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 administered during the antepartum, intrapartum, and postpartum periods, as well as prophylaxis for the neonate.
Breast-feeding is not recommended in resource-rich settings unless replacement feeding is not possible or feasible.
Human immunodeficiency virus (HIV) is a retrovirus that causes HIV infection by infecting CD4 T cells and can lead to acquired immunodeficiency syndrome (AIDS). 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
Other diagnostic factors
- oral candidiasis
- increasing dyspnea
- weight loss
- maculopapular blanching rash
- needle-sharing with injection drug use
- 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 (perinatal transmission)
- violence against women and girls
- receptive oral intercourse
- insertive oral intercourse
- multiple sexual partners
- low maternal CD4 count (perinatal transmission)
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)
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 test (genotyping)
- complete blood count
- glucose screening
- fetal ultrasound
- tests for coinfections
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
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 and Director
Women's Center for Positive Living
MedStar Washington Hospital Center Department of Women’s and Infants’ Services
RKS declares that she is an investigator on ViiV and Gilead Investigator Sponsored Research Awards managed through MedStar Health Research Institute.
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.
ID, CB, and MK declare that they have no competing interests.
Aisha Sethi, MD
Assistant Professor of Medicine
Associate Residency Program Director
University of Chicago
AS declares that she has no competing interests.
Graham P. Taylor, MBChB, FRCP, FHEA
Reader in Communicable Diseases
Faculty of Medicine
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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