CASE-BASED LEARNING
Management of HIV in
pregnancy
Eleanor Hamlyn
Tristan J Barber
Abstract
A cohesive multidisciplinary team approach is key in the management
of HIV in pregnancy. The primary aim is to prevent transmission to the
neonate but also to support the mother in any issues arising from her
pre-existing, or new, diagnosis of HIV. Specialist advice should be
sought, wherever possible.
Key areas discussed in this review include antenatal management of
the mother (particularly pharmacological management), obstetric man-
agement, pharmacological treatment for the neonate and infant
feeding. Due to progress made in both in HIV testing, and in the
way all patients with HIV in the UK are managed over the last few de-
cades, most women who present with HIV in pregnancy are aware of
their diagnosis and on treatment. However, it is not entirely uncommon
for women to be diagnosed in pregnancy and it is these cases that
present the greater challenge. The cases in this review cover the
most common scenarios encountered.
Keywords HIV; pregnancy; obstetrics; pregnancy complications;
breastfeeding
Introduction
Without treatment, the probability of vertical (mother to child)
transmission of HIV is 15e45%. Advances in antiretroviral
therapy (ART) over the last 20 years have meant that this risk
can be reduced to below 5% and in the UK is less than 0.5%.
Transmission can occur ante, peri- or post-natally (through
breastfeeding) and management aims to reduce potential risk at
each stage via suppression of HIV viral load in the mother.
Case 1
A 27 year old woman from Romania (G3 P0þ2) presents at
booking (13/40) with a five year history of known HIV infection
for which she has been taking antiretroviral therapy (ART) for
three years. She reports good adherence to her medication and
has been virally suppressed since starting therapy with no known
drug resistance. She has never been immunosuppressed or suf-
fered from any HIV related illness.
She has a history of injecting drug use (IDU) prior to her HIV
diagnosis but denies any recent use and completed a methadone
programme 18 months ago. She gives a history of two previous
Eleanor Hamlyn MSc MRCP SpR Specialist Registrar in HIV and
Genitourinary Medicine, Chelsea and Westminster Hospital, London,
UK. Conflicts of interest: none declared.
Tristan J Barber MA MRCP (UK) Consultant Physician, St Stephen’s
Centre, Chelsea and Westminster Hospital, London, UK. Conflicts of
interest: none declared.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
Please cite this article in press as: Hamlyn E, Barber TJ, Management of HIV in pregnancy, Obstetrics, Gynaecology and Reproductive Medicine
(2018), https://doi.org/10.1016/j.ogrm.2018.06.001
first trimester surgical terminations. She has a regular male
partner of two years, who is also HIV positive on treatment, and
this is a planned pregnancy.
She is currently taking Truvada (Emtricitabine/tenofovir)
(once daily) and raltegravir (400 mg twice daily) and folic
acid supplementation. She does not take any other regular
medications.
Her most recent HIV monitoring bloods (done 5 months prior)
show:
 CD4 count of 657 cells/mm3
 Viral load (VL) < 20 copies per ml.
Initial and pharmacological management
Initial assessment should involve a normal antenatal assessment
with additional attention to her HIV history including diagnosis,
medication and resistance history, coinfections, and any previ-
ous complications. Particular attention must also be paid to
sexual history and social history (due to the increased risk of
domestic violence in women living with HIV).
There are not many randomly controlled trials (RCT) of ART
in pregnancy and best practice in the safety of prescribing ART in
pregnancy is mainly guided by observational data. The general
principal in women who are already on ART at conception is to
continue on the current regimen. Switching therapy may lead to
side effects and potential non-adherence, and therefore treatment
failure. The only exceptions to this are if the patient is on mon-
otherapy with a protease inhibitor (as opposed to the usual triple
therapy) or on the combination of stavudine and didanosine
(which are older drugs and very seldom prescribed in recent
years due to their side effect profiles).
In addition to routine bloods at booking she should have a
baseline CD4 count and VL and these should be repeated at 36
weeks. If the viral load is found to be detectable it should be
repeated and sent for resistance testing.
Obstetric management and mode of delivery
Obstetric management including fetal ultrasound imaging should
be as per the Royal College of Obstetricians and Gynaecologists
(RCOG) guidance in the UK, regardless of HIV status. Additional
recommendations include using the most sensitive and specific
test available for trisomy 21 to reduce the risk of invasive testing.
Invasive testing should only be done after HIV status is known
and preferably not before HIV viral load is suppressed. If invasive
diagnostic testing is required in a woman who is not on treat-
ment, or viral load is not yet suppressed, she should be imme-
diately commenced on an ART regimen including an integrase
inhibitor and also be given a single dose of nevirapine 2e4 hours
after the procedure.
Previous advice was for caesarean section to reduce risk of
perinatal transmission. However, there is good evidence that
there is no difference in transmission rates in those women who
deliver vaginally compared to caesarean section as long as the
women is taking ART and has achieved viral suppression prior to
delivery. As such, for those women with an undetectable viral
load at 36 weeks, vaginal delivery is recommended notwith-
standing any other obstetric complications as per RCOG guide-
lines. Any obstetric complications that arise during delivery
should be treated as per national guidance. Please see Table 1 for
recommendations for mode of delivery based on viral load.
1 Ó 2018 Elsevier Ltd. All rights reserved.
 CASE-BASED LEARNING
Recommendations for mode of delivery based on viral
load
Viral load Recommended mode of delivery
(copies/ml)
at 36 weeks
<50 Planned vaginal (in absence of obstetric
contraindications)
50e399 Planned caesarean section (between 38 and
39 weeks) should be considered taking into
account the actual viral load and its trajectory,
length of time on treatment, adherence issues,
the woman’s views and obstetric factors.
400 Planned caesarean section (between 38 and
39 week) is recommended
Table 1
Neonatal management
All infants born to HIV positive mothers are given post exposure
prophylaxis (PEP). In all cases where the mother is virally sup-
pressed prior to delivery, which is defined as <50 copies/ml at 36
weeks, zidovudine (AZT) monotherapy for four weeks is given.
Dosing varies according to gestation at delivery and reference to
the British HIV Association (BHIVA) guidelines should be made
for dosing schedules (see further reading).
In all other cases three-drug therapy should be considered i.e.:
 If the mother is untreated or not virally suppressed
 If the viral load is not known
 If HIV is diagnosed immediately postnatally (see below)
Infants born to HIV positive mothers should follow the routine
national immunization schedule.
Infant feeding
Whilst ART can significantly reduce the risk of post-natal trans-
mission of HIV it does not abolish it completely. The current
guidance is that all HIV positive women should be advised to
exclusively formula feed their child. However, if the mother does
opt to breastfeed, as long as she is virally suppressed, this should
not be considered a child protection issue and she should be
offered intensive support (see below for further discussion).
Neonatal HIV testing
In exclusively non-breastfed infants, HIV testing with an HIV
DNA or RNA PCR should be performed at the following times:
 48 hours post delivery
 2 weeks post cessation of PEP (so at 6 weeks of age)
 12 weeks of age
HIV antibody testing should also be performed at 18e24
months of age to rule out rare cases of HIV seroconversion in the
infant without detectable virus on PCR.
If the mother is breastfeeding additional testing should be
performed (see below).
Case 1 continued
She has an uncomplicated vaginal delivery at 41 þ 2 and is fully
compliant with the infant PEP regimen. She has intensive
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
Please cite this article in press as: Hamlyn E, Barber TJ, Management of HIV in pregnancy, Obstetrics, Gynaecology and Reproductive Medicine
(2018), https://doi.org/10.1016/j.ogrm.2018.06.001
support from the health visiting team and social services (given
her history of IDU). She opts to exclusively formula feed as per
guidance and all follow up HIV testing in the infant is negative.
She continues to remain virally suppressed on her ART regimen.
Case 2
A 34 year old caucasian British commercial sex worker (CSW),
G4 P1 þ 2, is diagnosed with HIV at booking (14/40) having
previously had her last negative HIV test one year ago. She is
otherwise well and has no evidence of HIV related illness.
She has had two previous terminations and carried one
pregnancy to term and now has a five-year old daughter who is
in foster care. That pregnancy was uncomplicated and she had a
normal birth.
Initial and pharmacological management
Women diagnosed with HIV in pregnancy should have immedi-
ate emotional support and counseling, initially from a sexual
health advisor who may then involve peer support, clinical
psychology or psychiatry as necessary. Health advisors can be
accessed via your local genitourinary medicine (GUM) service.
Social services should be informed as necessary. Health advisors
will also arrange contact tracing and possible testing of any
children from previous pregnancies according to testing history.
Women who are diagnosed with HIV in pregnancy should be
referred to GUM services for full sexual health screening and any
genital tract infections should be treated in accordance with
national guidelines (British Association for HIV and Sexual
Health e BASHH). Referral for sexual health screening
should also be considered in women with known HIV infection
according to risk factors.
Women diagnosed with HIV in pregnancy should be referred
for urgent assessment by an HIV specialist clinic where routine
bloods for newly diagnosed patients, including screening for viral
hepatitis, syphilis and opportunistic infection, as well as HIV
specific bloods (CD4, VL and resistance testing) should be sent in
conjunction with a thorough assessment by an HIV physician.
All patients newly diagnosed with HIV are now offered im-
mediate ART regardless of immune status at diagnosis and
women diagnosed with HIV in pregnancy would also be offered
an immediate start. If the woman objects to an immediate start
she should at least start by week 24 of pregnancy or by week 14 if
her VL >30,000. If her VL >100,000 at diagnosis, she should be
strongly advised to start immediately.
The exact ART regimen may vary according to local guide-
lines, individual physician preference and the viral load and
resistance profile, but generally will be standard triple therapy
with a dual nucleoside backbone and either a boosted protease
inhibitor or integrase inhibitor. If the viral load is unknown or
very high (>100,000) then a four-drug regimen, which includes
an integrase inhibitor, may be considered.
Once the woman has been started on ART she should have the
viral load checked 2e4 weeks post commencement and then at
least once per trimester and at 36 weeks. More intensive moni-
toring may be necessary if she has failure to suppress for any
reason. If the viral load is not suppressed as expected, resistance
testing should be sent and this would be organized and evaluated
by her HIV physician.
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 CASE-BASED LEARNING
Prior to the introduction of immediate ART being offered to all
newly diagnosed patients (as above), HIV in pregnancy guide-
lines allowed for stopping ART post delivery for those with a high
CD4 count at baseline. Updated guidelines, taking into account
this new research and practice, are still awaited but are likely to
state that women should be advised to continue on antiretroviral
therapy after pregnancy regardless of immune status. In-
terruptions in therapy can be harmful for a number for reasons,
not least because uncontrolled virus is a risk factor for HIV
related complications, even if the CD4 count is normal.
Case 2 continued
The patient is counseled initially by a health advisor who ar-
ranges contact tracing. She has one regular male partner who is
an IDU although she does not currently use herself. The health
advisor team refer her to peer support and social services as well
as arrange her initial appointment with an HIV physician.
Her initial investigations reveal:
CD4 count 457 (23%) and an HIV viral load 87,000 copies per
ml
Resistance profile: NAD
Hepatitis A e natural immunity
Hepatitis B e vaccinated with sAb >1000
Hepatitis C PCR negative
Sexual health screening:
Syphilis TPPA pos, RPR 64 (indicates current infection)
Throat, rectal and vaginal swabs are all positive for chlamydia
(rectal swab negative for LGV), negative for gonorrhoea.
She is given a stat dose of benzathine penicillin for syphilis,
azithromycin for chlamydia and commenced on Kivexa (abacavir
and lamivudine), one tablet daily, and raltegravir 400 mg twice
daily for HIV.
A viral load three weeks later (18/40) is undetectable (<50
copies/ml) and remains so at repeat checks at 24/40 and 36/40.
Her pregnancy is uncomplicated until 34/40 when the baby is
found to be in breech presentation. A second scan at 36 weeks
confirms the baby is still in breech. She opts for ECV at 36 weeks
which is successful but complicated by premature rupture of
membranes. She is immediately induced and delivers a healthy
baby boy six hours later with no further complications. She ex-
presses a wish to breastfeed.
Obstetric management
ECV can be offered to women with HIV at 36þ weeks as long as
the viral load is <50 copies/ml and in the absence of obstetric
complications.
In all cases of pre-labour rupture of membranes (ROM) at
term, delivery should be expedited. If the viral load is <50
copies/ml induction of labour is recommended and there should
be a low threshold for treatment of intrapartum pyrexia.
If the viral load is 50e999 immediate caesarean section should
be considered taking into account the actual viral load and it’s
trajectory, any adherence issues, the length of time on treatment
and the woman’s wishes. If the viral load is 1000 then imme-
diate caesarean section is recommended.
All cases of prolonged premature rupture of membranes
(PPROM) at 34 weeks should be managed as above. When
PPROM occurs at <34 weeks it should be managed as per RCOG
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
Please cite this article in press as: Hamlyn E, Barber TJ, Management of HIV in pregnancy, Obstetrics, Gynaecology and Reproductive Medicine
(2018), https://doi.org/10.1016/j.ogrm.2018.06.001
guidance (with IM steroids) but, in addition, virological control
should be optimized and there should a multidisciplinary dis-
cussion about the timing of delivery.
Infant feeding
As discussed above, all HIV positive women, regardless of ART
should be advised to formula feed from birth. However, if
women who have a repeatedly suppressed viral load on ART
choose to breastfeed after sufficient counseling as to the risk,
then this no longer constitutes grounds for immediate child
protection referral (as it has done in the past). The woman
should be counseled that if she wishes to breastfeed she should
do so exclusively (except during the weaning period) and that all
breastfeeding should cease after six months.
The woman should be supported intensively during the period
of breastfeeding with regards to ART adherence and monitoring,
until one week after all breastfeeding has ceased. Additional
monthly testing of both mother and infant is recommended
during this time. There is no change to the recommendation for
neonatal PEP, however, with the duration of therapy remaining
at four weeks.
Case 3
A 37 year old British/Nigerian woman (G5 P3) presents to A&E at
37/40 with a possible deep vein thrombosis (DVT) following a
flight from Nigeria to the UK. She has not had any antenatal care
in the UK. DVT is ruled out by the accident and emergency
department but she is noted to have some evidence of immu-
nosuppression with oral thrush and some skin lesions suspicious
of Kaposi’s Sarcoma (KS). A rapid HIV test is performed which is
reactive.
She is referred to the obstetric and HIV teams for urgent
assessment.
She reports having had an uncomplicated pregnancy. She has
three children and has previously had three uncomplicated
vaginal deliveries in Nigeria with minimal intervention and
wishes to deliver vaginally again. Her children are 2, 5 and 8
years old. She is married and lives with her husband in Nigeria.
She has no other sexual partners.
She reports being fit and well prior to her pregnancy. She can
not remember how long she has had the skin lesions. She has
never had an HIV test before. Aside from the oral thrush and skin
lesions, multisystem examination does not reveal any evidence
of opportunistic infection.
A few days later, initial bloods reveal:
CD4 57 (4%) cells/mL and a viral load of 57,000 copies/ml.
Resistance profile: NAD.
Viral hepatitis screen is negative
Syphilis screen: TPPA neg, RPR negative
Sexual health screening NAD
Initial and pharmacological management
All patients presenting with HIV later than 28/40 should be
started on ART without delay. If the viral load is unknown or
>100,000 then a four-drug regimen including an integrase in-
hibitor (eg raltegravir or dolutegravir) is suggested.
Women presenting in labour or requiring delivery without a
documented HIV result should have an immediate rapid HIV test
3 Ó 2018 Elsevier Ltd. All rights reserved.
 CASE-BASED LEARNING
and a reactive result should be acted on immediately without
delay for serological confirmation.
Women presenting with HIV at term should be given an im-
mediate stat dose of nevirapine as well as commenced on daily
ART. The initial nevirapine dose crosses the placenta within two
hours and maintains an effective concentration in the neonate for
up to ten days. It is also recommended that intravenous zidovu-
dine be infused for the duration of labour and delivery (see below).
If late presenters go into pre term labour, such that the infant
may not be able to absorb medications, double dose tenofovir for
the mother should be considered in order to pre load the baby
with PEP.
Obstetric management
As this patient’s viral load is >400 she should be counseled for a
planned caesarean section which should be performed between
38 and 39 weeks. This woman may need intensive emotional
support and counseling to come to terms with her diagnosis and
its implications regarding mode of delivery and infant feeding.
As her viral load is high, with no time to suppress it before
delivery, an intrapartum infusion of zidovudine is recommended.
Intrapartum intravenous zidovudine is recommended for all
women who have a viral load of >1000 copies/ml (or in whom
the viral load is not known) and who present with labour, with
ruptured membranes or who require a planned caesarean sec-
tion. There is no data for intrapartum zidovudine in women with
viral load <1000 copies/ml but it can be considered on a case by
base basis if the woman’s viral load is between 50 and 1000.
Case 3 continued
The woman is immediately started on four-drug ART and a
healthy baby girl is delivered at 39 þ 0 by caesarean section
(giving the maximum amount of time possible to suppress the
virus). A viral load taken on the day of delivery is 7000. The
infant is started on three-drug ART for a duration of four weeks.
The woman expresses a strong desire to breastfeed. She is
planning to stay with relatives for the immediate future and does
not wish to reveal her status. There are concerns among the MDT
that she is reluctant to give the infant PEP once at home for the
same reason.
Neonatal management
Infants less than 72 hours old, born to untreated HIV positive
women should be immediately started on three-drug ART for the
duration of four weeks. This should be within four hours of birth
if the mother’s status is known at birth. If the mother is found out
to be HIV positive after birth, infant PEP can still be given but
must be started within 72 hours of birth. The duration of infant
therapy is always four weeks.
Three-drug therapy for the infant is also recommended in all
cases where the mother does not have an undetectable viral load
at 36 weeks e regardless of whether she is on treatment or not.
Options for infant therapy can be found on the BHIVA
guidelines for HIV in pregnancy, however, advice and support
should be sought for neonatal management from a specialist
paediatrician in conjunction with the local HIV service.
Any infants with an initial positive HIV DNA/RNA test (at 48
hours post birth) should also be started on pneumocystis pneu-
monia (PCP) prophylaxis with co-trimoxazole. If the mother’s
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
Please cite this article in press as: Hamlyn E, Barber TJ, Management of HIV in pregnancy, Obstetrics, Gynaecology and Reproductive Medicine
(2018), https://doi.org/10.1016/j.ogrm.2018.06.001
viral load at 36 weeks is >1000 copies/ml then co-trimoxazole
should also be given to the infant until HIV infection has been
ruled out (even in the case of a negative initial HIV DNA/RNA
test).
The mother may need intensive support during this time, as
she may not wish to disclose her HIV status to all members of the
household or her wider family. This may be more commonly
seen in women from cultures where HIV infection remains highly
stigmatised. Support may be via the health visiting team, social
services, or an HIV specialist community nurse if available in
that area. In extreme circumstances, directly observed therapy
may be necessary.
Infant feeding
Women may feel external pressure to breastfeed as well as their
own desire to do so e again, this may be particularly relevant in
some cultures, where suspicions may be raised among relatives if
she does not breastfeed, and the mother may feel that by
agreeing to formula feed she is revealing her HIV status. She may
even feel that she is at risk of domestic violence if she does not
breastfeed. Similarly women may feel that they might be ‘outed’
because of requiring a caesarean section or needing to take
medication throughout pregnancy.
The woman should be offered intensive counseling as to the
risks involved, and also discussion about how she can be sup-
ported in her own home and helped to navigate discussions with
her relatives about not breastfeeding without revealing her sta-
tus. However, in cases such as this, where the viral load is still
not suppressed, if the women insists on breastfeeding, and/or if
there are concerns that she may not be compliant with admin-
istering the infant PEP, a referral to social services and the child
protection register may have to be considered. This could result
in the infant being temporarily placed in care so every effort by
the MDT to avoid getting to this stage must be made.
General considerations
HIV positive women should have antenatal care provided by a
multidisciplinary team, the composition of which will vary
locally but which should include an HIV specialist, an obste-
trician, a specialist midwife and pediatrician as well as com-
munity support from the GP, health visiting team and
community midwives. Social services, clinical psychologists or
psychiatrists and peer support workers should be involved as
necessary. Those services that do not have many HIV positive
pregnant women may benefit from links with nearby tertiary
centres.
There are myriad psychosocial issues that may affect out-
comes in women living HIV e especially women diagnosed in
pregnancy who may have to quickly adjust to their diagnosis as
well as to learn to trust a new team of health professionals. We
have tried to highlight some of these issues in the above cases.
A new HIV diagnosis may lead to emotional, mental health,
professional, relationship, financial, confidentiality or legal is-
sues in any person and these may all be compounded in preg-
nancy. It’s important to note that studies have shown that
intimate partner violence has a higher prevalence in pregnancy
and even higher in women living with HIV.
As such, it is essential to take a multidisciplinary team
approach to all women living with HIV who are pregnant. A
4 Ó 2018 Elsevier Ltd. All rights reserved.
 CASE-BASED LEARNING
careful social history must be taken early on in all new diagnoses
of HIV positive women, particularly those presenting in preg-
nancy. This will ensure that the woman is given access to the
most appropriate sources of support available. A
FURTHER READING
Avert.org. Prevention of Mother-To-Child Transmission (PMTCT) of
HIV. https://www.avert.org/professionals/hivprogramming/
prevention/prevention-mother-child.
British HIV Association. British HIV Association, BASHH and FSRH
guidelines for the management of the sexual and reproductive
health of people living with HIV infection 2008. HIV Med 2008; 9:
681e720.
British HIV Association. BHIVA guidelines for the management of HIV
infection in pregnant women 2012 (2014 interim review). HIV Med
2014; 15(suppl 5): 1e77.
Acknowledgements
With thanks to Professor Simon Barton.
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Please cite this article in press as: Hamlyn E, Barber TJ, Management of HIV in pregnancy, Obstetrics, Gynaecology and Reproductive Medicine
(2018), https://doi.org/10.1016/j.ogrm.2018.06.001
Practice points
C A multidisciplinary approach is essential in the management of
HIV in pregnancy
C Women who are already on ART should be advised to continue
their current regimen unless advised otherwise by an HIV
physician
C Women who are diagnosed with HIV in pregnancy should be ur-
gently referred to GUM services
C Women with a suppressed HIV viral load should be advised to opt
for a vaginal delivery notwithstanding other obstetric
complications
C Women with uncontrolled virus at term may require caesarean
section
C All infants born to mothers with HIV will need 4 weeks of post
exposure prophylaxis (the number of drugs involved will depend
on the mothers viral load)
C Current advice is that all women should be advised to exclusively
formula feed their infants from birth (it’s possible this may change
when new guidelines are published e check BHIVA website)
C Women with stable, suppressed HIV, should be supported and
monitored if they do decide to breastfeed
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