HIV Infection in Pregnancy

HIV infection
in pregnancy
Straight to the point of care
Last updated: Apr 06, 2021

Table of Contents
Overview 3
Summary 3
Definition 3
Theory 4
Epidemiology 4
Aetiology 4
Pathophysiology 5
Case history 5
Diagnosis 6
Approach 6
History and exam 8
Risk factors 9
Investigations 11
Differentials 14
Management 16
Approach 16
Treatment algorithm overview 22
Treatment algorithm 24
Emerging 32
Primary prevention 32
Secondary prevention 33
Patient discussions 34
Follow up 35
Monitoring 35
Complications 36
Prognosis 37
Guidelines 38
Diagnostic guidelines 38
Treatment guidelines 39
Online resources 41
References 42
Images 52
Disclaimer 54
HIV infection in pregnancy Overview
Summary
All pregnant women should be tested for HIV as early as possible in pregnancy. Repeat testing is
recommended in the third trimester for pregnant women with initial negative tests who are known to be at risk
OVERVIEW
of acquiring HIV.
HIV-exposed infants should be tested for HIV infection at birth and specialty care for follow-up testing and
treatment.
All pregnant women with HIV should receive antiretroviral therapy (ART), as early as possible in the
pregnancy, regardless of CD4 count or viral load. ART should be administered during the antepartum,
intrapartum, and postnatal periods, as well as prophylaxis treatment to the neonate.
Breastfeeding is not recommended in resource-rich settings unless replacement feeding is not possible or
feasible.
Definition
Human immunodeficiency virus (HIV) is a retrovirus that causes HIV infection by infecting CD4 T cells
and can lead to acquired immunodeficiency syndrome (AIDS).[1] Pregnancy in women living with HIV
is complicated not only by HIV infection itself but also by the medical and psychosocial comorbidities
associated with HIV. HIV infection in pregnancy poses a threat to maternal immune health and can lead to
perinatal transmission of HIV in utero, intrapartum, or through breastfeeding postnatal.
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 06, 2021.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
3
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2021. All rights reserved.
HIV infection in pregnancy Theory
Epidemiology
Approximately 18.2 million women are living with HIV worldwide, comprising half of all adults living with
HIV.[2] Globally, HIV/AIDS is now the leading cause of death among women of reproductive age.[3]
THEORY
While women account for only 19% to 22% of HIV cases in Central and Western Europe and the US, HIV
disproportionately affects women of reproductive age in sub-Saharan Africa (where 58% of adults with HIV
are women).[3] [4] In the UK, 1 in 3 people living with HIV are women, and women make up one quarter of all
new HIV diagnoses.[5] Approximately 80% of pregnant women living with HIV access antiretroviral therapy
(ART) to prevent perinatal transmission.[2]
Approximately 1.4 million women living with HIV become pregnant each year. Untreated, the risk of perinatal
transmission of HIV is between 15% and 45%, but can be lowered to approximately 1% to 2% with a
combination of preventative measures including ART for mothers and prophylaxis for neonates.[6] [7]
Internationally, WHO is working to lower rates of perinatal transmission to less than 5% with the eventual
goal of eradicating perinatal transmission of HIV. Increased utilisation of ART during pregnancy has led to a
dramatic decrease in perinatal transmission and improved maternal outcomes.
The US Centers for Disease Control and Prevention (CDC) estimates that US cases of perinatal
transmission have decreased by over 90% since the mid-1990s. In the US, 8500 women living with HIV give
birth annually. An estimated 21,956 cases of perinatal transmission were prevented between 1994 and 2010.
In 2016, 99 children under the age of 13 years received a diagnosis of perinatally acquired HIV infection.[8]
Despite improved health status with the widespread use of ART, women living with HIV have persistently
higher rates of obstetric and postnatal morbidity, including elevated rates of caesarean delivery, preterm
premature rupture of membranes, spontaneous preterm delivery, endometritis, and intensive care unit
admission.[9] [10] [11] [12] Post-caesarean complications have decreased dramatically in the US from
210.6/1000 from 1995 to 1996 to 116.6/1000 in 2010 to 2011; however, rates of infection, surgical trauma,
hospital deaths, and prolonged hospitalisation remain significantly higher than in HIV-uninfected women.[13]
One retrospective cohort study suggests that neonates born to women with HIV are at increased risk for
complications such as low birth weight and transient tachypnoea of the newborn.[10]
Aetiology
The human immunodeficiency viruses can be broadly divided into two groups: HIV-1 and HIV-2, both of
which cause AIDS. Infection with HIV-1 is associated with a progressive decrease in CD4 T-cell count and
an increase in viral load leading to clinical AIDS. The stage of infection can be determined by measuring the
patient's CD4 T-cell count and correlating clinical findings, such as AIDS-defining illnesses. HIV-2 infection
has a more indolent course and is largely limited to West Africa.[14]
HIV is transmitted through blood or blood products, sexual contact, and vertical transmission from mother to
child. Transmission correlates with high levels of infectious virus in body fluids, and the nature and duration
of contact with these fluids.[15] The overwhelming majority of women contract HIV through heterosexual
transmission; the US Centers for Disease Control and Prevention (CDC) estimates that 87% of new cases
among women are through male-to-female sexual transmission, with 12% due to injection drug use.[4]
Perinatal transmission can take place in utero, intrapartum, or postnatally through breastfeeding. Without
intervention or antiretroviral therapy, rates of perinatal transmission range from 15% to 45%.[6]
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 06, 2021.
HIV infection in pregnancy Theory
Pathophysiology
In the early 1990s, a systematic examination of HIV replication within lymphoid tissues was conducted to
define the pathophysiological consequences of infection. These studies provided evidence for a continuum
THEORY
of destruction of various structural elements within the lymph nodes, spleen, and thymus, and supported the
involvement of the thymus in viral replication. It is presumed that most T cells are destroyed after direct viral
infection. In addition, apoptosis is thought to be responsible for the loss of CD4+ and CD8+ cells.[16] [17]
[18]
Perinatal transmission is the most common mode of acquisition of HIV infection in children worldwide.[19]
HIV can be transmitted throughout pregnancy, during labour and delivery, and postnatally through
breast milk. In settings where bottle feeding is the standard of care, approximately one third of perinatal
transmission occurs in utero and the remainder during labour or delivery. Disease progression or clinical
immune deficiency, high HIV viral load, sexually transmitted infections during pregnancy, and obstetric
factors such as prolonged rupture of membranes are associated with increased perinatal transmission.[20]
[21] During pregnancy, the placenta provides an important physical and immune barrier between maternal
and fetal circulations. It is also thought to provide protection against in-utero transmission of HIV-1
infection.[22] The exact mechanisms of in-utero transmission are not known, but factors that disrupt placental
integrity, such as chorioamnionitis, may play a role.[23] [24] Viral characteristics, such as viral subtype
or cellular tropism, and host genetic factors, such as HLA or chemokine receptor genotype, have been
reported in some studies to influence in-utero transmission.[25] [26] [27] [28] [29] [30] The majority of in-
utero transmission is thought to occur late in pregnancy.[31] [32] The mechanisms by which intrapartum
transmission occurs are by direct access of cell-free or cell-associated virus to the infant systemic circulation
through maternal-fetal transfusion. Maternal-fetal transfusion occurs during uterine contractions in labour,
or by the infant swallowing HIV-infected genital tract fluid during delivery, with viral passage through the
infant's gastrointestinal mucosa to underlying lymphoid cells followed by systemic dissemination.[19] Breast
milk contains high levels of the HIV virus,[33] [34] [35] [36] and transmission can occur at any point during
lactation. High maternal viral load (in plasma and in breast milk), breast milk immunological factors, maternal
breast pathology (such as mastitis, cracked or bleeding nipples, abscesses), and low maternal CD4 count
are associated with increased risk of transmission through breastfeeding. Infant gastrointestinal pathology,
such as candidiasis, may disrupt mucosal integrity and aid viral transmission.[37] [38] [39] [40] [41]
Case history
Case history #1
A 28-year-old woman presents for antenatal care at 8 weeks' gestation. Routine screening with the fourth-
generation antigen/antibody combination enzyme-linked immunosorbent assay (ELISA) is reactive,
and confirmatory testing with an antibody differentiation immunoassay is positive for HIV-1 antibody.
Laboratory results are consistent with HIV-1 infection.
Case history #2
A 35-year-old woman living with HIV on antiretroviral therapy presents after missing her last menstrual
period.
5
HIV infection in pregnancy Diagnosis
Approach
It is recommended that all pregnant women be tested for HIV as early as possible in pregnancy. Early
diagnosis of maternal HIV infection and initiation of antiretroviral therapy (ART) can optimise maternal
health and greatly reduce the risk of perinatal transmission. The recommended HIV screening test is the
fourth-generation enzyme-linked immunosorbent assay (ELISA), which detects HIV-1 and HIV-2 antibodies
HIV-1 p24 antigen. If the screening ELISA is positive, confirmatory testing with HIV-1/HIV-2 differentiation
immunoassay (or, if unavailable, western blot or indirect immunofluorescence assay) is needed for diagnosis.
Clinical evaluation
Universal HIV antenatal screening is recommended, as history and risk-factor-based screening can lead
to missed diagnoses. Nonetheless, the following key risk factors, if present, increase the possibility of
maternal exposure to HIV infection, and should be elicited during the first antenatal assessment:
• History of past or current injection drug use

• History of past or current sexually transmitted infections
• History of unprotected sexual encounters during pregnancy (including receptive anal intercourse
and penile-vaginal intercourse)
• History of multiple sexual partners.
A thorough history and physical examination should be performed for all pregnant women living with
HIV. The medical history should include enquiry into opportunistic infections or AIDS-defining illnesses,
tuberculosis, sexually transmitted infections, medication use, vaccine and immunisation status, mental
illness, and substance abuse. Women should be screened for fever and weight loss as possible indicators
of an underlying opportunistic infection such as tuberculosis.
Patients who present 2 to 4 weeks post-exposure may have symptoms and signs of acute retroviral
syndrome, characterised by fever, malaise, lymphadenopathy, and rash (typically presents as a
maculopapular blanching rash). These women should be retested for HIV regardless of previous results.
Signs suggestive of advanced HIV infection include oral candidiasis, increasing dyspnoea, and weight
loss.
DIAGNOSIS
Maternal testing
HIV testing is recommended in all sexually active women and should be a routine component of pre-
conception care. The risk of HIV exposure should be assessed in all women who are considering
becoming pregnant. All HIV-negative pregnant women should be tested for HIV as early as possible in
pregnancy. Partners of pregnant women should also be encouraged to undergo testing if their HIV status
is unknown.[7]
The fourth-generation ELISA, which detects HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen, is
recommended for screening as it can detect HIV infection earlier than third-generation assays. If the
screening ELISA is positive, confirmatory testing with HIV-1/HIV-2 differentiation immunoassay (or,
if unavailable, western blot or indirect immunofluorescence assay) is needed for diagnosis. If the
HIV-1/HIV-2 antigen/antibody combination immunoassay result is reactive and HIV-1/HIV-2 antibody
differentiation immunoassay is non-reactive or indeterminate, the specimen should be tested with an
HIV-1 nucleic acid test (NAT).[65] If there is clinical concern for acute HIV infection, HIV-1 RNA testing is
an option.[66]
HIV antibodies are detectable in at least 95% of infected people within 6 to 12 weeks after acute infection.
In rare cases, it can take up to 6 months to detect the virus. Although a negative antibody test usually
indicates the absence of disease, antibody tests cannot exclude recent infection. Repeat testing is
recommended 6 weeks, 3 months, and 6 months after possible exposure.[7]
Opt-out screening (i.e., routine testing for HIV except where a patient refuses) is recommended as a part
of antenatal laboratory testing. Women who decline HIV testing because of a previous negative HIV test
should be informed of the importance of retesting during pregnancy.
Repeat testing in the third trimester (before 36 weeks’ gestation) is recommended for pregnant women
with initial negative tests who are known to be at risk of acquiring HIV including those who are receiving
health care in facilities that have an HIV incidence of at least 1 case per 1000 pregnant women per year,
those who are incarcerated, those who reside in jurisdictions with elevated HIV incidence, or those who
reside in areas that require third-trimester testing. Repeat testing should also be considered at other
times during pregnancy when clinically indicated (e.g., a woman presents with symptoms that suggest a
sexually transmitted infection or acute HIV infection).[7]
Rapid HIV testing should be performed in labour or at the time of delivery in women who are at increased
risk of HIV infection and were not retested in the third trimester. Testing should be available 24 hours
a day and results should be available within 1 hour. If fourth-generation ELISA is not available, initial
testing should be performed by the most sensitive expedited or rapid test available. If results are positive,
intrapartum and infant postnatal ART prophylaxis should be started immediately, pending results of
confirmatory tests. Women who have not been tested before or during labour should undergo expedited
testing in the immediate postnatal period.[7]
In addition to routine antenatal laboratory screening, pregnant women with HIV need additional
laboratory testing to assess their HIV health status. CD4 count, which indicates the health of the immune
system, should be done at the initial visit and repeated as necessary depending on individual patient
circumstancess. Women should have an ultrasound as soon as possible to confirm gestational age.
An anatomy ultrasound is recommended in the second trimester. Frequent laboratory testing of plasma
HIV RNA or HIV viral load in pregnant women with HIV is indicated to monitor viral suppression. Viral
DIAGNOSIS
load testing in the third trimester of pregnancy is critical for planning mode of delivery and assessing
need for additional maternal zidovudine prophylaxis. All pregnant patients with HIV will also have:
baseline laboratory testing of renal and hepatic function; a full blood count; and drug resistance testing
(genotyping) prior to starting or modifying ART to aid in determining an appropriate ART regimen.
Screening for ART toxicity is dependent on the chosen regimen and is generally indicated 3 to 6 months
after initiation. Standard glucose screening is generally recommended at 24-28 weeks’ gestation for
women on ART. Amniocentesis should be performed only if clinically indicated after initiation of ART and,
ideally, once HIV RNA levels are undetectable.[7]
Additionally, pregnant patients with HIV should be screened for co-infection with tuberculosis, viral
hepatitis, or sexually transmitted infections. They should also be screened for anxiety and depression, as
well as the need for supportive care such as smoking cessation, substance abuse treatment, or mental
health services.[7]
Diagnosis in exposed infants

The HIV-exposed infant should be tested for HIV infection and referred to specialty care if the test is
positive. Virological assays, either HIV DNA or RNA polymerase chain reaction (PCR) tests, should be
used to detect HIV in infants <18 months of age. Testing is recommended in all infants with perinatal HIV
7
exposure at 14 to 21 days; 1 to 2 months; and 4 to 6 months. Testing at birth should be considered in
infants at high risk of transmission (and 2 to 4 weeks after cessation of ART prophylaxis). A positive result
should be confirmed by repeat testing on a second specimen as soon as possible. An assay that detects
HIV non-B subtype viruses or group O infections is recommended in infants and children born to mothers
with known or suspected non-B subtype virus or group O infections[7]
HIV can be excluded in infants who have not been breastfed with 2 or more negative tests (either 1 test
obtained at ≥1 month of age and 1 at ≥4 months of age, or 2 tests from separate specimens at ≥6 months
of age). Some physicians may also confirm the absence of infection at 12 to 18 months of age with an
HIV antibody test. Children aged 18 to 24 months with perinatal exposure may have residual maternal
HIV antibodies, and definitive exclusion (or confirmation) in this age group should be with an HIV nucleic
acid test. Testing in children >24 months of age with perinatal exposure relies on HIV antibody (or antigen/
antibody) tests.[7]
Zidovudine monotherapy for perinatal prophylaxis has not been shown to delay detection of HIV or
decrease the sensitivity or predictive value of virological assays.[67] [68] However, the performance of
these tests when the mother has received more intensive ART has not been studied. ART in an HIV-
exposed infant may lead to delayed diagnosis by HIV DNA PCR.
History and exam

Key diagnostic factors
increased risk of maternal HIV infection (common)
• Needle-sharing with injection drug use and percutaneous needle-prick injury carry risks of HIV
infection rates of 63 to 2400/10,000 exposures and 30/10,000 exposures to an infected source,
respectively.[42] [43] [47] [69]
• Unprotected receptive anal intercourse leads to an infection rate of 1/70 exposures to an infected
source with ejaculation and 1/154 without.[46] Receptive penile-vaginal intercourse without barrier
DIAGNOSIS
contraception carries a risk of 1 infection/333 exposures in low-income countries and 1 infection/1250

exposures in high-income countries.[43] [45]
• Recent sexually transmitted infection (STI) and vaginitis, particularly HSV-2, bacterial vaginosis, and
gonorrhoea, are associated with an increased risk of HIV acquisition.[49] [50] [51]
increased risk of perinatal HIV transmission (common)

• High maternal viral load is associated with an increased risk of perinatal HIV transmission.
Elevated HIV RNA at delivery is independently associated with risk of transmission.[20] The
absence of antenatal antiretroviral therapy (ART) is associated with an increased risk of perinatal
HIV transmission. Maternal antenatal ART is independently associated with reduced risk of
transmission.[20]
• Breast milk contains high levels of the HIV virus[1] [33] [34] [35] [36] and transmission can occur
at any point during lactation. High maternal viral load (in plasma and in breast milk), breast milk
immunological factors, maternal breast pathology (such as mastitis, cracked or bleeding nipples,
abscesses), and low maternal CD4 count are associated with increased risk of transmission through
breastfeeding. Infant gastrointestinal pathology, such as candidiasis, may disrupt mucosal integrity and
aid viral transmission.[37] [38] [39] [40] [41]
Other diagnostic factors

oral candidiasis (common)
• Suggestive of advanced HIV infection.
increasing dyspnoea (common)

weight loss (common)

fever (uncommon)
• Occurs in the acute seroconversion phase of the virus.
malaise (uncommon)
lymphadenopathy (uncommon)
maculopapular blanching rash (uncommon)

Risk factors
Strong
needle-sharing with injection drug use
• Causes 63 to 2400 infections/10,000 exposures to an infected source.[42] [43] Injection drug use
DIAGNOSIS
accounts for approximately 10% of all new HIV cases globally.[44]
receptive penile-vaginal intercourse

• Causes 1 infection/333 exposures to an infected source in low-income countries and 1 infection/1250
exposures to an infected source in high-income countries.[43] [45]
unprotected receptive anal intercourse

• Causes 1 infection/154 exposures to an infected source without ejaculation and 1 infection/70
exposures to an infected source with ejaculation.[46]
percutaneous needle prick

• Causes 30 infections/10,000 exposures to an infected source.[47]
sexually transmit ted infections (STIs) and bacterial vaginosis

• There is evidence that non-ulcerative STIs increase the risk of HIV transmission.[48] Multiple studies
have demonstrated the association between recent acquisition of an STI and transmission of HIV. After
controlling for demographic and behavioural risk factors, the population attributable risk was 50.4% for
sero-prevalent HSV-2, 5.3% for gonorrhoea, and 17.2% for bacterial vaginosis.[49] [50] [51]
9
high maternal viral load (perinatal transmission)
• High maternal viral load is associated with an increased risk of perinatal HIV transmission. Elevated
HIV RNA at delivery is independently associated with risk of transmission.[20]
absence of antenatal maternal antiretroviral therapy (perinatal transmission)

• The lack of antenatal maternal antiretroviral therapy is independently associated with risk of
transmission.[20]
breast feeding (perinatal transmission)

• Breast milk contains high levels of the HIV virus[1] [33] [34] [35] [36] and transmission can occur
at any point during lactation. High maternal viral load (in plasma and in breast milk), breast milk
immunological factors, maternal breast pathology (such as mastitis, cracked or bleeding nipples,
abscesses), and low maternal CD4 count are associated with increased risk of transmission through
breastfeeding. Infant gastrointestinal pathology, such as candidiasis, may disrupt mucosal integrity and
aid viral transmission.[37] [38] [39] [40] [41]
violence against women and girls

• Women who are victims of intimate partner violence have been shown to be at greater risk of HIV/STI
infection compared with women with no history of intimate partner violence.[52] [53] [54] A history of
sexual or physical abuse during childhood or adulthood is also associated with an increased risk of
HIV infection.
Weak
receptive oral intercourse
• Causes 1 infection/10,000 exposures to an infected source.[55] [56]
insertive oral intercourse

• Causes 0.5 infection/10,000 exposures to an infected source.[55] [56]
DIAGNOSIS
multiple sexual partners

• Data from epidemiological studies show that a history of multiple sexual partners is associated with
increased risk of HIV infection.[57] [58]
low maternal CD4 count (perinatal transmission)

• May accompany advanced maternal HIV disease and therefore a high plasma viral load.
Investigations
1st test to order
Test Result
maternal HIV-1/HIV-2 antigen/antibody enzyme-linked positive
immunosorbent assay (ELISA)
• All HIV-negative pregnant women should be tested as early as
possible during each pregnancy. Repeat testing is recommended 6
weeks, 3 months, and 6 months after a possible exposure. Repeat
testing is also recommended in the third trimester in patients with
an initial negative test who are known to be at risk of acquiring HIV
including those who are receiving health care in facilities that have
an HIV incidence of at least 1 case per 1000 pregnant women per
year, those who are incarcerated, those who reside in jurisdictions
with elevated HIV incidence, or those who reside in areas that require
third-trimester testing. Repeat testing should also be considered at
other times during pregnancy when clinically indicated (e.g., a woman
presents with symptoms that suggest a sexually transmitted infection
or acute HIV infection).[7]
• Initial test should be the fourth-generation antigen/antibody
combination ELISA that detects HIV-1 and HIV-2 antibodies and
HIV-1 p24 antigen. The assay is used to screen for established
infection with HIV-1 or HIV-2 and for acute HIV-1 infection.[7] [65]
• No further testing is required for specimens that are non-reactive on
the initial immunoassay.
maternal HIV-1/HIV-2 antibody differentiation immunoassay positive for HIV-1
antibodies; or
• If the antigen/antibody combination immunoassay result is reactive,
positive for HIV-2
the specimen should be tested with an antibody immunoassay that
antibodies; or positive
differentiates HIV-1 antibodies from HIV-2 antibodies. ELISA is
preferred, but western blot or indirect immunofluorescence assay may for HIV antibodies,
undifferentiated
also be used if ELISA is not available.[65]
DIAGNOSIS
neonatal HIV DNA or RNA polymerase chain reaction (PCR) positive
• HIV-exposed infants should be tested for HIV infection. Testing is
recommended in all infants with perinatal HIV exposure at 14 to 21
days; 1 to 2 months; and 4 to 6 months. Testing at birth should be
considered in infants at high risk of transmission (and 2 to 4 weeks
after cessation of antiretroviral prophylaxis). A positive result should
be confirmed by repeat testing on a second specimen as soon as
possible.[7]
• HIV can be excluded in infants who have not been breastfed with
2 or more negative tests (either 1 test obtained at ≥1 month of age
and 1 at ≥4 months of age, or 2 tests from separate specimens at ≥6
months of age).[7]
• Sensitivity of DNA and RNA PCR testing is high and increases rapidly
after 2 weeks of age.[70]
11
Other tests to consider
Test Result
HIV-1 western blot positive for HIV-1
• HIV-1 western blot may be used as a second-line alternative to HIV-1/ antibodies
HIV-2 antibody differentiation immunoassay.[65]
• If test results are negative or indeterminate, HIV-1 nucleic acid test
should be performed.
HIV-1 indirect immunofluorescence assay (IFA) positive for HIV-1
antibodies
• HIV-1 IFA may be used instead of an HIV-1/HIV-2 antibody
differentiation immunoassay.[65]
• If test results are negative or indeterminate, HIV-1 nucleic acid test
should be performed.
HIV-1 nucleic acid test (NAT) positive
• If the HIV-1/HIV-2 antigen/antibody combination immunoassay result
is reactive and HIV-1/HIV-2 antibody differentiation immunoassay is
non-reactive or indeterminate, the specimen should be tested with an
HIV-1 NAT.[65]
• A reactive HIV-1 NAT and a non-reactive HIV-1/HIV-2 antibody
differentiation immunoassay indicates laboratory evidence for acute
HIV-1 infection.
• A reactive HIV-1 NAT and an indeterminate HIV-1/HIV-2 antibody
differentiation immunoassay indicates the presence of HIV-1 infection
confirmed by HIV-1 NAT.
• A negative HIV-1 NAT and a non-reactive or indeterminate HIV-1/
HIV-2 antibody differentiation immunoassay result indicates a false-
positive result on the initial combination immunoassay.
CD4 count CD4 count >500 cells/
microlitre: patients are
• Indicates immune status and assists in the staging process.
• Should be done at the initial visit in all women. It should be repeated usually asymptomatic;
CD4 count <350 cells/
at least every 3 months in women who have been on treatment for
<2 years, who have a CD4 count <300 cells/microlitre, and those microlitre: implies
substantial immune
DIAGNOSIS
with inconsistent adherence and/or detectable viral loads. Women

suppression; CD4 count
who have been on treatment for 2 years or more and who have had
consistent viral suppression and CD4 counts > 300 cells/microlitre do <200 cells/microlitre:
places the patient at risk
not require further monitoring during pregnancy.[7]
for most opportunistic
infections
plasma HIV RNA levels (viral load) recently infected patients

or patients in late stages
• It is standard to obtain serial viral loads in pregnant women who test
of infection may have
positive for HIV.
levels in the region of
• Should be monitored at the initial visit, 2-4 weeks after initiating or
millions of copies/mL
changing drug treatment, monthly until RNA levels are undetectable,
and then at last every 3 months during pregnancy. Should also be
assessed a 34-46 weeks’ gestation to inform decisions about mode of
delivery.[7]
renal function tests may indicate impaired
renal function
• Performed at baseline initiation of antiretroviral therapy and
monitored.
liver function tests (LFTs) may be normal; baseline
abnormal LFTs may reflect
chronic hepatitis B,
Test Result
• Performed at baseline initiation or modification of antiretroviral chronic hepatitis C, or
therapy and monitored every 3 months during pregnancy or as alcoholism
needed.[7]
tests for co-infections may be positive
• Screening for tuberculosis, viral hepatitis, and sexually transmitted
infections should be done early in every pregnancy.
drug resistance test (genotyping) variable
• Should be performed in all pregnant women whose HIV RNA levels
are above the threshold for resistance testing (i.e., 500-1000 copies/
mL) prior to starting or modifying antiretroviral therapy. Treatment
should be initiated prior to receiving results as the regimen can be
modified once they are obtained. Phenotypic resistence testing is
indicated for treatment-experienced people on failing regimens who
are thought to have multi-drug resistance.[7]
• Aids in choice of the most appropriate treatment regimen.
full blood count may be normal or
show anaemia or
• Performed at baseline initiation of antiretroviral therapy and
thrombocytopenia
monitored.
glucose screening variable
• Standard glucose screening is generally recommended at 24-28
weeks’ gestation for women on antiretroviral therapy.[7]
fetal ultrasound confirms gestational age;
may show anatomical
• Women should have an ultrasound as soon as possible to confirm
abnormalities
gestational age. Ultrasound is also recommended for anatomical
survey during the second trimester.[7]
DIAGNOSIS
13
Differentials
Condition Differentiating signs / Differentiating tests

symptoms
Infectious mononucleosis • May see pharyngitis, • FBC typically shows at least
splenomegaly, 50% lymphocytes, of which
hepatomegaly, jaundice, 10% or more are atypical.
rash, and myalgia. • Confirmation of the
diagnosis is based on a
positive serum agglutination
test (such as Monospot) or
serological test for detection
of Epstein-Barr virus (EBV)-
specific antibodies directed
against the viral antigens,
such as viral capsid antigen
and EBV nuclear antigen.
Toxoplasmosis • Difficult to differentiate • Positive serological tests for

clinically. antibodies to Toxoplasma
gondii . Rising antibody titres
2 to 4 weeks after initial
infection, or positive IgM
tests, show recent infection.
Viral hepatitis • Right upper quadrant • Aminotransferases (alanine

abdominal pain, jaundice. aminotransferase [ALT]/
aspartate aminotransferase
[AST]) elevated.
• Hepatitis serology positive.
• HIV test negative.
Morbilliform drug • Typically presents as a • Diagnosis is usually

eruption maculopapular rash that clinical. However, FBC
DIAGNOSIS
develops within 2 weeks of with differential may

starting treatment, but can show leukopenia,
appear up to 14 days after thrombocytopenia, and
stopping the drug. The rash eosinophilia. Serum IgE
may become confluent and levels may be elevated.
spares the palms and soles. Biopsy of the skin lesion may
show eosinophils, oedema,
and inflammation.
Viral exanthems • May see acute febrile illness • Tests are usually not
(enterovirus) and rash. Diagnosis is necessary, as diagnosis
usually clinical, based on is clinical. HIV tests will
the specific features of the be negative unless the
prodromal period, rash, and patient has concomitant HIV
associated symptoms. infection.
Parvovirus B19 • Patients are typically • Serum parvovirus B19 IgM

asymptomatic. and IgG titres are positive in
• May present with 'slapped recent infection.
cheek' rash on the face and
a lacy red rash on the limbs
and trunk.
Condition Differentiating signs / Differentiating tests

symptoms
• Associated pain and swelling
of the joints of the hands,
wrists, and knees may be
present.
• Infection in pregnancy
can cause first-trimester
abortion, or haemolysis in
the older fetus, resulting in
fetal anaemia, hypoxia, heart
failure, and oedema.
Coronavirus disease 2019 • Residence in/travel to a • Real-time reverse

(COVID-19) country/area or territory transcription polymerase
with local transmission, chain reaction (RT-PCR):
or close contact with a positive for severe acute
confirmed or probable case respiratory syndrome
of COVID-19, in the 14 days coronavirus 2 (SARS-CoV-2)
prior to symptom onset. RNA.
• The situation is evolving
rapidly; see our COVID-19
topic for further information.
Screening
Universal antenatal screening for HIV is recommended, as history and risk-factor-based screening can
lead to missed diagnoses. Nonetheless, the following key risk factors, if present, increase the possibility of
maternal exposure to infection, and should be elicited during the first antenatal assessment:
• History of past or current injection drug use

• History of past or current sexually transmitted infections
• History of unprotected sexual encounters during pregnancy (including receptive anal intercourse and
DIAGNOSIS
penile-vaginal intercourse)
• History of multiple sexual partners.
Early diagnosis and treatment of maternal HIV infection can greatly reduce the risk of maternal-to-child
transmission.[71]
15
HIV infection in pregnancy Management
Approach
Optimising the management of maternal HIV infection improves maternal health and helps to prevent
perinatal transmission. All pregnant women with HIV should receive antiretroviral therapy (ART) to prevent
perinatal transmission. ART reduces perinatal transmission by decreasing maternal viral load in the blood
and genital secretions, as well as infant pre-exposure prophylaxis. ART should be initiated as early as
possible in the pregnancy, regardless of CD4 count or viral load, and should be administered during the
antepartum, intrapartum, and postnatal periods, as well as postnatally to the neonate. An infectious diseases
consultation is strongly recommended early in pregnancy.
Antiretroviral therapy in pregnant women

Women living with HIV who are receiving ART should continue their ART during pregnancy provided that
it is effective and well tolerated. Discontinuation of ART may lead to viral rebound and increased risk of
intrauterine HIV transmission. However, certain antiretroviral drugs are not recommended in pregnancy,
and some of the newer ART regimens lack significant experience in pregnancy and/or may need
additional dosing or therapeutic drug level monitoring secondary to decreased plasma concentrations in
the second and third trimesters. Switching to drug regimens that are recommended in pregnancy (see
section below) should be considered; however, this should only be done under specialist guidance to
ensure continued viral suppression and tolerability. Resistance testing is recommended before switching
active drugs.[7]
Women who are not currently taking ART should be started on a suitable regimen as soon as HIV
is diagnosed during pregnancy because earlier viral suppression is associated with a lower risk of
transmission. Resistance testing should be performed to help guide selection of drugs in women whose
HIV RNA levels are >500 copies/mL.[7]
Women who present for pregnancy care during the first trimester should be counselled on the risks
(e.g., potential teratogenic effects, maternal adverse effects, increased risk of preterm delivery) and
benefits (e.g., improved maternal health, reduced risk of perinatal transmission) of ART during this period.
No significant increased risk of congenital abnormalities has been detected following first-trimester
exposure to ART (as determined by prospective reporting to the Antiretroviral Pregnancy Registry) with
the exception of atazanavir, which has been associated with skin and musculoskeletal defects.[72] One
meta-analysis of data concerning first-trimester exposure to efavirenz did not show any evidence of an
increased risk of birth defects.[73] However, a prospective cohort study found efavirenz was associated
with an increased risk of microcephaly.[74] Previously, efavirenz was only recommended after 8 weeks’
gestation; however, it is commonly used in the first trimester and current guidelines support its use as an
alternative option.[7] There are mixed data regarding the increased risk of preterm delivery and low birth
weight with protease inhibitor- and non-protease inhibitor-based ART. Given the clear benefits of ART
in pregnancy for both the health of the mother and prevention of perinatal transmission, ART should not
be withheld due to concerns for adverse pregnancy outcomes. However, patients should be counselled
regarding the potential risks.[7] [75] [76] [77] [78] [79] [80] [81] [82]
All ART exposures in pregnancy should be reported to the Antiretroviral Pregnancy Registry.
MANAGEMENT
[Antiretroviral Pregnancy Registry] (http://www.apregistry.com)
Antepartum antiretroviral therapy
A regimen with at least 3 drugs is recommended. Regimens are complex and consultation with
an infectious diseases specialist is recommended. The US National Institutes of Health guidelines
suggest:[7]
• In general, the same regimens as recommended for treatment of non-pregnant adults should be
used in pregnant women unless there are known adverse effects for women, fetuses, or infants that
outweigh benefits
• Multiple factors must be considered when choosing a regimen for a pregnant woman including
comorbidities, convenience, adverse effects, drug interactions, resistance testing results,
pharmacokinetics, and experience with use in pregnancy
• Pharmacokinetic changes in pregnancy may lead to lower plasma levels of drugs and necessitate
increased dosages, more frequent dosing, or boosting, especially of protease inhibitors.
For antiretroviral-naive women without resistance, a combination regimen including 2 nucleoside reverse
transcriptase inhibitors (NRTIs), and either a protease inhibitor (PI) with low-dose ritonavir boosting
or an integrase strand transfer inhibitor (INSTI), is preferred. A non-nucleoside reverse transcriptase
inhibitor (NNRTI) may be used as an alternative option to a PI or INSTI. Recommended options for ART in
pregnant women include:[7]
NRTIs
• Preferred options: abacavir/lamivudine; emtricitabine/tenofovir disoproxil; lamivudine plus tenofovir

disoproxil
• Alternative option: lamivudine/zidovudine; tenofovir alafenamide.

PIs
• Preferred options: ritonavir-boosted atazanavir; ritonavir-boosted darunavir
• Alternative option: lopinavir/ritonavir is not recommended, except in special circumstances.

INSTIs
• Preferred options: dolutegravir; raltegravir.

NNRTIs
• Preferred options: there are no preferred options for use in treatment-naive pregnant women
• Alternative options: efavirenz; rilpivirine.

In patients with acute HIV infection, dolutegravir plus tenofovir disoproxil plus emtricitabine is the preferred
regimen in pregnant and breastfeeding women regardless of trimester. Alternative regimens include
raltegravir plus tenofovir disoproxil plus emtricitabine, or a regimen that includes a ritonavir-boosted
protease inhibitor.
MANAGEMENT
The regimens recommended here are from the US Department of Health and Human Services.[7]
Guidelines and protocols may differ between countries and regions. A local infectious disease consultant,
HIV practitioner, or obstetrician/gynaecologist should be consulted and patients referred to them for
further management.
17
A preliminary unscheduled analysis of an ongoing surveillance study reported an increased risk of serious
fetal neural tube defects in women who became pregnant while taking dolutegravir-based regimens (0.9%
compared with 0.1% in women not taking dolutegravir) in May 2018. The risk appeared to be highest in
women taking the drug at the time of becoming pregnant or early in the first trimester. No cases were
reported in infants born to women who started dolutegravir later in pregnancy.[83] [84] Based on this
safety signal, many guidelines advised against the use of dolutegravir in the first trimester of pregnancy.
However, two large clinical trials have expanded the evidence base, and found the risk of neural tube
defects associated with dolutegravir to be lower than the initial studies suggested (0.3% compared with
0.1% in women not taking dolutegravir).[85] [86] In light of these new data, US Department of Health and
Human Services guidelines now recommend dolutegravir as a preferred drug in pregnancy and in women
who are trying to conceive (as well as individuals who are not trying to conceive but who are sexually
active and not using contraception). When pregnant women who are already taking dolutegravir present
to care during pregnancy, these women should be counselled about the risks and benefits of continuing
dolutegravir or switching to an alternative regimen.[7] The World Health Organization (WHO) has also
updated its guidance to recommend dolutegravir-based regimens as the preferred first- and second-line
treatment for all populations, including pregnant women and women of childbearing age.[87] There is no
evidence to suggest that folate supplementation prevents dolutegravir-associated neural tube defects;
nonetheless, all pregnant women and women who are trying to conceive should take recommended
doses of folic acid.[7]
Cobicistat-based regimens are not recommended in pregnant women due to pharmacokinetic changes in
the second and third trimesters which may cause lower drug exposures and subsequent virologic failure.
However, some women may choose to continue with frequent viral load monitoring, rather than switching
to a new regimen.[7] Newer drugs such as bictegravir, doravirine, elvitegravir, etravirine, fostemsavir,
maraviroc, and ibalizumab are not recommended in pregnant women as there are insufficient data to
support their safety in pregnancy. There are no data about the use of two-drug regimens in pregnancy.[7]
Evidence from the BMJ Rapid Recommendations panel’s patient-centred guidelines does not support
the use of emtricitabine/tenofovir as a first-line treatment in pregnant women. The panel recommends
a regimen that includes lamivudine/zidovudine over emtricitabine/tenofovir due to a possible increased
risk of infant death and preterm delivery with the latter; however, the evidence for this recommendation
is weak. Emtricitabine/tenofovir may be a preferred option in certain women, including those with severe
anaemia, drug allergies to lamivudine/zidovudine, lamivudine- or zidovudine-resistant HIV, or hepatitis B
co-infection. There is strong evidence for the use of lamivudine/zidovudine over emtricitabine/tenofovir
when combined with lopinavir/ritonavir due to even greater neonatal risks. However, it is important to
note that current US guidelines and the British HIV Association do not support these recommendations,
and the latest US guidance still recommends emtricitabine/tenofovir as a preferred recommendation with
lamivudine/zidovudine as an alternative option.[7]
[BMJ Rapid Recommendations: antiretroviral therapy in pregnant women living with HIV] (http://
www.bmj.com/content/358/bmj.j3961)
MANAGEMENT
BMJ Rapid Recommendations: antiretroviral therapy in pregnant women living with HIV
(TDF: tenofovir, FTC: emtricitabine, AZT: zidovudine, 3TC: lamivudine, ABC: abacavir,
LPV/r: lopinavir [boosted with ritonavir], ATZ/r: atazanavir [boosted with ritonavir], DRV/
r: darunavir [boosted with ritonavir], EFV: efavirenz, RPV: rilpivirine, RAL: raltegravir)
BMJ. 2017;358:j3961
MANAGEMENT
19
BMJ Rapid Recommendations: antiretroviral therapy in pregnant women living with HIV
(TDF: tenofovir, FTC: emtricitabine, AZT: zidovudine, 3TC: lamivudine, ABC: abacavir,
LPV/r: lopinavir [boosted with ritonavir], ATZ/r: atazanavir [boosted with ritonavir], DRV/
r: darunavir [boosted with ritonavir], EFV: efavirenz, RPV: rilpivirine, RAL: raltegravir)
BMJ. 2017;358:j3961
[MAGICapp: recommendations, evidence summaries and consultation decision aids] (https://

www.magicapp.org/app#/guideline/1840)
MANAGEMENT
A more recent study using data from two US cohort studies found that the risk of adverse birth outcomes
(including preterm delivery and low birth weight) was not higher with emtricitabine/tenofovir plus lopinavir/
ritonavir compared with lamivudine/zidovudine plus lopinavir/ritonavir.[88]
Women should continue taking antepartum ART during labour and before delivery on schedule as much
as possible.
A specialist should be consulted for the management of special populations including pregnant women
with hepatitis B or C co-infection, renal or hepatic impairment, perinatally acquired infection, or HIV-2
infection; pregnant women who present to care and who are already on ART (or have been in the past);
and non-pregnant women who are trying to conceive.
Scheduled caesarean delivery

A scheduled caesarean delivery at 38 weeks' gestation (compared with 39 weeks for most other
indications) is recommended for pregnant women living with HIV who have HIV RNA levels >1000
copies/mL or with unknown viral load near the time of delivery, in order to reduce the risk of perinatal
transmission.[7] In non-virally suppressed patients who present in labour prior to their scheduled
caesarean delivery date, an emergency caesarean delivery should be performed. However, there are
insufficient data to address the question of how long after the onset of labour or rupture of membranes the
benefit of caesarean delivery for prevention of perinatal transmission is lost. Urgent consultation with a
perinatal HIV specialist is recommended.
Scheduled caesarean delivery is not routinely recommended for women on ART who have HIV RNA
levels ≤1000 copies/mL because of the low rate of perinatal transmission in these patients. There is
limited or no known evidence of benefit, and an increased risk of infection, surgical trauma, hospital
deaths, and prolonged hospitalisation in these patients.[7] [13] [89] If scheduled caesarean delivery
or induction is indicated in these patients, it should be performed at the standard time for obstetric
indications.
Intrapartum antiretroviral therapy

Intravenous zidovudine (started 3 hours before scheduled delivery) is recommended in women with HIV
RNA >1000 copies/mL or unknown viral load near delivery. It is not required in women receiving ART
with HIV RNA ≤50 copies/mL during late pregnancy and near delivery, provided there are no concerns
about adherence to ART. Intravenous zidovudine may be considered in women with HIV RNA between
50 and 999 copies/mL; however, there are inadequate data to determine whether this provides additional
protection against perinatal transmission in this group.[7] Women should continue taking ART after
delivery.
Postnatal antiretroviral therapy

All infants who have been perinatally exposed to HIV should receive postnatal ART to reduce the risk
of perinatal transmission. ART should be started as close to the time of delivery as possible, preferably
within 6 to 12 hours.
Infants born to mothers who received ART during pregnancy with sustained viral suppression (HIV RNA
<50 copies/mL) near delivery have a low risk of perinatal HIV transmission and should receive a 4-week
course of zidovudine.[7]
MANAGEMENT
Infants at a higher risk of perinatal transmission (e.g., mothers who did not receive antepartum and/or
intrapartum ART; mothers who received only intrapartum ART; mothers who received antepartum and
intrapartum ART but had detectable viral loads near delivery, particularly when delivery was vaginal;
mothers who have primary or acute HIV infection during pregnancy or breastfeeding) should receive
presumptive HIV therapy with zidovudine plus lamivudine plus nevirapine (treatment dose), or zidovudine
21
plus lamivudine plus raltegravir. The regimen should be administered from birth to 6 weeks of age,
although some practitioners may stop the lamivudine plus nevirapine (or lamivudine plus raltegravir) if the
newborn’s HIV test comes back negative, and continue the zidovudine only for 6 weeks). Nevirapine can
be replaced with lopinavir/ritonavir when infants reach a postmenstrual age of ≥14 days. Nevirapine can
be replaced with raltegravir at any age.[7]
In some situations, a two-drug prophylaxis regimen (zidovudine for 6 weeks plus 3 prophylactic doses
of nevirapine within 48 hours of birth, 48 hours after first dose, and 96 hours after second dose) may
be considered in infants aged ≥32 weeks gestation at birth who weigh ≥1.5 kg. However, this decision
depends on the likelihood of HIV transmission and should be made by a specialist.[7]
The selection of ART for newborns with presumed or confirmed HIV infection is beyond the scope of this
topic.
Breast feeding
Breastfeeding is not recommended because of the risk of HIV transmission to the infant. This
recommendation may not apply to some countries, particularly low-income and middle-income countries,
where cost limits access to formula, there is no access to safe water, or there are inadequate quantities
of formula. However, replacement feeding is recommended when possible. Harm-reduction measures
(e.g., ART prophylaxis in the infant during breastfeeding, exclusive breastfeeding for the first 6 months,
gradual weaning, immediate treatment of maternal mastitis and infant thrush, infant monitoring) are
recommended in women who choose to breastfeed despite the risks. Lactation inhibition strategies should
be considered. Women who desire to breastfeed should receive evidence-based counselling on infant
feeding options.[7]
Treatment algorithm overview

Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
MANAGEMENT
Acute ( summary )
HIV-1-infected pregnant women: <38
weeks not in labour (regardless of
HIV RNA level)
1st preferred 2-NRTI backbone
plus PI or INSTI or NNRTI
HIV-1-infected pregnant women with

HIV-1 RNA levels >1000 copies/mL: at
38 weeks or in labour
1st caesarean delivery
plus zidovudine plus continue antiretroviral

therapy

HIV-1 RNA levels ≤1000 copies/mL: at
1st await normal vaginal delivery plus

continue antiretroviral therapy
adjunct zidovudine
infants born to HIV-infected mothers
1st presumptive HIV therapy or two-drug

prophylaxis
plus replacement feeding (if possible) or harm-

reduction measures
MANAGEMENT
23
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
MANAGEMENT
Acute
HIV-1-infected pregnant women: <38
weeks not in labour (regardless of
HIV RNA level)
1st preferred 2-NRTI backbone

Primary options
» abacavir/lamivudine
Abacavir/lamivudine should not be used in
patients with HLA-B* 5701 because of the
risk of hypersensitivity reaction. It is also
not recommended with atazanavir/ritonavir
or efavirenz if pretreatment HIV RNA is
>100,000 copies/mL.
OR
» emtricitabine/tenofovir disoproxil
OR
» lamivudine
-and-
» tenofovir disoproxil
Secondary options
» lamivudine/zidovudine
Lamivudine/zidovudine has increased
potential for haematological toxicity.
OR
» tenofovir alafenamide
» Women living with HIV who are receiving

antiretroviral therapy (ART) should continue
their ART during pregnancy provided that it
is effective and well tolerated. Women who
are not currently taking ART should be started
on a suitable regimen as soon as HIV is
diagnosed during pregnancy because earlier
viral suppression is associated with a lower risk
of transmission.[7]
» Antiretroviral regimens are complex and a

specialist should be consulted for guidance on
the best combination to use. The options listed
here are based on current US guidance for
pregnant women.[7] Consult local guidelines for
MANAGEMENT
options in other countries.
» Nucleoside reverse transcriptase inhibitors

(NRTIs) are recommended as the backbone of
combination regimens.[7]
25
Acute
» The BMJ Rapid Recommendations
panel guidelines do not support the use of
emtricitabine/tenofovir first-line in pregnant
women due to a possible increased risk
of infant death and preterm delivery. They
recommend a regimen that includes lamivudine/
zidovudine; however, the evidence for this
recommendation is weak. Emtricitabine/tenofovir
may be a preferred option in patients with
severe anaemia, drug allergies to lamivudine/
zidovudine, lamivudine- or zidovudine-resistant
HIV, or hepatitis B co-infection. Strong evidence
supports the use of lamivudine/zidovudine
over emtricitabine/tenofovir when combined
with lopinavir/ritonavir due to even greater
neonatal risks with this combination. However,
it is important to note that the current US
guidelines and the British HIV Association do not
support these recommendations, and the latest
US guidance still recommends emtricitabine/
tenofovir as a preferred recommendation
with lamivudine/zidovudine as an alternative
option.[7]
» [BMJ Rapid Recommendations: antiretroviral

therapy in pregnant women living with HIV]
(http://www.bmj.com/content/358/bmj.j3961)
» [MAGICapp: recommendations, evidence

summaries and consultation decision aids]
(https://www.magicapp.org/app#/guideline/1840)
» A more recent study using data from two US

cohort studies found that the risk of adverse birth
outcomes (including preterm delivery and low
birth weight) was not higher with emtricitabine/
tenofovir plus lopinavir/ritonavir compared with
lamivudine/zidovudine plus lopinavir/ritonavir.[88]
plus PI or INSTI or NNRTI
Treatment recommended for ALL patients in
selected patient group
Primary options
PI-based regimen
» atazanavir
Atazanavir has been associated with benign
indirect maternal hyperbilirubinaemia.
-and-
» ritonavir
MANAGEMENT
OR
PI-based regimen
» darunavir
-and-
» ritonavir
Acute
OR
INSTI-based regimen
» dolutegravir
OR
INSTI-based regimen
» raltegravir
Secondary options
PI-based regimen
» lopinavir/ritonavir
Lopinavir/ritonavir is not recommended,
except in special circumstances.
OR
NNRTI-based regimen
» efavirenz
Previously, efavirenz was only recommended
after 8 weeks’ gestation; however, it is
commonly used in the first trimester and
current guidelines support this.
OR
NNRTI-based regimen
» rilpivirine
» Antiretroviral regimens are complex and a

specialist should be consulted for guidance on
the best combination to use. The options listed
here are based on current US guidance for
pregnant women.[7] Consult local guidelines for
options in other countries.
» A protease inhibitor (PI) or an integrase strand

transfer inhibitor (INSTI) are the preferred agents
to add to the 2-NRTI backbone. Non-nucleoside
reverse transcriptase inhibitors (NNRTIs) may
also be used; however, there are no preferred
NNRTIs in treatment-naive pregnant women.
HIV-1 RNA levels >1000 copies/mL: at
1st caesarean delivery

MANAGEMENT
» A scheduled caesarean delivery at 38 weeks'

gestation is recommended for pregnant women
living with HIV and who have HIV-1 RNA levels
>1000 copies/mL or with unknown viral load
near the time of delivery, in order to reduce the
risk of perinatal transmission.[7]
27
Acute
» In non-virally suppressed patients who present
in labour prior to their scheduled caesarean
delivery date, an emergency caesarean delivery
should be performed. In patients who present
with rupture of membranes, there are insufficient
data to address the question of how long after
the onset of labour or rupture of membranes the
benefit of caesarean delivery to prevention of
perinatal transmission is lost.
plus zidovudine plus continue antiretroviral
therapy
Primary options
» zidovudine: 2 mg/kg intravenously as a

loading dose, followed by 1 mg/kg/hour
infusion until cord clamp
» Intravenous zidovudine should be started 3

hours before surgery.
» Women should also continue taking their

antepartum ART during labour and before
delivery on schedule as much as possible.
HIV-1 RNA levels ≤1000 copies/mL: at
1st await normal vaginal delivery plus

continue antiretroviral therapy
» Scheduled caesarean delivery is not routinely

recommended for women on ART who have
HIV RNA levels ≤1000 copies/mL because of
the low rate of perinatal transmission in these
patients. There is limited or no known evidence
of benefit and an increased risk of infection,
surgical trauma, hospital deaths, and prolonged
hospitalisation in these patients.[7] [13] [89]
» If scheduled caesarean delivery or induction

is indicated in these patients, it should be
performed at the standard time for obstetric
indications.
» Women should also continue taking their

antepartum ART during labour and before
delivery on schedule as much as possible,
regardless of route of delivery.
MANAGEMENT
adjunct zidovudine
Treatment recommended for SOME patients in
Primary options
Acute
» zidovudine: 2 mg/kg intravenously as a
loading dose, followed by 1 mg/kg/hour
infusion until cord clamp
» Intravenous zidovudine may be considered

in women with HIV RNA between 50 and 999
copies/mL; however, there are inadequate data
to determine whether this provides additional
protection against perinatal transmission in this
group.[7]
infants born to HIV-infected mothers
1st presumptive HIV therapy or two-drug

prophylaxis
Primary options
» zidovudine: consult specialist for guidance

on dose
OR

on dose
--AND--
» lamivudine: consult specialist for guidance
on dose
--AND--
» nevirapine: consult specialist for guidance
on dose
-or-
» raltegravir: consult specialist for guidance
on dose
-or-
» lopinavir/ritonavir: consult specialist for
guidance on dose
Nevirapine can be replaced with lopinavir/
ritonavir when infants reach a postmenstrual
age of ≥14 days.
Secondary options

on dose
-and-
» nevirapine: consult specialist for guidance
on dose
» All infants who have been perinatally exposed

to HIV should receive postnatal ART to reduce
MANAGEMENT
the risk of perinatal transmission. ART should

be started as close to the time of delivery as
possible, preferably within 6 to 12 hours.[7]
» Infants born to mothers who received

ART during pregnancy with sustained viral
29
Acute
suppression (i.e., HIV RNA <50 copies/mL)
near delivery have a low risk of perinatal HIV
transmission and should receive a 4-week
course of zidovudine.[7]
» Infants at a higher risk of perinatal

transmission (e.g., mothers who did not receive
antepartum and/or intrapartum ART; mothers
who received only intrapartum ART; mothers
who received antepartum and intrapartum
ART but who have detectable viral loads near
delivery, particularly when delivery is vaginal;
mothers who have primary or acute HIV infection
during pregnancy or breastfeeding) should
receive presumptive HIV therapy with zidovudine
plus lamivudine plus nevirapine (treatment
dose), or zidovudine plus lamivudine plus
raltegravir. The presumptive regimen should
be administered from birth to 6 weeks of age,
although some practitioners may stop the
lamivudine plus nevirapine (or lamivudine plus
raltegravir) if the newborn’s HIV test comes
back negative, and continue the zidovudine
only for 6 weeks). Nevirapine can be replaced
with lopinavir/ritonavir when infants reach a
postmenstrual age of ≥14 days. Nevirapine can
be replaced with raltegravir at any age.[7]
» In some situations, a two-drug prophylaxis

regimen (zidovudine for 6 weeks plus 3
prophylactic doses of nevirapine within 48 hours
of birth, 48 hours after first dose, and 96 hours
after second dose) may be considered in infants
aged ≥32 weeks gestation at birth who weigh
≥1.5 kg. However, this decision depends on the
likelihood of HIV transmission and should be
made by a specialist.[7]
» Consultation with a paediatric HIV specialist is

recommended.
plus replacement feeding (if possible) or harm-
reduction measures
» Breastfeeding is not recommended because
of the risk of HIV transmission to the infant.[7]
This recommendation may not apply to some
countries, particularly low-income and middle-
income countries, where cost limits access
to formula, there is no access to safe water,
MANAGEMENT
or there are inadequate quantities of formula.

However, replacement feeding is recommended
when possible.
» Harm-reduction measures (e.g., ART

prophylaxis in the infant during breastfeeding,
Acute
exclusive breastfeeding for the first 6 months,
gradual weaning, immediate treatment of
maternal mastitis and infant thrush, infant
monitoring) are recommended in women who
choose to breastfeed despite the risks. Lactation
inhibition strategies should be considered.[7]
MANAGEMENT
31
Emerging
Topical microbicide formulations
Topical microbicide formulations applied vaginally or rectally are an experimental strategy for HIV
prevention.[64] [90] Tenofovir-based microbicide gel has reduced rates of HIV transmission to women.[91]
[US Department of Health and Human Services: tenofovir (microbicide)] (https://aidsinfo.nih.gov/drugs/272/
tenofovir--microbicide/0/patient) Dapivirine, a non-nucleoside reverse transcriptase inhibitor (NNRTI)
formulated as a monthly intravaginal ring, has completed two phase III trials. The ASPIRE study reported
a 27% reduction in HIV-1 acquisition compared to placebo, while the Ring study reported a 31% reduction
in HIV-1 acquisition compared to placebo. Both trials showed greater efficacy in women over the age of 21
years. No significant safety concerns were noted.[92] [93] These formulations are not commercially available
as yet.
Maraviroc
Maraviroc is an antiretroviral indicated to treat CCR5-tropic HIV-1 infection in adults and children who weigh
at least 2 kg. It may provide an additional treatment option for newborns of women carrying multi-drug
resistant HIV-1 that remains CCR5-tropic. However, the lack of data about maraviroc as prophylaxis or
treatment in infants weighing <10kg, as well as the risk of drug interactions, limits its role for routine use in
neonates.[7]
Primary prevention
Education and counselling about HIV in pregnancy is recommended early in the course of HIV care to enable
women to make informed decisions about contraception and pregnancy. Discussions about contraception
and pregnancy should be repeated at intervals throughout care, especially with changes in personal
circumstances (e.g., a new sexual partner).
Preconception counselling and care[7]
• For couples where one or both partners are living with HIV and they want to conceive, expert
consultation is recommended so that the approach can be tailored to the couple’s specific needs.
• Partners should be screened and treated for genital tract infections before attempting to conceive.
• For serodiscordant couples who want to conceive, initiation of antiretroviral therapy (ART) and
sustained viral suppression of the partner living with HIV is recommended.
• Sexual intercourse without a condom allows for conception with effectively no risk of sexual
transmission of HIV to the partner without HIV, provided the partner with HIV is on ART and has
achieved sustained viral suppression. If the partner with HIV has not been able to achieve viral
suppression (or their status is unknown or there are concerns about adherence to ART), pre-
exposure prophylaxis (PrEP) with tenofovir disoproxil/emtricitabine in the partner without HIV may be
recommended to reduce the risk of transmission. The partner without HIV can choose to take PrEP
even if the partner with HIV has achieved viral suppression. Timing condomless sex to coincide with
ovulation (peak fertility) can optimise the probability of conception.
• For couples where both partners are living with HIV, both partners should be on ART with maximal
viral suppression before attempting conception, with unprotected intercourse during the periovulatory
period being a reasonable option.
• For women living with HIV who have an HIV-negative male partner, assisted insemination with the
MANAGEMENT
partner's semen during the periovulatory period either at home or in a provider's office eliminates the
risk of transmission.
• For men living with HIV who have an uninfected female partner, the use of a sperm donor from a man
who is uninfected eliminates the risk of HIV transmission. Sperm preparation techniques coupled with
either intrauterine insemination or in vitro fertilisation with intracytoplasmic sperm injection may be
considered, particularly in cases of male infertility. Semen analysis is recommended before conception
is attempted to check for sperm abnormalities.
The impact of HIV on the course and outcome of pregnancy and the impact of pregnancy on HIV progression
should be discussed. Coexisting drug or alcohol use and existing medical conditions, such as hypertension
and diabetes, and, where applicable, advanced maternal age should also be discussed. Pre-conception
nutritional counselling (e.g., folic acid) should be offered, and the importance of early and intense antenatal
care stressed. The issues of safe conception (if the partner is HIV negative), use of antiretrovirals and other
medications in pregnancy, and perinatal HIV transmission should also be discussed.[59]
Reducing risk of HIV infection
• Women may be more susceptible to HIV infection during pregnancy and breastfeeding.[60] Modifying
behaviours that increase the risk of exposure to HIV can prevent infection. High-risk behaviours
include having multiple sexual partners, unprotected sexual contact, recent diagnosis of an
sexually transmitted infection (STI), exchanging sex for money or drugs, or illicit substance use. It is
recommended that people classified at high risk of infection are referred to HIV risk reduction services,
including drug rehabilitation clinics and STI treatment centres. Prevention counselling need not be
linked explicitly to HIV testing, but it is recommended that counselling is offered or made available
through referral in all healthcare facilities.[61] By obtaining regular sexual and illicit drug use histories
from their patients, healthcare providers can address the management of risk reduction.
• PrEP may be considered in women who are at risk of HIV and trying to conceive or pregnant,
postnatal, or breastfeeding. Indications for PrEP include any risk factors for acquiring HIV, such as
condomless sex with a partner with HIV whose HIV RNA level is detectable or unknown, recent
sexually transmitted infection, or injection drug use. Women who become pregnant while using PrEP
can continue PrEP throughout their pregnancy. The risk of HIV acquisition should be reassessed, and
patients should be counselled regarding the benefits and risks of the use of PrEP during pregnancy.[7]
• When used consistently and correctly, male condoms are highly effective in preventing the sexual
transmission of HIV infection.[62] A limited number of studies found that, if used consistently and
correctly, the female condom substantially reduced the risk of contracting an STI.[63]
• Over one half of pregnancies in the US are unplanned, and many of the risk factors for unintended
pregnancy (e.g., substance abuse in patient or partner, mental illness, and domestic violence) also
place women at increased risk for HIV. Adolescents are at an increased risk for unintended pregnancy
and may also be at increased risk for HIV because of frequent unstable sexual relationships and
unsafe sexual practices.
• Male circumcision has been shown to reduce the efficiency of HIV transmission.[64]
• In cases of sexual assault, an experienced clinician should conduct an examination of the victim in
a way that minimises further trauma to her. An initial examination should include testing for HIV and
other STIs. HIV seroconversion has occurred in people whose only risk factor was sexual assault or
sexual abuse, but the frequency of this occurrence is probably low. In consensual sex, the risk of HIV
transmission from vaginal intercourse is 0.1% to 0.2%, and from receptive anal intercourse 0.5% to
3%.[55] The risk for HIV transmission from oral sex is substantially lower. Children may be at higher
risk of transmission because child sexual abuse is frequently associated with multiple episodes of
assault and might result in mucosal trauma.
Post-exposure prophylaxis (PEP) is discussed in detail in a separate topic.
Secondary prevention
Secondary prevention strategies focus on the prevention of perinatal transmission. There are various factors
MANAGEMENT
involved in reducing the risk of perinatal transmission including:
• Universal HIV screening in the antenatal setting

• Early diagnosis and treatment of maternal HIV infection
• Antepartum, intrapartum, and postnatal antiretroviral therapy
33
• Scheduled caesarean delivery in patients with HIV RNA levels >1000 copies/mL or unknown viral load
• Replacement feeding in infants where possible.
Integration of HIV and antenatal care may improve the use of antiretroviral therapy during pregnancy, thereby
reducing the risk of perinatal transmission.[100]
Patient discussions
At the initial visit, the healthcare provider should assess the patient's support system, establishing who
knows of the patient's HIV status, problems encountered with disclosure, family and/or friends to whom
she turns for ongoing support, and barriers to disclosure to sexual or needle-sharing partners. These
issues should be readdressed at intervals throughout pregnancy as needed. The use of peer counsellors
may be especially helpful.
Women who present for pregnancy care during the first trimester should be counselled on the risks (e.g.,
potential teratogenic effects, maternal adverse effects, increased risk of preterm delivery) and benefits
(e.g., improved maternal health, reduced risk of perinatal transmission) of antiretroviral therapy (ART)
during this period.
Discussion about postnatal contraceptive plans should be initiated in early to mid-pregnancy to allow
comprehensive education and counselling about available options and adequate time for informed
decision-making. Sexual activity should be reviewed at each visit and condom use reinforced. History of
and/or ongoing substance abuse, including abuse of tobacco and alcohol as well as illicit drugs, should
be assessed at the initial visit and at intervals during antenatal care, if indicated. Type of substance(s),
amount of use, route of administration, and prior drug or alcohol treatment should be documented. The
patient should be counselled about specific risks associated with substance abuse in pregnancy, and drug
or alcohol addiction treatment during pregnancy encouraged and facilitated for active problems.
Patient education and counselling about the importance of adherence to prescribed medications,
particularly antiretroviral drugs, before they are initiated is recommended. Medication adherence should
be assessed and reinforced at each visit. Pregnant women who are living with HIV should be informed
about the availability of, and offered participation in, clinical trials for which they are eligible.
While breastfeeding is not recommended, replacement feeding may not be feasible in some countries
(e.g., low-income and middle-income countries where cost limits access to formula, there is no access
to safe water, or there are inadequate quantities of formula). Harm-reduction measures (e.g., ART
prophylaxis in the infant during breastfeeding, exclusive breastfeeding for the first 6 months, gradual
weaning, immediate treatment of maternal mastitis and infant thrush, infant monitoring) are recommended
in women who choose to breastfeed despite the risks.[7]
MANAGEMENT
HIV infection in pregnancy Follow up
Monitoring
Monitoring
FOLLOW UP
Women should have contact with their obstetric care provider within the first 3 weeks of the postpartum
period, and their HIV practitioner within the first 2-4 weeks after discharge.[7]
Healing of wound sites, uterine involution, and appropriate cessation of postnatal bleeding should
be assessed. Because of the potential for an increase in post-caesarean section wound infection,
assessment of wound healing should be carried out between the time of hospital discharge and the
routine postnatal visit.[59]
Women living with HIV often neglect their own health while caring for their children and family
members.[59] Women should be offered comprehensive medical and supportive care services, including
HIV specialty care, primary medical and gynaecological care, family planning, and mental health or
substance abuse treatment services, as well as assistance with food, housing, transportation, and legal/
advocacy services, if needed.[59] As women living with HIV have higher rates of mental illness and
depression they appear to be at risk for postnatal depression.[59]
The Antiretroviral Pregnancy Registry is a collaborative effort between pharmaceutical companies, the US
Centers for Disease Control and Prevention (CDC), the US National Institutes of Health, and obstetric and
paediatric practitioners, to collect observational information on antiretroviral exposure during pregnancy
to assess potential fetal/infant anomalies. Patient names are not used and information is confidential.
Healthcare providers who are treating pregnant women living with HIV are strongly encouraged to report
cases of antenatal exposure to antiretroviral drugs to the Registry. [Antiretroviral Pregnancy Registry]
(http://www.apregistry.com)
35
Complications
Complications Timeframe Likelihood

FOLLOW UP
long-term effects of antiretroviral therapy exposure in long term low

utero
ART exposure in utero may have long-term effects in children, including organ system toxicities and
neoplasia; however, available evidence does not permit definitive conclusions about this risk. The data
gathered over the past two decades are reassuring, particularly in relation to zidovudine exposure. Further
study is required.[7] Children who develop significant organ system abnormalities after exposure to ART,
particularly those of the nervous system or heart, should be evaluated for mitochondrial dysfunction.[7]
vertical transmission variable high
Vertical transmission of the virus, from mother to child, can occur throughout pregnancy, during labour and
delivery, and postnatally through breast milk.
The incidence of vertical transmission has been reported to be 2500 infections per 10,000 exposures to an
infected source.[94] The risk has been reduced to 2% or less in the US and Europe.[7]
Risk is reduced with preventive strategies including early diagnosis and treatment, antepartum and
intrapartum antiretroviral therapy (ART), ART prophylaxis in the neonate, and scheduled caesarean
delivery if maternal HIV RNA levels are >1000 copies/mL or viral load is unknown.
fetal risk with early antiretroviral therapy exposure variable low
Current data are generally insufficient to either support or refute fetal risk with early exposure to ART.[59]
Overall, no significant increased risk of congenital abnormalities has been detected following first-trimester
exposure to ART, as determined by prospective reporting to the Antiretroviral Pregnancy Registry (APR),
with the exception of atazanavir, which has been associated with skin and musculoskeletal defects.[72]
A preliminary unscheduled analysis of an ongoing surveillance study reported an increased risk of serious
fetal neural tube defects in women who became pregnant while taking dolutegravir-based regimens (0.9%
compared with 0.1% in women not taking dolutegravir) in May 2018.[83] [95] However, more recently, two
large clinical trials have expanded the evidence base and found the risk of neural tube defects associated
with dolutegravir to be lower than the initial studies suggested (0.3% compared with 0.1% in women not
taking dolutegravir).[85] [86]
There were reports of first-trimester birth defects with didanosine exposure in the past; however, recent
analysis has not found any trend. Nonetheless, the APR continues to monitor didanosine for any signal or
pattern of birth defects.[96]
One meta-analysis of data concerning first-trimester exposure to efavirenz did not show any evidence of
an increased risk of birth defects.[73] However, a prospective cohort study found efavirenz was associated
with an increased risk of microcephaly.[74] Previously, efavirenz was only recommended after 8 weeks’
gestation; however, it is commonly used in the first trimester and current guidelines support its use as an
alternative option.[7]
Discontinuation of therapy may lead to viral rebound, which could theoretically increase risk of intrauterine
HIV transmission or have an adverse effect on maternal disease.
preterm delivery variable low
Complications Timeframe Likelihood

Studies have found conflicting data on the association between ART and increased risk of preterm
birth.[75] [76] [77] [78] [79] [80] [81] [82] Given these conflicting data, no changes in ART are indicated in
FOLLOW UP
pregnancy.
Several studies have found increased preterm birth rates in women on no antiretroviral therapy, especially
with more advanced disease.[97] [98] [99]
Prognosis
The disease status of women living with HIV infection in pregnancy does not differ significantly from the
prognosis for women living with HIV outside of pregnancy. Pregnancies complicated by HIV are more
complicated than their HIV-negative counterparts, however. Women living with HIV have persistently higher
rates of obstetric and postnatal morbidity such as elevated rates of caesarean delivery, preterm premature
rupture of membranes, spontaneous preterm delivery, endometritis, and intensive care unit admission.[9]
[10] [11] [12] Post-caesarean complications have decreased dramatically in the US from 210.6/1000 from
1995 to 1996 to 116.6/1000 in 2010 to 2011; however, rates of infection, surgical trauma, hospital deaths,
and prolonged hospitalisation remain significantly higher than in HIV-uninfected women.[13] In addition,
retrospective data suggest that neonates born to women with HIV are at increased risk for complications
such as low birth weight and transient tachypnoea of the newborn.[10]
With physical recovery after delivery, the stresses and demands of caring for a new baby, and the risk of
postnatal depression, mothers living with HIV are particularly vulnerable to problems with adherence to
antiretroviral treatment. Support and attention to this issue is warranted. The risk of perinatal transmission of
HIV has been reduced to less than 2% or less in the US and Europe.[7]
37
HIV infection in pregnancy Guidelines
Diagnostic guidelines
Europe
BHIVA guidelines on the management of HIV in pregnancy and postpartum

(ht tps://www.bhiva.org/pregnancy-guidelines)
Published by: British HIV Association (BHIVA) Last published: 2020
HIV testing: increasing uptake among people who may have undiagnosed HIV
(ht tps://www.nice.org.uk/guidance/ng60)
Published by: National Institute for Health and Care Excellence; Public Last published: 2016
Health England
HIV testing (ht tps://iusti.org/treatment-guidelines/)

Published by: European Office of International Union against Sexually Last published: 2014
GUIDELINES
Transmitted Infections; European Office of the World Health Organization
North America
Recommendations for the use of antiretroviral drugs in pregnant women with

HIV infection and interventions to reduce perinatal HIV transmission in the
United States (ht tps://clinicalinfo.hiv.gov/en/guidelines)
Published by: US Department of Health and Human Services Last published: 2021
Quick reference guide: recommended laboratory HIV testing algorithm

for serum or plasma specimens (ht tps://stacks.cdc.gov/cbrowse?pid=cdc
%3A100&parentId=cdc%3A100)
Published by: Centers for Disease Control and Prevention Last published: 2018
Laboratory testing for the diagnosis of HIV infection: updated

recommendations (ht tps://stacks.cdc.gov/cbrowse?pid=cdc
%3A100&parentId=cdc%3A100)
Evaluation and management of the infant exposed to HIV in the United States
(ht tps://pediatrics.aappublications.org/content/146/5/e2020029058) [70]
Published by: American Academy of Pediatrics Last published: 2020
Treatment guidelines
Europe
BHIVA guidelines on the management of HIV in pregnancy and postpartum

(ht tps://www.bhiva.org/pregnancy-guidelines)
Published by: British HIV Association (BHIVA) Last published: 2020
International
Update of recommendations on first- and second-line antiretroviral regimens

(ht tps://www.who.int/hiv/pub/arv/arv-update-2019-policy/en/)
Published by: World Health Organization Last published: 2019
Contraceptive eligibility for women at high risk of HIV (ht tps://www.who.int/
GUIDELINES
reproductivehealth/publications/contraceptive-eligibility-women-at-high-
risk-of-HIV/en/)
Hormonal contraceptive methods for women at high risk of HIV and

living with HIV (ht tp://www.who.int/reproductivehealth/publications/
family_planning/policybriefs/en/)
39
North America
Recommendations for the use of antiretroviral drugs in pregnant women with

HIV infection and interventions to reduce perinatal HIV transmission in the
United States (ht tps://clinicalinfo.hiv.gov/en/guidelines)
Published by: US Department of Health and Human Services Last published: 2021
Canadian HIV pregnancy planning guidelines (ht tps://www.jogc.com/article/

S1701-2163(17)30701-6/fulltext)
Published by: Society of Obstetricians and Gynaecologists of Canada Last published: 2018
Update to U.S. Medical Eligibility Criteria for contraceptive use, 2016: updated
recommendations for the use of contraception among women at high risk
for HIV infection (ht tps://www.cdc.gov/mmwr/volumes/69/wr/mm6914a3.htm?
s_cid=mm6914a3_w)
GUIDELINES
Sexually transmit ted diseases treatment guidelines: special populations

(ht tp://www.cdc.gov/std/tg2015/default.htm)
A guide to the clinical care of women with HIV (ht tps://aidsetc.org/resource/

guide-clinical-care-women-hivaids)
Published by: US Department of Health and Human Services - Health Last published: 2013
Resources and Services Administration
Evaluation and management of the infant exposed to HIV in the United States
(ht tps://pediatrics.aappublications.org/content/146/5/e2020029058)
Published by: American Academy of Pediatrics Last published: 2020
HIV infection in pregnancy Online resources
Online resources
1. Antiretroviral Pregnancy Registry (http://www.apregistry.com) (external link)
2. BMJ Rapid Recommendations: antiretroviral therapy in pregnant women living with HIV (http://
www.bmj.com/content/358/bmj.j3961) (external link)
3. MAGICapp: recommendations, evidence summaries and consultation decision aids (https://

www.magicapp.org/app#/guideline/1840) (external link)
4. US Department of Health and Human Services: tenofovir (microbicide) (https://aidsinfo.nih.gov/

drugs/272/tenofovir--microbicide/0/patient) (external link)
ONLINE RESOURCES
41
HIV infection in pregnancy References
Key articles
• The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal
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51
HIV infection in pregnancy Images
Images
IMAGES
Figure 1: BMJ Rapid Recommendations: antiretroviral therapy in pregnant women living with HIV (TDF:
tenofovir, FTC: emtricitabine, AZT: zidovudine, 3TC: lamivudine, ABC: abacavir, LPV/r: lopinavir [boosted with
ritonavir], ATZ/r: atazanavir [boosted with ritonavir], DRV/r: darunavir [boosted with ritonavir], EFV: efavirenz,
RPV: rilpivirine, RAL: raltegravir)
BMJ. 2017;358:j3961
HIV infection in pregnancy Images
IMAGES
Figure 2: BMJ Rapid Recommendations: antiretroviral therapy in pregnant women living with HIV (TDF:
tenofovir, FTC: emtricitabine, AZT: zidovudine, 3TC: lamivudine, ABC: abacavir, LPV/r: lopinavir [boosted with
ritonavir], ATZ/r: atazanavir [boosted with ritonavir], DRV/r: darunavir [boosted with ritonavir], EFV: efavirenz,
RPV: rilpivirine, RAL: raltegravir)
BMJ. 2017;358:j3961
53
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55
Contributors:
// Authors:
Rachel K. Scot t, MD, MPH, FACOG

Assistant Professor of Obstetrics and Gynecology
Georgetown University School of Medicine, Scientific Director of Women’s Health Research, MedStar
Health Research Institute, Associate Chair for Research and Director, Women's Center for Positive Living,
MedStar Washington Hospital Center Department of Women’s and Infants’ Services, Washington, DC
DISCLOSURES: RKS declares that she is a principal investigator on a Gilead Investigator Sponsored
Research Award through MedStar Health Research Institute.
// Acknowledgements:
Dr Rachel K. Scott would like to gratefully acknowledge Dr Isaac Delke, Dr Christina Bailey, and Dr
Mettassebia Kano, the previous contributors to this topic.
DISCLOSURES: ID, CB, and MK declare that they have no competing interests.
// Peer Reviewers:
Aisha Sethi, MD
Assistant Professor of Medicine
Associate Residency Program Director, University of Chicago, Chicago, IL
DISCLOSURES: AS declares that she has no competing interests.
Graham P. Taylor, MBChB, FRCP, FHEA

Reader in Communicable Diseases
Faculty of Medicine, Imperial College, London, UK
DISCLOSURES: GPT has been reimbursed by various pharmaceutical companies for attending
conferences, lecturing, and consulting, and has been chief investigator of investigator-initiated industry-
funded research on HIV and pregnancy.

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HIV infection

Straight to the point of care

Last updated: Apr 06, 2021

• History of past or current injection drug use

Diagnosis in exposed infants

History and exam

contraception carries a risk of 1 infection/333 exposures in low-income countries and 1 infection/1250

increased risk of perinatal HIV transmission (common)

Other diagnostic factors

increasing dyspnoea (common)

weight loss (common)

maculopapular blanching rash (uncommon)

receptive penile-vaginal intercourse

unprotected receptive anal intercourse

percutaneous needle prick

sexually transmit ted infections (STIs) and bacterial vaginosis

absence of antenatal maternal antiretroviral therapy (perinatal transmission)

breast feeding (perinatal transmission)

violence against women and girls

insertive oral intercourse

multiple sexual partners

low maternal CD4 count (perinatal transmission)

Other tests to consider

with inconsistent adherence and/or detectable viral loads. Women

plasma HIV RNA levels (viral load) recently infected patients

Condition Differentiating signs / Differentiating tests

Toxoplasmosis • Difficult to differentiate • Positive serological tests for

Viral hepatitis • Right upper quadrant • Aminotransferases (alanine

Morbilliform drug • Typically presents as a • Diagnosis is usually

develops within 2 weeks of with differential may

Parvovirus B19 • Patients are typically • Serum parvovirus B19 IgM

Condition Differentiating signs / Differentiating tests

Coronavirus disease 2019 • Residence in/travel to a • Real-time reverse

• History of past or current injection drug use

Antiretroviral therapy in pregnant women

[Antiretroviral Pregnancy Registry] (http://www.apregistry.com)

• Preferred options: abacavir/lamivudine; emtricitabine/tenofovir disoproxil; lamivudine plus tenofovir

• Alternative option: lamivudine/zidovudine; tenofovir alafenamide.

• Preferred options: ritonavir-boosted atazanavir; ritonavir-boosted darunavir

• Alternative option: lopinavir/ritonavir is not recommended, except in special circumstances.

• Preferred options: dolutegravir; raltegravir.

• Alternative options: efavirenz; rilpivirine.

[MAGICapp: recommendations, evidence summaries and consultation decision aids] (https://

Scheduled caesarean delivery

Intrapartum antiretroviral therapy

Postnatal antiretroviral therapy

Treatment algorithm overview

1st preferred 2-NRTI backbone

plus PI or INSTI or NNRTI

HIV-1-infected pregnant women with

1st caesarean delivery

plus zidovudine plus continue antiretroviral

HIV-1-infected pregnant women with

1st await normal vaginal delivery plus

infants born to HIV-infected mothers

1st presumptive HIV therapy or two-drug

plus replacement feeding (if possible) or harm-

1st preferred 2-NRTI backbone

» Women living with HIV who are receiving

» Antiretroviral regimens are complex and a

options in other countries.

» Nucleoside reverse transcriptase inhibitors

» [BMJ Rapid Recommendations: antiretroviral