HIV in Pregnancy

Background

• In 2017, there were 18.2 million women and 1.8 million children living with HIV worldwide.
• Mother-to-child transmission (MTCT) accounts for > 90% of HIV infection in children.
• Starting antiretroviral therapy early in pregnancy is associated with decreased viral loads at time of delivery.

Evaluation

• Screen all pregnant patients for HIV infection, regardless of the risk (Strong recommendation).
• Test as soon as possible, and repeat testing in the third trimester for patients at high risk (Strong recommendation).
• For patients diagnosed with HIV infection during pregnancy, perform a thorough evaluation that includes:
  • a complete medical history
    • context of HIV diagnosis
    • prior HIV-related illness, past CD4 T cell count, and past plasma RNA level
    • any prior treatment with antiretroviral therapy (ART) including pre- or postexposure prophylaxis (PEP or PrEP) and past adherence to regimen
    • other medications and potential teratogens
    • psychosocial history, including tobacco, alcohol, and other substance use
  • a complete physical exam, including cervical cancer screening
  • a laboratory evaluation including
    • complete blood count, kidney function, and liver panel
    • HIV antibody test to confirm diagnosis, if results of screening testing are not available
    • CD4 T-cell count and HIV plasma RNA levels (viral load)
    • HIV genotypic resistance testing
    • testing for HLA-B*5701 in patients for whom abacavir is being considered
  • ultrasound for gestational age according to current obstetric guidelines
• Discuss key intrapartum and postpartum considerations, including ART use and adherence both during and after pregnancy, mode of delivery, infant feeding, and prevention of secondary transmission to infant and sex partner (Strong recommendation). Assess support systems.

Management

• Before pregnancy (or at time of diagnosis during pregnancy):
  • Start antiretroviral therapy for all pregnant patients with HIV infection regardless of CD4 T-cell count or viral load (Strong recommendation).
    • Use the same regimens recommended for treatment of nonpregnant adults, unless the known adverse effects for women, fetuses, or infants outweigh the benefits (Strong recommendation).
    • The preferred regimen in the United States consists of 2 nucleoside reverse transcriptase inhibitor (NRTI) backbone plus protease inhibitor (PI) or integrase inhibitor.
    • For pregnant patients receiving and tolerating a regimen that is suppressing viral replication, continue that regimen in most cases (Strong recommendation).
  • Use the same criteria for prophylaxis against opportunistic infection as in nonpregnant adults, noting potential changes in pharmacodynamics and side effect profiles when selecting prophylactic medications.
• During pregnancy:
  • Monitor HIV viral load at first visit (Strong recommendation), 2-4 weeks after starting or changing therapy, monthly until viral load is undetectable, and then at least every 3 months (Weak recommendation).
  • Monitor CD4 T-cell count at first visit (Strong recommendation), with additional measurements every 3-6 months for patients on ART < 2 years, patients with CD4 T cell counts < 300 cells/mcL, or patients with inconsistent adherence and/or detectable loads (Weak recommendation).
  • Screen for diabetes with standard glucose screening at 24-28 weeks gestation (Strong recommendation), with earlier glucose screening suggested by some experts in patients having ongoing protease inhibitor-based regimens initiated before pregnancy (Weak recommendation).
  • Administer recommended vaccines:
    • Provide Tdap vaccination between 27 and 36 weeks and inactivated influenza vaccine (IIV) during influenza season.
    • Offer pneumococcal polysaccharide vaccine (PPSV23), hepatitis B, hepatitis A, and meningococcal vaccination for women with specific risk factors.
    • Avoid live virus vaccines such as measles, mumps, and rubella (MMR) and varicella zoster vaccination.
  • Recommend a cesarean delivery at 38 weeks gestation for patients with viral loads > 1,000 copies/mL or unknown viral loads near time of delivery (Strong recommendation).
• During labor and delivery:
  • Continue the same antiretroviral regimen to the extent that it is tolerated (Strong recommendation).
  • For patients with HIV viral loads > 1,000 copies/mL, start zidovudine 2 mg/kg IV over 1 hour at labor onset and then 1 mg/kg/hour IV until delivery (Strong recommendation).
  • For patients with HIV infection receiving combination antiretroviral regimen consistently during pregnancy and HIV RNA ≤ 1,000 copies/mL near delivery, intrapartum zidovudine is not required (Weak recommendation).
  • Artificial rupture of membranes can be performed for standard obstetric indications in the setting of antiretroviral therapy and virologic suppression, as there is no association with increased risk of perinatal transmission (Weak recommendation).
  • Avoid invasive labor procedures, such as an artificial rupture of membranes in the setting of viremia, the use of fetal scalp electrodes, and the use of forceps or vacuum extractor when feasible to minimize fetal exposure to bodily fluids, unless the benefit outweighs the risk (Weak recommendation).
• Following delivery:
  • Give antiretroviral prophylaxis to all HIV-exposed infants to reduce perinatal transmission (Strong recommendation).
  • Recommend against breastfeeding in the United States due to the availability of safe alternatives (Strong recommendation).
  • Discuss family planning and make arrangements for support services and follow-up care for the mother and infant prior to hospital discharge (Strong recommendation).