36 weeks a planned caesarean section is recom-
mended regardless of the ART agents, additionally when the pa-
tient is on zidovudine monotherapy regardless of the viral load.
For women who have a viral load between 50 and 399 copies/ml
current recommendations are to consider caesarean section taking
into account the actual viral load, the trajectory for the viral load,
length of treatment, obstetric factors and the woman’s views. This
is based on unpublished European and NHSPC UK cohort data
which show the risk of MTCT in this group is double for women
intending vaginal delivery. Although this was not a significant
finding given the small number of events.
The timing of caesarean section is a balance between the risks
of transient tachypnoea of the newborn and the likelihood of
275 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW

Outlining the main classes of antiretroviral therapy, mechanism of action and use in pregnancy
Class of drug Mechanism of action Use in pregnancy

Nucleoside reverse transcriptase inhibitors
(NRTI) e.g. Zidovudine, tenofovir,
emtricitabine, lamivudine
Non-nucleoside reverse transcriptase
inhibitors (NNRTI) e.g. nevirapine, efavirenz,
etravirine, rilpivirine
Protease inhibitors (PI’s) e.g. lopinavir,
atazanavir, darunavir, ritonavir
Integrase inhibitors (INI) e.g. raltegravir,
elvitegravir, dolutegravir
Competes with natural substrates for HIV
reverse transcriptase and inhibits its DNA
polymerisation
Bind directly to reverse transcriptase inhibit its
function
Substrate analogues for an HIV protease
enzyme. Blocks enzyme’s activity resulting in
lack of virion formation
Target the HIV enzyme integrase which is
responsible for integration of viral genetic
material into human DNA
Two drugs from this class form the backbone
of the majority of ART regimens. Well used in
pregnancy.
Normally used in addition to 2 NRTI’s.
Experience and studies show that nevirapine
and efavirenz are safe to use in pregnancy. No
data to support the newer agents such as
etravirine and rilpivirine. However if a woman
conceives on an effective regimen containing
these agents may be able to continue.
Normally used in addition to 2 NRTI’s.
Lopinavir, atazanavir and ritonavir shown to
have congenital malformation rates within
expected range and well used in pregnancy.
Normally used in addition to 2 NRTI’s. Not yet
sufficiently studied to exclude increased risk
of congenital malformation in the first
trimester. Although if a woman conceives on
an effective regime containing one of these
drugs may be able to continue.

Table 1

labour occurring before the scheduled caesarean section. Where
the indication is to prevent MTCT, caesarean section at 38e39
weeks is considered; the earlier timing reflects the importance of
avoiding the onset of labour.
In the pre-ART era, several studies suggested that prolonged
duration of ruptured membranes, usually analysed as greater
than 4 hours, in women who were either untreated or receiving
ZDV monotherapy, resulted in a significantly increased risk of
MTCT. The few studies available from the ART era do not sup-
port this. According to BHIVA guidelines therefore, for any
women on ART who ruptures her membranes at term with a viral
load of <50 copies/ml and who does not have an obstetric
contra-indication to vaginal delivery, a caesarean section is not
recommended.
Studies have shown an association between both acute/
chronic chorioamnionitis and perinatal transmission. Although
these studies were largely performed in the pre-ART era, it is
recommended that labour should be expedited for all women
with rupture of membranes at term. Therefore women with an
undetectable viral load and ROM at term should have immediate

Mode of delivery for different HIV viral loads

Review of HIV viral load at 36 weeks

40 400
(Undetectable) copies/ml
50–399
copies/ml
In the absence of Planned Caesarean
obstetric complications section
planned vaginal delivery

Consider Caesarean section

taking into account actual viral load,
the trajectory for the viral load,
length of treatment, obstetric factors
and the woman’s views

Figure 1

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:10 276 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW
induction of labour with a low threshold for the treatment of
intrapartum pyrexia.
Women in whom difficult labour/obstetric complications are
anticipated should be considered for referral to a tertiary centre.
Additionally women who opt for a vaginal birth after caesarean
should be allowed to proceed if they have an undetectable viral load.
Home birthing and the use of birth pools is not commonly
routine in HIV positive labouring women, and there is no evi-
dence to inform guidelines at present. This situation requires the
view of the MDT taking into account all relevant factors.
There is a lack of current data since the introduction of ART on
the use of fetal scalp electrodes/fetal blood sampling. However it is
felt that these are unlikely to confer an increased risk of trans-
mission in a woman who has an undetectable viral load. In a
woman for whom vaginal delivery has been recommended and
labour has commenced, obstetric management should follow the
same principles as for the uninfected population. There are theo-
retical reasons why a low traction forceps may be preferred to a
ventouse delivery (with potential lower rates of fetal trauma)
however there are no data to inform this. In a woman with an
undetectable viral load it is unlikely that the type of instrument will
affect MTCT therefore the most appropriate for the situation should
be used.
Late booking or women presenting in labour who are
untested
Late booking or presentation in labour, prior to adequate treat-
ment with ART (and thus likely detectable viraemia) can lead to
MTCT. A national audit of pregnant women with HIV revealed
that women who received ART for fewer than 2 weeks were more
likely to be first diagnosed with HIV, during their pregnancy. The
most common reason for not receiving ART were late booking, a
denial of HIV diagnosis and refusal of treatment. Children born to
these women had a higher rate of MTCT (13.4%).
If a woman presents after 28 weeks and is subsequently found
to be infected with HIV she should start treatment without delay.
The ART regimen selected is normally based on a resistance test;
however, if this is not rapidly available a PI- based regimen
(either ritonavir-boosted atazanavir, lopinavir or darunavir)
should be initiated immediately. Where the viral load is un-
known or >100,000 copies/ml, a fourth drug, raltegravir, may be
added to this regimen.
If a woman presents in labour and is untested or had signifi-
cant risk since previous testing an urgent point of care test should
be performed. These widely available near patient tests provide
an accurate view of the patient’s status from 6 weeks prior to the
test (the window period for antibody formation that the test is
detecting). If a woman presents in labour and is not on treat-
ment, she should be given a stat dose of nevirapine as this
rapidly crosses the placenta (effective concentrations are ach-
ieved within 2 hours and then maintained in the neonate for up
to 10 days). Obstetric emergency management is the priority,
however if time permits prior to caesarean section, attending
staff should also commence potent therapy which crosses the
placenta and results in rapid reduction of viral load, such as an
oral combination of zidovudine, lamivudine and raltegravir, with
intravenous zidovudine being administered throughout labour.
The newborn should then initiate a combination of three drugs,
usually zidovudine, lamivudine and nevirapine for four weeks,
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:10
adjusted according to further information available about the
maternal pre-natal viral load. In preterm labour where the infant
is unlikely to be able to absorb oral therapy the addition of
double dose tenofovir to the mother can ensure ARV’s reach the
baby as soon as possible.
Preterm delivery
There is a large amount of conflicting evidence as to whether
ART is associated with preterm delivery. The ART implicated
predominantly are the protease inhibitors. Observational and
cohort data are mixed as to the association with pre term delivery
and RCT data from Africa is also mixed. A current trial-PROMISE
study (NCT01061151) will likely provide some more answers
around the use of PI’s in pregnancy.
Decisions regarding the optimum treatment of preterm ROM
necessitate assessment of exact gestation, maternal viral load and the
presence of other co-morbidities as well as the facilities available.
Consideration of corticosteroids to improve fetal lung matu-
ration and oral erythromycin should be given as per the RCOG
guidelines. The viral load should be optimised, if it is not un-
detectable. A concern that the pre-term infant may not be able to
tolerate oral therapy may make it more desirable to load the
infant through the transplacental route with maternal therapy.
Post-partum management
Neonatal post exposure prophylaxis
Antiretroviral treatment to the newborn is an example of pre-
exposure prophylaxis and should be decided before the delivery.
The choice of the drugs given to the baby depends on the mother’s
antiretroviral drug history and known resistance mutations. This
treatment should be planned in a multi-disciplinary setting with a
paediatrician with interest in HIV disease, obstetrician and HIV
physician; there may be need for advice from a virologist.
Monotherapy (usually AZT) is usually sufficient where there
is a very low risk of transmission to the newborn, i.e. when the
mother is on combination ART with an undetectable viral load.
There are however two situations where triple combination (i.e.
ART) neonatal post-exposure prophylaxis is advised: where the
mother is found to be HIV positive after delivery (whereby
treatment needs to be given within 72 hours), when there is
detectable maternal viraemia at birth. Choices for newborn are
fairly limited given the toxicities of many drugs. Neonatal PEP
should be given for 4 weeks. In addition Pneumocystis pneu-
monia (PCP) prophylaxis should be started at 4 weeks in: all HIV
infected infants, infants with an initial positive HIV DNA/RNA
test, infants whose mothers viral load at 36 weeks or delivery is
>1000 copies/ml.
Breast feeding in HIV positive women
Women who breast feed may transmit HIV by this route, espe-
cially if the viral load in plasma and breast milk is high, delivery
is premature, breastfeeding is prolonged, or if nipples are
cracked. The current standard of care in the UK is to avoid
breastfeeding in HIV positive mothers. There may be wide vari-
ations between plasma and breast milk viral load, which is why
breast feeding should be avoided even in the presence of an
undetectable serum viral load. Intestinal permeability is a
possible entry site for the virus and mixed feeding is thought to
277 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW
double the risk of HIV transmission secondary to inflammation.
It should be noted that in a mother who chooses to breastfeed
when on ART with an undetectable viral load this does not
constitute an automatic referral to child protection teams how-
ever feeding whilst not on ART or with detectable viraemia does
constitute a potential child protection issue.
Testing of infants
All infants born to HIV positive mothers should be tested for HIV.
HIV DNA PCR (or HIV RNA testing however this may require
more blood volume to test) should be performed during the first
48 hours and prior to hospital discharge, 2 weeks post infant
prophylaxis (6 weeks of age), 2 months post infant prophylaxis
(12 weeks of age), HIV antibody testing for seroreversion (loss of
maternal antibodies) should be performed at age 18 months.
Diagnosis of in utero transmission can be made by the identifi-
cation of proviral DNA through amniocentesis or from the cord
blood/newborns blood sample at birth.
Stigma and mental health conditions in HIV positive
pregnant women
Chronic HIV infection, subsequent opportunistic infections,
homelessness, stigma, poverty, immigration, disclosure, family
and peer pressure and drug use can all contribute to complex
mental illness. Mental health issues can affect engagement with
community care, midwifery, obstetricians and HIV clinicians.
Additionally, fears around accessing NHS care and entitle-
ment to health and social care can limit engagement. It has been
clarified that HIV care is provided to all people who have resi-
dency in the UK and those who have applied for residency
however there remains uncertainty about antenatal care and this
requires clarification with commissioners.
Many HIV positive women are unable to disclose the diag-
nosis to their partners as they fear violence; separation and
rejection. Furthermore, studies from around the world show
significant intimate partner violence in pregnancy which seems
to be greater in women who are HIV positive. Women may
depend on their partners for financial support, right to remain in
the UK and accommodation. Antenatal HIV are should be
delivered by an MDT with every effort to involve the woman’s
GP and health visitor. Additionally trained peer-support workers
can be invaluable.
Conclusion
HIV remains one of the most important diseases in the UK despite
remarkable improvements in treatment and reduction in
morbidity and mortality. Delays in diagnosis and their subse-
quent costs and complex treatment and care continue to need
specialist support. Advances in the management of HIV infection
have led to changes in how HIV infection is managed in preg-
nancy. With undetectable viral loads, antenatal procedures and
instrumentation have become safer and vaginal deliveries are a
viable first line management option. As more data becomes
available, better informed drug choices can be made. The over-
riding issue when dealing with HIV in pregnancy is to have clear
lines of communication with input from the multidisciplinary
team and to ensure continuity of care for the woman, her family
and her baby. A
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:10
FURTHER READING
Antiretroviral Pregnancy Registry Steering Committee. Antiretroviral
pregnancy register international interim report for 1 January 1989
through 31 January 2011. Antiretroviral pregnancy registry. 2011
(accessed 22 Dec 2011), www.APRegistry.com.
BHIVA. Guidelines for the management of HIV infection in
pregnant women 2012. 2012, http://www.bhiva.org/documents/
Guidelines/Treatment/2012/120430PregnancyGuidelines.pdf.
HPA, HIV in the United Kingdom: November 2011 report. http://www.hpa.
org.uk/webc/HPAwebFile/HPAweb_C/1317131685847.
Induction of Labour: NICE guideline. National institute of health and
clinical excellence. 2008, http://www.nice.org.uk/CG70 (accessed Feb
2012).
Modestini C, Roedling S, French C, Martin N, Tookey P, Burns F. HIV
positive pregnant women who receive less than two weeks of anti-
retroviral therapy before delivery: why does it occur? HIV Med 2012;
13(suppl 1): 1e11.
National study of HIV in pregnancy and childhood (NSHPC)/CHIVA. 2007,
www.nshpc.ud.ac.uk.
Royal College of Obstetricians and BASHH. Management of genital herpes
in pregnancy. 2014, http://www.rcog.org.uk/en/guidelines-research-
services/guidelines/genital-herpes.
de Ruiter A, Mercey D, Anderson J, et al. British HIV Association
and Children’s HIV Association Guidelines for the management of
HIV infection in pregnant women 2008. HIV Med 2008; 9:
452e502.
Taylor GP, Anderson J, Clayden P, et al. British HIV Association and Chil-
dren’s HIV Association position statement on infant feeding in the UK
2011. HIV Med 2011; 12: 389e93.
Townsend CL, Cortina-Borja M, Peckham CS, de Ruiter A, Lyall H,
Tookey PA. Low rates of mother-to-child transmission of HIV
following effective pregnancy interventions in the United
Kingdom and Ireland, 2000e2006. AIDS 2008 May 11; 22:
973e81.
Practice points
C MTCT of HIV has dramatically decreased in the UK in the last 20
years
C A high viral load is the most important risk factor for MTCT;
mothers with a viral load of less than 50 copies/ml (undetectable)
and who do not breast feed have a 0.5% chance of transmitting
the virus
C A planned vaginal delivery is recommended for women on ART
with an undetectable viral load in the absence of obstetric
complications
C In circumstances when the viral load is >400 copies/ml at 36
weeks a planned caesarean is recommended
C For women who have a viral load between 50 and 399 copies/ml
current recommendations are to consider caesarean section tak-
ing into account the actual viral load, the trajectory for the viral
load, length of treatment, obstetric factors and the woman’s views
C If a woman presents in labour and is untested or had significant
risk since previous testing an urgent point of care test should be
performed
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