Approach to Reducing Vertical Transmission of HIV in Pregnancy

  • Maternal Antiretroviral Treatment

    Maternal Antiretroviral Treatment

    The use of antiretroviral therapy (ART) during pregnancy reduces perinatal transmission. All pregnant women with HIV should receive ART, regardless of CD4 cell count or plasma HIV RNA load, to prevent perinatal transmission. <sup>1,2 </sup> The combination of maternal antepartum, maternal intrapartum, and infant prophylaxis is recommended to maximize infant pre-exposure and post-exposure.<sup>3</sup>

  • HIV Viremia and Minimizing Risk of Fetal Infection

    HIV Viremia and Minimizing Risk of Fetal Infection

    In general, the risk of perinatal transmission declines with low levels of maternal HIV RNA, although there is still some element of risk.<sup>4</sup> <i>Photo Credit: CDC/ Cynthia Goldsmith</i>

  • ART Efficacy in Reducing HIV Transmission

    ART Efficacy in Reducing HIV Transmission

    In 1994, the AIDS Clinical Trial 076 evaluated the safety and efficacy of zidovudine prophylaxis in preventing perinatal HIV transmission in the US and UK.<sup>5</sup> After it was conducted, subsequent clinical studies have been performed in other geographical settings to determine if lower-cost medications would also be effective. One study found that a combination regimen is more effective than a single-drug regimen.<sup>6</sup> In another study, a three-part strategy (antepartum, intrapartum, and subsequent infant prophylaxis) was found to be more effective than a medication-only intrapartium and/or postpartum approach.<sup>7 </sup> It was later found that earlier initiation of ART is more effective in reducing perinatal transmission.<sup>8</sup> <i>Photo Credit: CDC/Maureen Metcalfe, Tom Hodge</i>

  • Timing of ART Initiation

    Timing of ART Initiation

    For HIV treatment-naïve women, earlier ART initiation is associated with increased likelihood of viral suppression and decreased risk of vertical transmission.<sup>9</sup> Drug resistance testing is indicated for patients with detectable viral loads, but ART can be initiated prior to receiving resistance testing results. Earlier ART initiation is associated with a lower risk of vertical HIV transmission.<sup>10</sup>

  • Testing of HIV Drug Resistance

    Testing of HIV Drug Resistance

    ART should be initiated in pregnant women while results of drug resistance testing are pending. Drug resistance testing may not be feasible if maternal viral load is <500 to 1000 copies/mL.<sup>1</sup>

  • Selection of ART in Pregnancy

    Selection of ART in Pregnancy

    ART selection, ideally tailored according to viral resistance profile, should take into account history of the medication’s safety profile during pregnancy.<sup>11</sup> Because of its extensive safety profile, zidovudine-lamivudine (ZDV/3TC) has been a favored combination nucleoside/nucleotide reverse transcriptase inhibitors.<sup>12,13,14</sup> <i>Photo Credit: James Gathany</i>

  • ART and Pregnancy Adverse Outcomes

    ART and Pregnancy Adverse Outcomes

    There may be a small increased risk of preterm delivery and intrauterine growth restriction with the use c-section of ART, particularly protease inhibitors, but the data from studies are still accumulating.<sup>15-17</sup>

  • ART Use During Labor and Delivery

    ART Use During Labor and Delivery

    Women should continue taking ART during the labor and delivery period or scheduled cesarean section.<sup>3</sup>

  • ART Use in the Post Partum Period

    ART Use in the Post Partum Period

    In most cases, continuation of ART is recommended in the postpartum period. Factors that may be important in the clinical decision to continue ART include HIV RNA levels, medication adherence, HIV status of sexual partner, and patient preferences.

  • HIV Prophylaxis for the Newborn

    HIV Prophylaxis for the Newborn

    It is currently recommended that all infants born to HIV-infected mothers receive antiretroviral postexposure prophylaxis after birth to decrease the risk of vertical transmission. Zidovudine, dosed according to gestational age at birth, should be given within 6 to 12 hours of delivery.<sup>18</sup> Pharmacokinetic data for dosing adjustments in neonates according to birthweight in full-term infants are available only for zidovudine, lamivudine, nevirapine, and nelfinavir. In infants delivered prematurely, this data is only available for zidovudine and nevirapine.<sup>19</sup> <i>Photo Credit: CDC/Dr A Harrison; Dr P Feorino</i>

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In August 2015, the Department of Health and Human Services in the United States published updated guidelines on the evaluation and management of pregnancy in women with HIV.1


In the United States and Europe, the risk of HIV transmission from mother to infant had declined to historically low levels with the use of antiretroviral medications.2 Contributions to this successful prevention effort include universal screening of pregnant women for HIV, the appropriate use of cesarean section, and avoidance of breastfeeding.1

 

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