HIV and Pregnancy: Preventing Mother-to-Child Transmission

Current Guidance From the Department of Health and Human Services

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Preventing the transmission of HIV from mother to child involves all stages of pregnancy—from the moment of conception right through to delivery—as well as preventive therapies given to the baby immediately after childbirth.

The main goal is to reduce the mother's viral load (the concentration of HIV in the body) to undetectable levels using antiretroviral drugs. By achieving this, the risk of transmission can be reduced to near-negligible levels.

Pregnant woman holding her stomach
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Antenatal Prevention

The antenatal (prenatal) period is the time between conception and the onset of labor. This is time when antiretroviral therapy is prescribed to the mother to achieve complete viral suppression. By sustaining an undetectable viral load, the chance of HIV transmission is almost entirely eliminated.

In the absence of antiretroviral therapy, the risk of HIV transmission from mother to child is between 25% and 30%. With fully suppressive antiretroviral therapy, the risk of transmission is reduced to between 0.1% and 0.3%.

DHHS Recommendations

The choice of antiretroviral drug varies by whether a mother is newly treated or is currently on treatment. Recommendations are issued by a panel of experts in the Department of Health and Human Services (DHHS), who have assigned a preferred status to certain combination therapies.

The DHHS lists 14 preferred options for pregnant persons newly treated for HIV. Some require anywhere from one to four pills taken either on a once-daily or twice-daily schedule.

None of the options are inherently "better" than the others, although some conditions may either exclude certain drugs or make them a more attractive option.

Option Recommended Therapy Notes
1 Ezpicom (abacavir + lamivudine) once daily plus Truvada (tenofovir disoproxil fumarate + emtricitabine) once daily Abacavir requires a HLA-B*5701 test to avoid a hypersensitive drug reaction. Tenofovir is avoided in people with severe kidney dysfunction.
2 Ziagen (abacavir) once daily plus Viread (tenofovir disoproxil fumarate) once daily plus Epivir (lamivudine) once daily Same as above.
3 Triumeq (abacavir + dolutegravir + lamivudine) once daily Dolutegravir is an integrase inhibitor (INSTI) that can bring down the viral load quickly in women who present late in their pregnancy.
4 Tivicay (dolutegravir) once daily plus Truvada (tenofovir disoproxil fumarate + emtricitabine) once daily Same as above.
5 Tivicay (dolutegravir) once daily plus Viread (tenofovir disoproxil fumarate) once daily plus Epivir (lamivudine) once daily Same as above.
6 Isentress (raltegravir) twice daily plus Ezpicom (abacavir + lamivudine) once daily Raltegravir, another INSTI, may also be ideal for women who present late in pregnancy, although it requires twice-daily dosing.
7 Isentress (raltegravir) twice daily plus Truvada (tenofovir disoproxil fumarate + emtricitabine) once daily Same as above.
8 Isentress (raltegravir) twice daily plus Viread (tenofovir disoproxil fumarate) once daily plus Epivir (lamivudine) once daily Same as above.
9 Reyataz (atazanavir) once daily plus Norvir (ritonavir) once daily plus Ezpicom (abacavir + lamivudine) once daily Atazanavir is a protease inhibitor (PI) used extensively in pregnancy.
10 Reyataz (atazanavir) once daily plus Norvir (ritonavir) once daily plus Truvada (tenofovir disoproxil fumarate + emtricitabine) once daily Same as above.
11 Reyataz (atazanavir) once daily plus Norvir (ritonavir) once daily plus Viread (tenofovir disoproxil fumarate) once daily plus Epivir (lamivudine) once daily Same as above.
12 Prezcobix (darunavir + ritonavir) twice daily plus Ezpicom (abacavir + lamivudine) once daily Darunavir is another PI option but one that requires twice-daily dosing.
13 Prezcobix (darunavir + ritonavir) twice daily plus Truvada (tenofovir disoproxil fumarate + emtricitabine) once daily Same as above.
14 Prezcobix (darunavir + ritonavir) twice daily plus Viread (tenofovir disoproxil fumarate) once daily plus Epivir (lamivudine) once daily Same as above.

For pregnant women already on antiretroviral therapy, the DHHS recommends the continuation of treatment if the viral load is undetectable.

Intrapartum Prevention

The intrapartum period starts with the onset of contractions and ends when the baby is delivered. While pregnant people with HIV should ideally be on treatment and have an undetectable viral load, this is not always the case.

According to the Centers for Disease Control and Prevention (CDC), around 2,000 people with HIV in the United States remain undiagnosed during pregnancy each year. Others receive little to no antenatal care or only begin HIV treatment late in the third trimester.

For those who are untreated or unable to achieve an undetectable viral load, more aggressive last-minute interventions may be needed. This may include a continuous intravenous (IV) infusion of the antiretroviral drug AZT (zidovudine) to quickly bring down the viral load prior to delivery.

In addition, a cesarean section (C-section) may be recommended over a vaginal delivery to reduce contact with vaginal fluids, which can contain high concentrations of HIV in women with untreated infection.

DHHS Recommendations

The DHHS recommendations regarding intrapartum prevention vary by the treatment status of the mother at the time of delivery. According to the guidelines:

  • People who are currently on antiretroviral therapy should continue taking their medications for as long as possible. Upon arrival at the hospital, a viral load test will be performed to decide if additional interventions are needed.
  • People who are not on treatment or of unknown status will be given an HIV test to confirm their status. Women who test positive will also undergo viral load testing.

Based on the findings, the DHHS recommends the following preventive interventions:

Viral Load Recommendations
Over 1,000 copies/mL A continuous IV infusion of AZT (zidovudine) is recommended.
  Schedule a C-section at 38 weeks.
  Consider a vaginal delivery if there is the premature rupture of membranes.
1,000 or less copies/mL IV AZT is not required if the mother is on treatment with an undetectable viral load.
  IV AZT may be considered in women with viral loads between 50 and 1,000.
  C-section is not recommended as the risk of transmission is low.
  If C-section is performed, do not induce labor as this can increase the baby's exposure to HIV.

Postnatal Prevention

Postnatal refers to the period immediately following childbirth. For the mother, this involves the continuation of the current antiretroviral therapy. For the baby, antiretroviral therapy will be given prophylactically to prevent infection.

The choice of prophylactic medication varies by the treatment and viral load status of the mother, as well as whether the baby is confirmed to have HIV.

HIV can be diagnosed in babies with a nucleic acid test (NAT) that directly detects the virus rather than HIV antibodies. The test is able to accurately detect HIV in 30% to 50% of newborns and 100% of infants by four to six weeks.

Traditional antibody tests are not used in newborns because they will often detect the mother's antibodies (which will disappear in time) rather than the baby's.

DHHS Recommendations

Depending on the risk category of the mother, postnatal interventions for the baby may involve either a short course of AZT (zidovudine) syrup on its own or a longer course of treatment with one of the following therapies:

  • AZT (zidovudine) + Epivir (lamivudine) + Viramune (nevirapine)
  • AZT (zidovudine) + Epivir (lamivudine) + Isentress (raltegravir)

The doses of the drugs are calculated based on the child's weight in kilograms (kg).

Risk Category Definition Recommendations
Low risk Mothers on antiretroviral therapy with an undetectable viral load Four weeks of AZT syrup alone, followed by HIV testing
High risk -Mothers who were not treated -Mothers treated at the time of delivery -Mothers with a detectable viral load -Mothers with acute HIV symptoms Six weeks of presumptive therapy with three antiretroviral drugs, followed by HIV testing
Presumed exposure to HIV -Mothers who test positive at delivery -Newborns with a positive antibody test Same as above (although the treatment may be stopped if supplemental tests show that the mother is HIV-negative)
Newborn with HIV Positively diagnosed with a NAT Permanent antiretroviral therapy

Breastfeeding

The DHHS advises against breastfeeding in mothers with HIV irrespective of their viral load or treatment status. In developed countries like the United States, where infant formula is safe and readily available, breastfeeding poses an avoidable risk that arguably outweighs the benefits (including maternal bonding and infant immune constitution).

The same may not be true in developing countries where the lack of access to clean water and affordable baby formula is often lacking. In countries like these, the benefits of breastfeeding outweigh the risks.

A 2017 review of studies published in the Journal of the International AIDS Society concluded that the risk of HIV transmission via breastmilk was around 3.5% at six months and 4.2% at 12 months from mothers on antiretroviral therapy.

A Word From Verywell

The routine testing of HIV in pregnant women In the United States has reduced the incidence of mother-to-child transmission to less than one of every 100,000 births.

As effective as these interventions are, there is evidence that treating a mother before she becomes pregnant may be even more effective. A 2015 study from France involving 8,075 mothers with HIV concluded that starting antiretroviral therapy before conception effectively reduced the risk of mother-to-child transmission to zero.

If you are planning to get pregnant and don't know your status, speak to your doctor about getting an HIV test. The U.S. Preventive Services Task Force currently recommends HIV testing for all Americans 15 to 65 as part of a routine doctor visit.

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