Contributor: Sharon Keiser, MD
Last Update: 5/25/2016
Background – Nearly 50,000 individuals become infected with HIV annually in the United States. The number of women with HIV giving birth in the United States increased approximately 30% from 6-7,000 in 2000 to 8,700 in 2006. Approximately 18% of all people with HIV do not know their HIV status.
If an HIV positive woman is not aware of her status and is therefore not appropriately managed during pregnancy, the risk of transmission to her unborn child (MTCT – Mother-to-child transmission) is 25%. With early testing, appropriate treatment with HAART (Highly Active Antiretroviral Therapy) and achievement of an undetectable maternal viral load, this transmission rate can be reduced to less than 2%
Screening for HIV
First prenatal visit – HIV with prenatal panel. This is an OPT-OUT TEST (per CDC Guidelines, 2006) – patients will be tested as part of the routine prenatal panel unless they opt out of testing. A separate consent form is NOT required to be signed for this test.
Screening is done with an antigen/antibody combination immunoassay that detects HIV-1 and HIV-2 antibodies, and HIV-1 p24 antigen to screen for established infection and for acute HIV-1 infection.
1. Non-reactive specimens – no further testing necessary
2. Reactive antibody/antigen combination immunoassay result – reflex confirmatory testing done
3. Specimens that are reactive initially, followed by a nonreactive confirmatory test – test with an FDA-approved HIV-1 nucleic acid test.
4. Repeat HIV testing in the 3rd trimester is recommended for women in areas with high HIV incidence or prevalence, and in women known to be at risk of acquiring HIV infection.
Management of the pregnant patient with HIV
- First prenatal visit
a. Inform the patient and her sex partner (if aware of the woman’s infection status) about risks of perinatal and sexual HIV transmission Note: A woman with HIV must explicitly grant permission to her provider to discuss her HIV infection status with her partner(s). If she does NOT grant permission, UNCHECK THE “SHARE WITH PATIENT” BOX that is associated with this in the problem list.
b. Inform women about
i. the availability of pre-exposure prophylaxis for HIV-uninfected partners during unprotected sexual intercourse
ii. the availability of post-exposure prophylaxis for HIV-uninfected partners to reduce the risk of HIV acquisition in the event of inadvertent sexual or parenteral HIV exposure in the past 72-hours
c. Advise women to urge sex partners and drug-injection partners to get HIV testing and to use condoms to prevent HIV acquisition
d. Provide education and counseling for postpartum contraception services
e. Provide education about delivery options that can reduce the risk of perinatal transmission (see #6)
f. Inform women and their partners that breastfeeding by HIV-infected women is not recommended in the United States and that formula feeding is recommended.
g. Counsel patients that no combination of therapies can guarantee that a newborn will not become infected.
h. Labs (Many of these will have already been collected by the Infectious Disease team. If so, review them)
i. Standard prenatal panel
ii. CBC w/diff, CMP, Mg PO4
iii. Lipase, GGT, G6PD level, HgbA1C
iv. PPD (no controls)
v. Hep A and C antibodies, Hep-B surface antigen
vi. Toxoplasma IgG (baseline)
vii. HIV genotype
viii. CD4 count, HIV viral load
i. Ultrasound to confirm EDC (amniocentesis is not recommended for either genetics or FLM)
2. Refer to Infectious Disease service if patient not already in their system
3. Social services consult
4. Use of antiretroviral drugs during pregnancy – The Infectious Disease physicians will start HAART and manage throughout the pregnancy. Do not start or change a regimen at any time. If questions arise about a patients HAART regimen, contact the ID physician directly.
a. The goal of ART is to maintain a viral load below the limit of detection throughout pregnancy for all women
b. Consideration should now be given to initiating combined ART (cART) as soon as HIV is diagnosed during pregnancy in light of data demonstrating an association between earlier viral suppression and lower risk of transmission.
c. Medication regimen recommendations change frequently – refer to resources below for up-to-date recommendations
d. Drug-resistance testing will be performed by ID before starting ART
5. Subsequent visits
a. If CD4 <200, give PJP (Pneumocystistic jirovecii pneumonia) prophylaxis (Bactrim DS, 1qday), if not already done – Notify ID
b. IF CD4<50 add MAI (Mycobacterium avium intracellulare) prophylaxis (Azithromycin 1200mg/day) if not already done – Notify ID
c. ID will obtain serial viral load, other labs as necessary – review these results
d. Postpartum contraception counseling
e. Growth scans q 4 weeks
f. At EACH visit – ask the patient about tolerance of medications (if they are not compliant with the medications, the likelihood for resistance increases)
6. 34-36 weeks – evaluate viral load and counsel patient:
a. Breastfeeding ALWAYS contraindicated
b. Counsel patients about infant prophylaxis with antiviral medications, to be started within 12 hours of birth to all HIV-exposed infants
c. Viral load <1000 copies/ml – no difference in vertical transmission rate between SVD and C/S
i. Await spontaneous labor up to 41 weeks (or consider IOL for controlled delivery or for other obstetric reasons)
ii. Reserve Cesarean delivery for obstetric reasons; can be done at 39 weeks in this setting.
d. Viral load >1000 copies/ml – vertical transmission rate <2% with elective C/S
i. Admit patient at 38 weeks (or with labor or ROM, if earlier)
ii. If Labor/ROM occurs before admission for delivery – counsel patients that the available data indicate no reduction in the transmission rate if C/S is performed after the onset of labor or ROM. Individualize route of delivery.
e. Viral load >1000 copies/ml, patient declines C/S – see (c) instructions for SVD
7. Intrapartum – ALL PATIENTS, REGARDLESS OF VIRAL LOAD OR MODE OF DELIVERY
i. ZDV 2mg/kg/hr IV load, then 1mg/kg/hr drip until cord clamp
ii. Ideally, patient will receive ZDV for 3 hours prior to
iii. Continue all ART meds as scheduled during labor
iv. Delay AROM; NO FSE, avoid assisted delivery
v. Notify Pediatrics
vi. Epidural anesthesia can be used safely regardless of ARV regimen
8. For women who present for pregnancy care during labor with unknown HIV status, offer expedited HIV testing (opt-out strategy)
a. If preliminary result is positive:
i. Notify the patient immediately
ii. IV Zidovudine to prevent perinatal transmission
iii. Confirmatory testing
iv. Notify Peds
b. If patient declines HIV test
i. Address reasons for declination
ii. Notify Peds of patient declination
9. Postpartum –
a. Continue ART regimen
b. Contraceptive counseling – Women living with HIV can continue to use all existing hormonal contraceptive methods without restriction. Strongly advise to also always use condoms and other HIV preventive measures
c. Schedule follow-up with ID
d. Counsel about no breastfeeding (and not donating milk to breast milk banks)
e. Advise against pre-chewing food for infants and children
f. Peds ID follow-up if not already scheduled
- The National Perinatal HIV Hotline – 888-448-8765
- NEW app for IOS and Android devices – AIDSinfo Guidelines App – provides mobile access to the federally approved HIV/AIDS medical practice treatment guidelines. Free download.
- Medication Regimens (HAART) – Refer to https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/o for recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States.
- Bradley H, Hall HI, Wolitski RJ, Van Handel MM, Stone AE, LaFlam M, et al. Vital signs: HIV diagnosis, care and treatment among persons living with HIV – United States, 2011. MMWR 2014;63:113-7
- ACOG Committee Opinion #234, May 2000, Reaffirmed 2015 – “Scheduled Cesarean Delivery and the Prevention of Vertical Transmission of HIV Infection”
- Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available at https://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf