REVIEW
Management of HIV in
pregnancy
Shereen Munatsi
Elizabeth Marie Carlin
Abstract
HIV management in pregnancy aims to optimise the health of the
mother and reduce the risk of HIV transmission to the infant. Early
diagnosis of maternal HIV infection, the use of combination antiretro-
viral therapy (ART) for the mother, and post exposure prophylaxis
(PEP) for the infant are key and reduce the transmission risk to
<1%. A multidisciplinary team holistic approach with strong collabora-
tion between specialist HIV, obstetric and maternity services is
important.
Keywords antiretroviral therapy; breastfeeding; HIV; pregnancy
Introduction
The aim of good HIV management in pregnancy is to optimise the
health of the mother and to reduce the risk of vertical trans-
mission of HIV to the infant.
In the early 1990s, in the UK, the number of children (<16
years) diagnosed with HIV infection via vertical transmission
was approximately 70 per year and the rate of vertical HIV
transmission amongst those diagnosed was around 25%.
One of the main problems at this time was that only a third of
pregnant women with HIV were aware of their status before they
became pregnant. In 2000, universal antenatal HIV screening
was introduced in England and by 2002, this was implemented
throughout the UK. Since 2011, the uptake of HIV antenatal
screening is over 97%.
Now that women are tested for HIV in early pregnancy, and
are able to start effective treatment while pregnant, the HIV
vertical transmission rate has reduced from >25% to <1% in
those that have received at least 14 days of antiretroviral therapy.
Antenatal screening and treatment, along with other in-
terventions described in this article, has reduced the number of
vertical transmissions in women living with HIV (WLWH) in the
UK to fewer than 5 per year. Two thirds of the children diagnosed
with HIV in the UK were born outside the UK.
Psychosocial factors
HIV is associated with a higher risk of poor mental health, and
depression amongst WLWH can be as high as 30%. This is before
Shereen Munatsi BMedSci BM BS DFSRH Dip GUM Dip HIV MRCP Integrated
Sexual Health Service, Nottingham University Hospitals NHS Trust,
Nottingham, UK. Conflicts of interest: none declared.
Elizabeth Marie Carlin MB ChB DFSRH FRCP Integrated Sexual Health
Service, Nottingham University Hospitals NHS Trust, Nottingham,
UK. Conflicts of interest: none declared.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 31:8
the addition of other factors such as pregnancy. Postnatal
depression in WLWH, in high income settings, has been reported
at 30e53%, and factors contributing to this include HIV-
associated stigma, intimate partner violence, financial issues,
immigration and housing concerns, substance misuse and trans/
non-binary discrimination.
Therefore, the British HIV Association (BHIVA) recommends
that an assessment for antenatal and postnatal depression should
be undertaken at the booking visit, fouresix weeks postpartum
and threeefour months postpartum.
All discussions should take account of social and cultural
factors, which can vary and can be particularly important in
relation to confidentiality and infant feeding.
Reassurance about confidentiality, especially regarding
friends and family, who are unaware of the woman’s HIV status
but are involved with the pregnancy is essential.
Multidisciplinary approach
A multidisciplinary team (MDT) approach to management is
important, as a high proportion of women have other comor-
bidities and/or challenging social circumstances. The team
members should include, as a minimum, an obstetrician, a HIV
physician, a paediatrician and a HIV specialist midwife. Other
members may include the woman’s GP and health visitor, a
specialist pharmacist, a sexual health advisor and a HIV/paedi-
atric clinical nurse specialist.
Access to counselling services, particularly to help those
newly diagnosed with HIV to come to terms with their HIV
diagnosis, and to encourage engagement with healthcare, is
important as is access to social workers.
Screening and monitoring
Sexual health
All pregnant women should be offered screened for syphilis and
hepatitis B, along with HIV as part of their booking bloods.
Checking for genital infections, including sexually transmitted
infections (STIs) and bacterial vaginosis, is not routine in the
general antenatal population. However, it is recommended for all
WLWH who are pregnant, as early as possible in the pregnancy,
and should be considered again at 28 weeks’ gestation. This is
because HIV transmission may be higher in the presence of genital
infection. This may be due to raised levels of HIV virus in genital
secretions, the development of chorioamnionitis, or because some
infections are implicated as potential causes of premature delivery.
The likelihood, if any, of vertical transmission of HIV from
WLWH with a fully suppressed HIV viral load, who also has a
genital infection is unclear.
Ulcerative genital diseases are associated with an increase in
HIV sexual transmission. The position is inconclusive though
with respect to genital herpes simplex virus (HSV) and vertical
transmission. There may be a greater risk of HSV shedding in
WLWH but the outcomes in respect of vertical HSV and HIV
transmission are less clear.
The guidance given by the British Association for Sexual
Health and HIV (BASHH)/Royal College of Obstetrics and Gy-
naecology (RCOG) is that WLWH, who have a history of genital
HSV, should be offered Aciclovir suppression therapy at a dose of
400 mg three times daily from 36 weeks’ gestation. The BHIVA
215 Crown Copyright Ó 2021 Published by Elsevier Ltd. All rights reserved.
 REVIEW
guidelines recommend an earlier start of Aciclovir suppression
therapy at 32 weeks’ gestation.
Cervical cytology
Routine cervical cytology should be deferred until three months
post-partum.
Abnormal cervical cytology and colposcopy should be
managed as detailed in the current national guidelines and the
NHS Cervical Screening Programme.
HIV specific bloods
CD4 count: the CD4 cells play an important role in the immune
system. They are the body’s natural defence system against
pathogens, infections and illnesses. The CD4 count gives an
indication of the health of a person’s immune system.
In people without HIV infection, the CD4 count is usually
between 500e1500 x 106/L. People living with HIV (PLWH) with
a CD4 count
500 x 106/L are usually in good health, whilst
those with a CD4 count <200 x 106/L, are at high risk of
developing opportunistic infections. As a general principle, the
higher the CD4 count the better the immune system.
Whether a woman conceives on antiretroviral therapy (ART)
or whether she starts ART during pregnancy, as a minimum, a
CD4 count should be taken at the start of the pregnancy and
again at delivery.
HIV viral load: the HIV viral load indicates the ‘amount’ of HIV
that is detectable in the blood and measures how ‘active’ the
virus is.
The viral load is reported as below detection if the value is too
low for the assay to measure. The ‘cut off’ point differs between
assays but is usually below 20 or 40 copies/ml. The aim of HIV
treatment is to achieve a viral load below detection, also known
as undetectable.
A detectable viral load is reported as an absolute numerical
value. The higher the number, the higher the risk of transmission
to others, including vertically, and the greater the risk of the HIV
virus attacking the body’s immune system.
Once the viral load is undetectable and a person is adherent with
effective ART, the virus cannot be sexually transmitted to another
person. This is known as U]U or Undetectable ¼ Untransmissable.
This is not extrapolated to vertical transmission.
If a woman is already on ART and has an undetectable HIV
viral load, then a viral load should be taken at least once every
trimester, at 36 weeks and at delivery.
If a woman is newly diagnosed HIV positive, or starts ART in
pregnancy, a viral load is taken at the start of the pregnancy, two
efour weeks after commencing ART, at least once every
trimester, at 36 weeks and at delivery.
Resistance testing: HIV resistance testing is a blood test that is used
to determine whether the HIV virus has mutated to a different form
that would not respond to specific antiretroviral drugs.
If drug resistance is present and a drug that the virus is resistant to
is started, or continued, then the HIV virus is able to multiply faster,
because the drug cannot stop it from replicating. If the resistant virus
makes enough copies of itself, it may eventually become the domi-
nant type of HIV in the body. Once this happens, the drug is inef-
fective, and the individual will be resistant to that medication.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 31:8
In a non-pregnant person, HIV resistance testing is done at
diagnosis and whenever the viral load rises to check for viral
susceptibility and possible treatment failure.
In pregnancy, resistance testing should be performed and the
results checked prior to the initiation of ART. This is to ensure
that an effective regime is chosen and this should work if taken
as prescribed. An exception to this is in late presenting women
(i.e after 28 weeks) where an ART regime needs to be started as
soon as possible aiming to achieve an undetectable viral load by
the time of delivery. The ART regime may need to be modified
once the resistance test becomes available.
HIV management
ART in pregnancy
It has been shown that it is beneficial to start treatment before
any significant damage occurs to the immune system. Therefore,
it is now recommended that all PLWH are commenced on
effective ART irrespective of the CD4 count.
In an ideal situation, a woman would know her HIV status
and plan the pregnancy with her HIV physician. She could then
be fully counselled on conceiving, take appropriate prenatal
supplements and take an effective ART regime that is not con-
traindicated in pregnancy.
There is a lack of evidence for the use of ART in pregnancy,
except for the use of Zidovudine in the third trimester. However,
over the years, data have been collected on the Antiretroviral
Pregnancy Registry, so there is evidence of longer term safety
data in pregnancy for some medications.
The choice of ART is based on a number of factors:
a) The woman - lifestyle, concerns, comorbidities
b) Knowledge - guidelines, evidence, safety
c) Results - CD4 count, HIV viral load, resistance profile
d) Previous ART regimes
e) Others - availability of specific ART
Most decisions regarding ART choice are discussed in an ART
MDT to identify the best possible regime, with the fewest side
effects, that is most likely to be tolerated and adhered to, as
compliance with ART is essential.
A combination of antiretroviral drugs should be used, how-
ever there are some tablets, which contain multiple drugs in a
single tablet, so these may be used depending on the clinical
situation and the viral resistance profile.
If ART is started before conception but the woman wishes to
have children in the near future then ideally an ART regime
should be chosen that is simple to take, safe to conceive on and
could be used throughout the pregnancy, so she would not have
to change treatment.
Co-infection with hepatitis B or hepatitis C, makes manage-
ment of HIV infection more complicated and will influence the
choice of ART. In this situation, involvement of a hepatologist in
the MDT is advised.
Given the diverse factors in choosing a suitable ART regime,
not all WLWH are prescribed the same medication during their
pregnancy and any initiation or changes need to be made in
conjunction with their HIV physician.
Specific details of ART regimes used in pregnancy are given in
the BHIVA Guidelines for the Management of HIV in Pregnancy
and Postpartum.
216 Crown Copyright Ó 2021 Published by Elsevier Ltd. All rights reserved.
 REVIEW
If a woman is on effective ART at conception, this should be
continued throughout her pregnancy and continued after de-
livery. The exception is where the regime contains a component
that is not advised in pregnancy so specialist HIV advice should
be sought.
All pregnant women not on ART (newly diagnosed HIV pos-
itive or have chosen not to start prior to pregnancy) should
commence ART and continue this after delivery.
When to start ART:
1) As soon as they are able to in the SECOND TRIMESTER
where the baseline viral load is 30,000 copies/ml
2) As soon as possible in the SECOND TRIMESTER where the
baseline viral load is 30,000e100,000 copies/ml
3) Within the FIRST TRIMESTER if the viral load is >100,000
copies/ml and/or CD4 count <200 x 106/L
4) ALL women should have commenced ART by WEEK 24 of
pregnancy
In a woman with a history of preterm delivery, there may be a
need to start ART as soon as possible aiming to ensure the viral
load is undetectable prior to delivery.
Women should be advised to continue with ART after delivery
but if the woman chooses to discontinue her treatment after
delivery, this should be done in discussion with her HIV physi-
cian, and a further resistance test should be taken to ensure that
no mutations are missed during the ‘off treatment’ period.
Late presenters
If a woman presents late i.e. after 28 weeks’ gestation, it is
essential to start ART immediately, without the result of the viral
resistance test or even a viral load result. With the ART medi-
cation now available, it is still possible for a woman who pre-
sents at 28 weeks to become undetectable by 36 weeks and plan
for a possible vaginal delivery. In order to maximize the chances
of this, a three to four drug regime, including an Integrase In-
hibitor, is likely to be used, with the Integrase Inhibitor being
particularly effective at reducing the viral load quickly.
Presenting in labour
Term: if an untreated woman presents in labour, or an untreated
woman has a spontaneous rupture of membranes (SROM) at
term, antiretroviral drugs for the woman and the infant will need
to be obtained and given as soon as possible.
The woman is likely to be given the following;
1) A stat oral dose of Nevirapine 200 mg (this rapidly crosses
the placenta and, within two hours, achieves and then
maintains effective concentrations in the neonate for up to
10 days)
2) Oral Zidovudine 300 mg twice daily and Lamivudine 150 mg
twice daily
3) Oral Raltegravir 400 mg twice daily (rapidly crosses the
placenta)
4) Intravenous (IV) Zidovudine for the duration of labour and
delivery (loading dose of two mg/kg for one hour and then
maintain with one mg/kg per hour until the cord is clamped)
If the delivery is not imminent, then a caesarean section (CS)
should be considered.
Preterm: if in preterm labour, a double dose of oral Tenofovir
Disoproxil Fumarate (DF) 490 mg, rather than the standard
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 31:8
245 mg dose, may be added to the above regime. This crosses the
placenta rapidly and can quickly pre-load the infant so is
particularly useful where the level of prematurity is such that the
infant will be unable to take oral post exposure prophylaxis
(PEP) for the first few days of life.
No documented HIV test: if presenting in labour or SROM without
a documented HIV test, then an urgent HIV test is needed, provided
the woman is able and willing to consent to this. This could be a
HIV Point of Care Test (POCT), although a confirmatory laboratory
test should also be sent at the same time. A reactive or positive
POCT must be acted upon immediately. Specialist HIV advice
should be sought and interventions to reduce the risk of vertical
HIV transmission should be initiated without delay and without
waiting for laboratory serological confirmation.
Obstetric management
Antenatal
The antenatal management of a WLWH is similar to their HIV
negative peers, except for a few caveats, which are described below.
BHIVA, NICE and the NHS Fetal Anomaly Screening Pro-
gramme recommend that fetal ultrasound should be performed
as per national guidelines, regardless of HIV status.
NICE also recommends that women with HIV should be
offered combined screening for fetal aneuploidies and non-
invasive prenatal testing (NIPT) for those whose screen iden-
tifies high risk, as these tests have the best sensitivity and
specificity and should minimize the number of women who need
invasive testing.
Where invasive testing is required, this should be offered, but
ideally the HIV status of the woman should be known. Where
this is positive, if possible, invasive testing should be deferred
until the HIV viral load is undetectable. If it is not possible to
defer then HIV specialist advice should be sought. Immediate
initiation of ART will be required, usually including an Integrase
Inhibitor to reduce the viral load rapidly. A single dose of Ne-
virapine may also be recommended two to four hours before the
procedure.
There is no evidence to suggest external cephalic version (ECV)
increases the risk of vertical transmission of HIV, therefore, ECV for
a breech presentation can be offered from 37 weeks’ gestation, if a
woman’s HIV viral load is <50 copies/mL. In nulliparous women,
ECV can be offered from 36 weeks’ gestation.
Infants born to women with HIV need PEP within four hours
of birth so WLWH should be advised antenatally to plan to
deliver in a facility that has on-site obstetric and paediatric care.
It is a good opportunity to discuss plans during the antenatal
period for contraception after the infant is born so that this can
be initiated in a timely way.
Mode of delivery at term
Options with regards to the mode of delivery of the infant are usually
based on the viral load results taken at 36 weeks’ gestation.
Viral load <50 copies/mL at 36 weeks: if there are no obstetric
complications, a normal vaginal delivery is advised. Obstetric
management should follow the same guidelines as for HIV
negative women.
217 Crown Copyright Ó 2021 Published by Elsevier Ltd. All rights reserved.
 REVIEW
The exception to this is the duration of the ruptured membranes,
where delivery should occur within 24 hours of SROM. If this is a pre-
labour SROM in a WLWH, immediate induction or augmentation of
labour is recommended, with a low threshold for treatment of
intrapartum pyrexia. This is due to a number of studies that have
reported an increased risk of vertical HIV transmission if there is a
prolonged duration of ruptured membrane.
Viral load 50e399 copies/ml at 36 weeks: if the viral load at
36 weeks is between 50 and 399 copies/ml, planned CS should be
considered, but the actual viral load, it’s trajectory, the length of
time on treatment, the woman’s adherence and her views should
be taken into account. A vaginal delivery may be considered.
Discussion at an MDT is recommended. This is also the case for a
pre-labour SROM.
Viral load
400 copies at 36 weeks: if the viral load at 36 weeks
is
400 copies/mL, then an elective CS is recommended. If this is
solely to reduce the risk of vertical HIV transmission, this should
be between 38 and 39 weeks’ gestation, with consideration of the
use of maternal corticosteroid administration. If an elective CS is
indicated for obstetric reasons and not because of the HIV infec-
tion, then the timing should be directed by the obstetric indication.
If a woman has a SROM with a viral load >400 copies/ml,
then an immediate CS is recommended.
Another consideration to minimize vertical transmission in
women who have a detectable viral load, is the addition of an intra-
partum IV Zidovudine infusion, irrespective of the mode of delivery.
Mode of delivery preterm - SROM
If SROM occurs after 34 weeks’ gestation, then the management
of the SROM is the same as that of term SROMs. However,
women between 34 and 37 weeks’ gestation, will require group B
Streptococcus prophylaxis in line with national guidance.
It is more complicated if SROM occurs in a woman who is
<34 weeks’ gestation. There are a few other factors to consider:
1) An MDT should occur to discuss the timing and mode of
delivery
2) ART medication needs to be optimised if the viral load is not
undetectable
3) PEP for the neonate is problematic. An early preterm infant
would not be able to tolerate oral therapy, so loading the in-
fant via the trans-placental route by adding to the mother’s
current regime is a good option. This may include Nevirapine
as a stat oral dose at least two hours prior to delivery, but
double dose Tenofovir DF and Raltegravir may also be added.
Fetal monitoring
Fetal monitoring should be performed as per national guidelines
and HIV is not an indication for continuous monitoring.
It is unlikely that fetal blood sampling or fetal scalp electrodes
for continuous monitoring will increase the risk of vertical
transmission in a woman with an undetectable HIV viral load,
although this has not been confirmed on current evidence.
Neonatal antiretroviral management
Following the delivery of the infant, PEP should be started as
soon as possible and within four hours of birth.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 31:8
The neonatologist/paediatrician will usually have seen the
woman during her antenatal journey and will have looked at the
risk factors that could contribute to vertical HIV transmission.
The infant is stratified into ‘Very low risk’, ‘Low risk’ and
‘High risk’ based on a number of criteria. This determines both
the duration and the number of antiretroviral drugs that need to
be given to the infant.
Very low risk
1) If the mother has been on ART for more than 10 weeks
AND
2) She has had two documented HIV Viral loads <50 copies/mL
during pregnancy at least four weeks apart
AND
3) Maternal viral load is <50 copies/mL at 36 weeks’ gestation
Provided all three criteria are met, then the infant is deemed
‘very low risk’ and two weeks of Zidovudine monotherapy is
advised after delivery.
Low risk
1) If all of the ‘very low risk’ criteria are not met but the
maternal viral load is <50 copies/mL at/after 36 weeks
2) If the infant is born prematurely (<34 weeks) but the
maternal viral load is <50 copies/mL
In this situation, four weeks of Zidovudine monotherapy is
advised post delivery.
High risk
Four weeks of an ART combination is advised in those infants
where the maternal birth viral load is unknown or likely to be
>50 copies/mL, or if there is any uncertainty around maternal
ART adherence.
This is likely to be a combination of Zidovudine, Lamivudine
and Nevirapine, but this may be altered in exceptional circum-
stances, such as multi-drug resistance and after specialist advice.
Premature babies
Intravenous Zidovudine is used for very premature babies until
enteral feeding is established. These babies are at risk of
necrotising enterocolitis if enteral feeding is started too early or
increased too quickly. It is not known if very early enteral
Zidovudine can increase this risk. Similarly, intravenous Zido-
vudine is also used for sick or premature babies who are not able
to take oral medication.
Reduced oral and intravenous dosing schedules should be
used.
Infant feeding
Breastfeeding of infants can be a controversial topic irrespective
of HIV status. The pressure faced by expectant mothers from
professionals, culturally and family and friends may be difficult
to deal with.
It is particularly challenging for WLWH who are trying to keep
their HIV status confidential and trying to prevent HIV trans-
mission to the infant.
Prior to the development of effective ART, vertical trans-
mission through breastfeeding was 30e35%. With the use of
ART this has been reduced to 0e3%.
Factors that increase HIV transmission via breast milk include:
218 Crown Copyright Ó 2021 Published by Elsevier Ltd. All rights reserved.
 REVIEW
1) The mother not being on effective ART, or not adhering to
treatment, and having a detectable viral load
2) Advanced HIV infection in the mother
3) Longer duration of breastfeeding
4) Breast and nipple inflammation
5) Infant mouth or gut infection/inflammation
6) Mixed feeding, especially solid food given to infants under
two months old
In the UK and other high income settings, the safest way to
feed infants born to WLWH is with formula milk. These countries
have easy access to clean water, formula milk and bottles. Using
formula feeding the risk of HIV transmission is eliminated and so
is recommended in high income settings.
WLWH who formula feed should be offered one mg Caber-
goline on day one postpartum to inhibit lactation.
The current WHO guidance is aimed at women from low and
middle income countries, where access to clean water is not al-
ways possible, access to formula milk is not always affordable,
and there is a high risk of infant morbidity and mortality from
diarrhoea, pneumonia and other infections. In these situations,
breastfeeding is advised and the mother should adhere to ART.
Breastfeeding should be exclusive for the first six months,
following which other foods may be added, and should continue
up to 12e24 months until other safe food is available.
Some WLWH prefer to breastfeed for a mixture of reasons
including financial, emotional, psychological, cultural or social.
Discussion during the pregnancy and peer support may be
helpful to understand the reasons and address concerns.
If a woman does choose to breastfeed, she should be supported to
do this, but in the safest possible way, and a number of criteria should
be met, including an undetectable viral load, particularly during the
last trimester, good adherence, good engagement with healthcare,
and be prepared to attend monthly for a review and blood tests for
themselves and their infant during and for two months after stopping
breastfeeding. They should also be advised to exclusively breastfeed
and for as short a time as possible (maximum six months), to stop
breastfeeding immediately if they develop a breast infection/mastitis
or if their infant has gastro-intestinal symptoms, and about possible
breastfeeding complications and their management.
Whilst a supportive approach should be taken, WLWH who
breastfeed with a known detectable HIV viral load should be
referred to social care as this places their infant at significant risk
of HIV infection.
Infant testing
After delivery, the care of the infant is delivered by the neonatal/
paediatric team.
HIV testing is performed on the infant to check whether ver-
tical transmission has occurred. The tests are all HIV molecular
tests (PCR) except for the final HIV test at 22e24 months, which
should be a HIV antibody test. The timings are:
1. During the first 48 hours and prior to hospital discharge
2. At six weeks (or at least two weeks after cessation of infant PEP)
3. At 12 weeks (or at least 8 weeks after cessation of infant PEP)
4. At 22e24 months.
If a woman has chosen to breastfeed her infant, the testing
schedule for the infant changes slightly. Again these are all HIV
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 31:8
molecular tests (PCR) except for the final HIV test at 22
e24 months, which should be a HIV antibody test:
1. During the first 48 hours and prior to hospital discharge
2. At two weeks of age
3. Monthly for the duration of breastfeeding
4. At four weeks after the cessation of breast feeding
5. At eight weeks after the cessation of breastfeeding
6. At 22e24 months of age (or eight weeks after stopping
breastfeeding if this is later)
If the infant tests HIV positive, they need to be referred to a
specialist unit that has experience in managing HIV in children
and should start oral Cotrimoxazole after 4 weeks of age.
Summary
The management of HIV in pregnancy is complex and ideally
care should be delivered by a specialised MDT working together
to protect the health of both mother and infant. A
FURTHER READING
British Association for Sexual Health and HIV. Standards for the
management of STIs. April 2019, https://www.bashh.org/about-
bashh/publications/standards-for-the-management-of-stis/
(accessed 26 March 2021).
British HIV Association guidelines for the management of HIV in preg-
nancy and postpartum 2018 (2020 third interim update), https://
www.bhiva.org/file/5f1aab1ab9aba/BHIVA-Pregnancy-guidelines-
2020-3rd-interim-update.pdf (accessed 26 March 2021).
NHSCSP Publication number 20. NHS cervical screening programme:
Colposcopy and Programme management. 3rd Edition. March
2016, https://www.bsccp.org.uk/assets/file/uploads/resources/
NHS_Cervical_Screeing_Programme._Publication_Number_20_-_
Third_Edition.pdf (accessed 26 March 2021).
NICE guideline 25. Guideline for the management of preterm labour
and birth. 2015 (updated 02 August 2019), https://www.nice.org.
uk/guidance/ng25/chapter/recommendations (accessed 26 March
2021).
The National Surveillance of Hv in Pregnancy and childhood (NSHPC).
National surveillance of HIV in pregnancy and childhood - UCL -
University College London https://www.ucl.ac.uk/integrated-
screening-outcomes-surveillance/(accessed 26 March 2021).
Practice points
C Early diagnosis of maternal HIV infection is important. Offer and
encourage HIV testing at booking. If a woman declines, offer
testing throughout the rest of her pregnancy
C WLWH should be managed during their pregnancy by a multidis-
ciplinary team (MDT) that includes an obstetrician, a HIV physician
and a paediatrician as a minimum
C Combination antiretroviral therapy (ART) aims to improve the
health of the woman and reduce the risk of vertical HIV trans-
mission to her infant
C With effective ART, if the HIV viral load is <40 copies/ml, a vaginal
delivery can be recommended
C Breastfeeding is not recommended in the UK but is in resource
poor settings
219 Crown Copyright Ó 2021 Published by Elsevier Ltd. All rights reserved.