HIV Infection in Pregnancy: A Comprehensive Guide

February 08, 2025

Summary

Testing: All pregnant women should be tested for HIV as early as possible in pregnancy. Repeat testing is recommended in the third trimester for those at risk.
Infant Testing: HIV-exposed infants should be tested for HIV infection and provided specialty care if positive.
Antiretroviral Therapy (ART): All pregnant women with HIV should receive ART as early as possible, regardless of CD4 count or viral load. ART should be administered during the antepartum, intrapartum, and postnatal periods.
Breastfeeding: Not recommended unless replacement feeding is not feasible.

Basics

Definition

Human immunodeficiency virus (HIV) is a retrovirus that infects CD4 T cells, leading to HIV infection and potentially acquired immunodeficiency syndrome (AIDS). Pregnancy in women with HIV is complicated by the infection itself and associated medical and psychosocial comorbidities.

Epidemiology

Global: Approximately 18.2 million women are living with HIV worldwide, making up half of all adults with HIV.
Sub-Saharan Africa: 58% of adults with HIV are women.
UK: 1 in 3 people living with HIV are women, and women make up one quarter of all new HIV diagnoses.
MTCT: Without treatment, the risk of mother-to-child transmission (MTCT) is 15%-45%, but with ART, this risk drops to 1%-2%.

Aetiology

HIV is caused by two types of viruses: HIV-1 and HIV-2. HIV-1 is more common and leads to a progressive decrease in CD4 T-cell count, while HIV-2 has a slower progression and is mainly found in West Africa.

Pathophysiology

HIV is transmitted through blood, sexual contact, and vertical transmission from mother to child. Perinatal transmission is the most common mode of HIV acquisition in children worldwide. Transmission can occur in utero, during labor, or through breastfeeding.

Prevention

Primary Prevention

Education: Early education and counseling about HIV in pregnancy are crucial.
Preconception Counseling: For couples where one or both partners are HIV-positive, expert consultation is recommended.
Risk Reduction: Women should be educated about behaviors that increase HIV risk, such as unprotected sex and drug use.

Screening

Universal Screening: Recommended for all pregnant women, with repeat testing in the third trimester for those at risk.
Risk Factors: History of injection drug use, sexually transmitted infections (STIs), unprotected sex, and multiple sexual partners.

Secondary Prevention

MTCT Prevention: Strategies include universal HIV screening, early diagnosis, ART, scheduled cesarean delivery for women with high viral loads, and replacement feeding for infants.

Diagnosis

Case History

Case 1: A 28-year-old woman with a positive HIV test at 8 weeks’ gestation.
Case 2: A 35-year-old HIV-positive woman on ART who misses her menstrual period.

Step-by-Step Diagnostic Approach

Testing: Fourth-generation ELISA for HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen.
Confirmatory Tests: HIV-1/HIV-2 differentiation immunoassay or western blot.
Infant Testing: HIV DNA or RNA PCR for infants exposed to HIV.

Risk Factors

Strong Risk Factors: Needle-sharing, unprotected receptive anal intercourse, high maternal viral load, absence of antenatal ART, breastfeeding.
Weak Risk Factors: Receptive oral intercourse, multiple sexual partners.

Diagnostic Tests

Maternal Testing: Fourth-generation ELISA, CD4 count, plasma viral load, renal and liver function tests.
Infant Testing: HIV DNA or RNA PCR at 14-21 days, 1-2 months, and 4-6 months.

Differential Diagnosis

Infectious Mononucleosis
Toxoplasmosis
Viral Hepatitis
Morbilliform Drug Eruption
Viral Exanthems

Treatment

Step-by-Step Treatment Approach

ART: Should be initiated as early as possible in pregnancy, regardless of CD4 count or viral load.
Antepartum ART: A regimen with at least 3 drugs is recommended, including 2 nucleoside reverse transcriptase inhibitors (NRTIs) and a protease inhibitor (PI) or integrase strand transfer inhibitor (INSTI).
Intrapartum ART: Intravenous zidovudine is recommended for women with high viral loads.
Postnatal ART: All HIV-exposed infants should receive ART, starting within 6-12 hours of birth.

Treatment Options

Preferred NRTIs: Abacavir/lamivudine, emtricitabine/tenofovir disoproxil.
Preferred PIs: Ritonavir-boosted atazanavir or darunavir.
Preferred INSTIs: Dolutegravir (after the first trimester), raltegravir.

Follow-Up

Monitoring: Women should have follow-up visits within 2-4 weeks postpartum.
Adherence: Support for adherence to ART is crucial, especially in the postpartum period.

Complications

Long-Term Effects of ART: Potential organ system toxicities and neoplasia in children exposed to ART in utero.
Vertical Transmission: Risk is reduced with ART and other preventive measures.
Preterm Delivery: Conflicting data on the association between ART and preterm birth.

Prognosis

Maternal Outcomes: Women with HIV have higher rates of obstetric complications, such as cesarean delivery, preterm birth, and pre-eclampsia.
Infant Outcomes: Neonates born to women with HIV are at increased risk for low birth weight and transient tachypnea.

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