Treatment of HIV-infected pregnant women

All antenatal care for women who are HIV positive should be managed by a multidisciplinary team, including (as a minimum) an HIV physician, obstetrician, specialist midwife, health advisor and paediatrician.

• all women who are newly diagnosed as HIV positive should have an early assessment of their social circumstances
• clinicians should be empathetic, nonjudgemental when providing care to women living with HIV and their children
• important to maintain confidentiality, including with relatives
• advice on testing of partners and previous children if their HIV status is unknown
• address the medical and psychological needs of the fathers
• explain the importance of the use of condoms to prevent the transmission of HIV and other sexually transmitted infections
  • if both partners have HIV and engage in unprotected sex, there is a possibility of superinfection
• clinician should respect the decision of a mother who refuses antenatal cART after being fully informed and counselled

Antenatal care

• should receive similar obstetric antenatal care to that given to HIV-negative women, unless indicated by the need to provide specific HIVrelated treatment.
• women should start or ideally continue taking folic acid 1 mg daily for at least the first 3 months of their pregnancy
• all women in resource-rich settings who are HIV positive should be advised to avoid breastfeeding.
• investigations
  • do not require any additional baseline investigations compared with non-pregnant HIV-positive women other than those routinely performed in the general antenatal clinic
  • screening blood test for syphilis, hepatitis B and rubella in every pregnancy at their booking antenatal visit
    • additional recommended blood tests for women who are HIV positive include hepatitis C, varicella zoster, measles and toxoplasma
  • screen for genital infections at booking (or after multidisciplinary team referral if diagnosed HIV positive in pregnancy) and again at 28 weeks
  • women who are taking HAART at the time of booking should be screened for gestational diabetes
  • fetal ultrasound imaging regardless of maternal HIV status
  • the combined screening test for trisomy 21 is recommended
    • this has the best sensitivity and specificity and will minimize the number of women who may need invasive testing
    • combined test includes maternal age, nuchal translucency, βHCG and pregnancy-associated plasma protein A (PAPP-A)
    • carried out during 11 + 0 to 13 + 6 weeks’ gestation
  • invasive prenatal diagnostic testing should not be performed until after the HIV status of the mother is known and should be ideally deferred until HIV viral load has been adequately suppressed
• external cephalic version (ECV) can be performed in women with HIV
  • ECV should be offered to women with a viral load <50copies/mL and a breech presentation at >36 + 0 in the absence of obstetric contraindications
• medical treatment
  • should be tailored to the individual needs of the woman
  • antiretroviral drug therapy (ART)
  • prophylaxis for opportunistic infections
  • additional vaccines should be offered e.g - hepatitis B, pneumococcus and influenza immunisation

Mode of delivery

• for women taking cART, a decision regarding recommended mode of delivery should be made after review of plasma viral load results at 36 weeks
  • for women with a plasma viral load of <50 HIV RNA copies/mL at 36 weeks, and in the absence of obstetric contraindications, a planned vaginal delivery is recommended
  • for women with a plasma viral load of 50–399 HIV RNA copies/mL at 36 weeks, planned caesarean section (PLCS) should be considered, taking into account the actual viral load, the trajectory of the viral load, length of time on treatment, adherence issues, obstetric factors and the woman’s views
  • where the viral load is ≥400 HIV RNA copies/mL at 36 weeks, PLCS is recommended
  • where the indication for PLCS is the prevention of mother-to-child transmission (MTCT), PLCS should be undertaken at between 38 and 39 weeks’ gestation

Management of spontaneous rupture of membranes:

• term pre-labour spontaneous rupture of the membranes (ROM)
  • delivery should be expedited in all cases
  • if maternal HIV viral load is < 50 HIV RNA copies/mL immediate induction of labour is recommended, with a low threshold for treatment of intrapartum pyrexia
  • for women with a last measured plasma viral load of 50–999 HIV RNA copies/mL, immediate Caesarean section should be considered, taking into account the actual viral load, the trajectory of the viral load, length of time on treatment, adherence issues, obstetric factors and the woman’s views
  • if maternal HIV viral load is ≥ 1000 RNA copies/mL plasma, immediate Caesarean section is recommended
• prolonged premature rupture of membranes (PPROM)
  • at ≥ 34 weeks
    • management is the same as term ROM
  • at <34 weeks
    • intramuscular steroids should be administered
    • virological control should be optimized
    • timing of delivery should be made after multidisciplinary team consultation, involving the HIV physicians and paediatricians (1)

Note:

• pregnant women with HIV should be informed that with consistent use of cART and abstinence from breastfeeding, the risk of perinatal transmission is <1% (2)

Reference:

• (1) de Ruiter A et al. British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review). HIV Med. 2014;15 Suppl 4:1-77
• (2) Money D et al. Guidelines for the care of pregnant women living with HIV and interventions to reduce perinatal transmission: executive summary. J Obstet Gynaecol Can. 2014;36(8):721-734.
• (3) Rimawi BH et al. Management of HIV Infection during Pregnancy in the United States: Updated Evidence-Based Recommendations and Future Potential Practices. Infect Dis Obstet Gynecol. 2016;2016:7594306.