HIV infection in pregnancy

Last reviewed: 28 Oct 2023

Last updated: 15 Jun 2023

HIV infection in pregnancy not only poses a threat to maternal immune health, but can lead to perinatal transmission of HIV in utero, intrapartum, or through breast-feeding postpartum.

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 at risk of acquiring HIV, live in an area with a high HIV prevalence, or receive care at a facility with a high HIV incidence.

HIV-exposed infants should be tested for HIV infection at birth and seek 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 prescribed continuously during the antepartum, intrapartum, and postpartum periods, as well as prophylaxis for the neonate.

Evidence-based, patient-centered counseling regarding breast-feeding and replacement feeding not recommended to inform shared decision-making.

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 with HIV is complicated not only by HIV infection itself but also by the medical and psychosocial comorbidities associated with HIV.

History and exam

Key diagnostic factors

increased risk of maternal HIV infection
increased risk of perinatal HIV transmission

More key diagnostic factors

Other diagnostic factors

oral candidiasis
increasing dyspnea
weight loss
fever
malaise
lymphadenopathy
maculopapular blanching rash

Other diagnostic factors

Risk factors

needle-sharing with injection drug use
unprotected receptive penile-vaginal intercourse
unprotected receptive anal intercourse
percutaneous needle stick
sexually transmitted infections (STIs) and bacterial vaginosis
high maternal viral load (perinatal transmission)
absence of prenatal maternal antiretroviral therapy (perinatal transmission)
breast-feeding in mothers without viral suppression (perinatal transmission)
violence against women and girls
receptive oral intercourse
insertive oral intercourse
multiple sexual partners
low maternal CD4 count (perinatal transmission)

More risk factors

Diagnostic investigations

1st investigations to order

maternal HIV-1/HIV-2 antigen/antibody enzyme-linked immunosorbent assay (ELISA)
maternal HIV-1/HIV-2 antibody differentiation immunoassay
neonatal HIV DNA or RNA polymerase chain reaction (PCR)

More 1st investigations to order

Investigations to consider

HIV-1 western blot
HIV-1 indirect immunofluorescence assay (IFA)
HIV-1 nucleic acid test (NAT)
CD4 count
plasma HIV RNA levels (viral load)
renal function tests
liver function tests (LFTs)
drug resistance tests
complete blood count
glucose screening
fetal ultrasound
tests for coinfections

More investigations to consider

Treatment algorithm

ACUTE

HIV-1-infected pregnant women: <38 weeks not in labor (regardless of HIV RNA level)

HIV-1-infected pregnant women with HIV-1 RNA levels >1000 copies/mL: at 38 weeks or in labor

HIV-1-infected pregnant women with HIV-1 RNA levels ≤1000 copies/mL: at 38 weeks or in labor

infants born to HIV-infected mothers

Contributors

Authors

Rachel K. Scott, 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

MedStar Washington Hospital Center Department of Women’s and Infants’ Services

Washington

Disclosures

RKS declares that she is an investigator on ViiV and Gilead Investigator Sponsored Research Awards managed 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

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

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.

Differentials
- Infectious mononucleosis
- Toxoplasmosis
- Viral hepatitis
More Differentials
Guidelines
- Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States
- Sexually transmitted infections treatment guidelines
More Guidelines
Patient leaflets
HIV infection in pregnancy
More Patient leaflets
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HIV infection in pregnancy

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

HIV-1-infected pregnant women: <38 weeks not in labor (regardless of HIV RNA level)

HIV-1-infected pregnant women with HIV-1 RNA levels >1000 copies/mL: at 38 weeks or in labor

HIV-1-infected pregnant women with HIV-1 RNA levels ≤1000 copies/mL: at 38 weeks or in labor

infants born to HIV-infected mothers

Contributors

Authors

Rachel K. Scott, MD, MPH, FACOG

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Aisha Sethi, MD

Disclosures

Graham P. Taylor, MBChB, FRCP, FHEA

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

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