General principles of managing HIV infection in pregnancy

Australasian Society for Infections Diseases (ASID), 2022

Management of antiretroviral therapy during pregnancy is complex and requires consultation with an HIV specialist. General principles include:

An HIV-negative person of childbearing potential with an HIV-positive partner who are planning natural conception in the next 3 months are considered to be at risk of HIV infection – Pre-exposure prophylaxis (PrEP) against HIV is recommended.
HIV testing is recommended for pregnant people at the first antenatal visit and should be repeated during the pregnancy for those at high risk of HIV infection (eg people with an HIV-positive partner, people with new sexual partners during pregnancy, people with sexual partners from high-prevalence countries).
Antiretroviral therapy should be recommended to all pregnant people with HIV infection. This is for their own health benefit as well as for prevention of perinatal transmission of HIV infection. For detailed information about antiretroviral drugs and regimens recommended in pregnancy, see the guidelines listed in Australian and international HIV guidelines. Pregnancy affects the pharmacokinetics of some antiretrovirals, particularly in the third trimester, so dosages may need to be adjusted.
In general, if a person of childbearing potential with HIV infection conceives while on an effective antiretroviral regimen, the regimen should not be changed.
Intrapartum zidovudine is indicated for the prevention of perinatal transmission if the birthing parent’s (eg mother’s) prebirth viral suppression has been inadequate or is unknown, as in cases of late presentation. Other additional therapies may be used – seek expert advice.
Consider a caesarean section if the pregnant person’s plasma viral load is more than 50 HIV RNA copies/mL at 36 weeks gestation. Caesarean section is recommended when viral load is more than 400 copies/mL at 36 weeks gestation. If the viral load can be promptly reduced before 38 weeks gestation, a caesarean section may not be required – seek expert advice.
Neonatal antiretroviral prophylaxis should be started as soon as possible after birth (within 6 to 12 hours) and continued for 4 weeks. In very low-risk scenarios, this can be reduced to 2 weeks – see Assessment of HIV perinatal transmission risk and the Australasian Society for Infectious Diseases (ASID) Management of perinatal infections guidelines for more advice.
Where the birthing parent (eg mother) has HIV infection, formula feeding is recommended as this minimises the risk of HIV transmission to the infant. For more information, see Breastfeeding with HIV infection.