HIV infection in pregnancy

Last reviewed: April 2018

Last updated: December 2017

Summary

All pregnant women should be tested for HIV infection as early as possible in pregnancy. Third trimester screening is recommended in high-risk patients, high incidence and prevalence communities, and in medical centers with a screen-positive rate of greater than 1 per 1,000.

HIV-1/HIV-2 antigen/antibody combination immunoassay is the preferred HIV screening test. It can be performed on blood or on oral fluid in the laboratory or as a rapid test. If the immunoassay is reactive, it must be followed by confirmatory testing with an HIV-1/HIV-2 antibody differentiation immunoassay.

A negative test does not preclude diagnosis, as antibody tests cannot exclude recent infection. Repeat testing 6 weeks after exposure is recommended.

Combination antiretroviral therapy (cART) should be initiated as early as possible in the pregnancy, or continued in women already on cART, to prevent mother-to-child transmission (MTCT) of HIV.

Scheduled cesarean delivery with zidovudine (AZT, ZDV) prophylaxis at 38 weeks’ gestation is recommended for women with HIV RNA levels >1000 copies/mL, and women with unknown viral load, for prevention of MTCT.

Breastfeeding is not recommended in resource-rich settings, secondary to the risk of MTCT of HIV through breast milk. Exclusive breastfeeding with maternal cART until 12 months is recommended in settings where bottle feeding is not feasible.

Definition

Human immunodeficiency virus (HIV) is a retrovirus that causes HIV by infecting CD4 T cells and can lead to acquired immunodeficiency syndrome (AIDS). [1] Pregnancy in women living with HIV is complicated not only by HIV infection itself but also by the medical and psychosocial comorbidities associated with HIV. HIV infection in pregnancy poses a threat to maternal immune health and can lead to perinatal transmission of HIV in utero, intrapartum, or through breastfeeding postpartum.

History and exam

Key diagnostic factors

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

Full details

Other diagnostic factors

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

Full details

Risk factors

needle-sharing with intravenous drug use
receptive penile-vaginal intercourse
unprotected receptive anal intercourse
percutaneous needle stick
sexually transmitted infections and bacterial vaginosis
high maternal viral load (perinatal transmission)
absence of prenatal maternal antiretroviral therapy (perinatal transmission)
breastfeeding (perinatal transmission)
violence against women and girls
receptive oral intercourse
insertive oral intercourse
hx multiple sexual partners
low maternal CD4 count (perinatal transmission)

Full details

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
HIV DNA and RNA PCR: neonatal

Full details

Investigations to consider

HIV-1 Western blot
HIV-1 indirect immunofluorescence assay (IFA)
HIV-1 nucleic acid test (NAT)
CD4 count
plasma viral load
renal function tests
liver function tests
tuberculin skin test
viral hepatitis
tests for STDs
drug resistance test (genotyping)
CBC

Full details

Treatment algorithm

ACUTE

HIV-1-infected pregnant women: <38 weeks not in labor (regardless of 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 VIEW ALL 

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

Director

MedStar WHC Women's Center for Positive Living

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

Washington

Disclosures

RKS declares that she has no competing interests.

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 monograph. ID, CB, and MK declare that they have no competing interests.

Peer reviewers VIEW ALL 

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.

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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 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 VIEW ALL 

Rachel K. Scott, MD, MPH, FACOG

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Aisha Sethi, MD

Disclosures

Graham P. Taylor, MBChB, FRCP, FHEA

Disclosures

Differentials

Guidelines

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