HIV in Pregnancy

Key Points HIV in Pregnancy

 HIV is a lentivirus (retrovirus)

 Primarily infects CD4+ T-helper cells
 UK prevalence around 2 per 1000 live births (3.5 per 1000 in london and 0.7 per 1000
in rest of England)
 Rate of HIV Mother to child transmission was 25% in 1993. With retroviral therapy and
appropriate care rate had decreased to 1.2% by 2006
 Use of combined antiretroviral therapy (cART) can reduce vertical transmission rate to
<1%
 HIV can be transmitted via breastfeeding so breastfeeding should be avoided regardless
of viral load.

Management HIV during labour

Deciding Mode of delivery in women taking cART

 Viral load should be checked at 36 weeks then delivery planned as follows:

Viral Load at
36 weeks Recommendation

< 50 HIV RNA Vaginal delivery

copies/mL

50–399 HIV PLCS considered

RNA copies/mL Take into account the actual viral load, trajectory of viral
load, length of time on treatment, adherence issues,
obstetric factors and the womans views

≥400 HIV RNA PLCS

copies/mL

Mode of delivery Women taking Zidovudine mono therapy

  Zidovudine mono therapy was widely used at the time of the 2012 guidelines but is rarely
used anymore. At the time of writing the 2018 guidelines are still in final consultation draft
format so you may still get asked about this as they form part of the previous guidelines
 Delivery by PLCS is recommended for women, except elite controllers, taking zidovudine
monotherapy irrespective of plasma viral load at the time of delivery

Zidovudine Infusion

 Still indicated for women with a viral load of >1000 HIV RNA copies/mL who present in
labour or with ruptured membranes or who are admitted for planned CS.
 Indicated for women presenting in labour or with ruptured membranes in whom the
current viral load is not known
 Women taking zidovudine monotherapy

Infant Antiretroviral therapy(ART)

Risk
Category Criteria Treatment

Very low Mother has been on cART for longer 2 weeks zidovudine
risk than 10 weeks and monotherapy
Two documented maternal HIV viral
loads <50 HIV RNA copies/mL during
pregnancy
at least 4 weeks apart and
Maternal HIV viral load <50 HIV RNA
copies/mL at or after 36 weeks

Low risk maternal viral load <50 HIV RNA 4 weeks zidovudine
copies/mL at 36 weeks or monotherapy
maternal viral load <50 HIV RNA at time
of delivery if born prematurely

High risk Doesnt meet low risk criteria Combination PEP

Infant testing

Formula fed infants:

 During the first 48 hours and prior to hospital discharge

  If HIGH RISK, at 2 weeks of age
 at 6 weeks (at least 2 weeks post cessation of infant prophylaxis)
 at 12 weeks (at least 8 weeks post cessation of infant prophylaxis)
 On other occasions if additional risk
 HIV antibody testing for seroreversion should be checked at age 18–24 months

Breastfed infants as above plus the following additional tests:

 At 2 weeks of age
 Monthly for the duration of breastfeeding
 At 4 and 8 weeks after cessation of breastfeeding

HIV in Pregnancy (antiretroviral therapy in

pregnancy)

Antiretroviral therapy (ART) in pregnancy

 ART is mostly unlicensed for use in pregnancy

 Zidovudine is licensed in the third trimester
 Women who conceive on effective combination of ART (cART) should continue
throughout pregnancy
 Atypical regimes such as protease inhibitor (PI) monotherapy should be modified
 Zidovudine is now rarely used as part of cART due to concerns about toxicity
 Data shows no difference in pregnancy outcomes between zidovudine-based and
zidovudine-sparing cART
 Data does not support increased risk of congenital malformations with cART so far but
some agents have insufficient data

Starting cART if not taking

 All pregnant women, including elite controllers, should start cART during pregnancy and
continue lifelong
 BHIVA recommend treatment of all people living with HIV regardless of CD4 cell count
or clinical status
 All women should have commenced ART at the latest by week 24 of pregnancy
 Evidence mounting that cART is safe in the first trimester but due to theoretical risks
initiation of cART is often delayed until the start of the second trimester.
 Current advise is to start ART at start of second trimester*
 *If a women presents with opportunistic infection treatment should not be delayed due
to pregnancy
 *Start in 1st trimester if VL >100,000 HIV RNA copies/mL and/or CD4 cell count is less
than 200 cells/mm³
Deciding Mode of delivery in women taking cART

 Viral load should be checked at 36 weeks then delivery planned as follows:

Viral Load at
36 weeks Recommendation

< 50 HIV RNA Vaginal delivery

copies/mL

50–399 HIV PLCS considered

RNA copies/mL Take into account the actual viral load, trajectory of viral
load, length of time on treatment, adherence issues,
obstetric factors and the womans views

≥400 HIV RNA PLCS

copies/mL