PREGNANCY

Reducing HIV Transmission During Pregnancy, Labor and Delivery, and Postpartum Care Guideline

Introduction and Resources

Perinatal Transmission Prevention Guideline Committee, February 2017

This evidence-based guideline is one of a collection of New York State Department of Health (NYSDOH) AIDS Institute guidelines on the prevention of perinatal HIV transmission and is intended to aid clinicians in the management of factors that influence MTCT during pregnancy, during labor and delivery, and in the postpartum period. Decisions regarding obstetrical procedures, modes of delivery, administration of prophylaxis during labor and delivery, breastfeeding, and pre-exposure prophylaxis (PrEP) are also addressed.

Care providers are strongly encouraged to consult HIV Testing in Pregnancy and at Delivery for guidelines on the following:

RESOURCES
  • NYSDOH AIDS Institute Clinical Education Initiative (CEI) Line (1-866-637-2342): Provides access (during regular business hours) to physicians experienced in the treatment of HIV.
  • UCSF Clinical Consultation Center (1-888-448-8765): Provides free clinical consultation to providers on all aspects of perinatal HIV care and testing and is open 24 hours/7 days a week.

Antenatal Management

RECOMMENDATION
  • Clinicians should educate women about the importance of disclosing their HIV status to their obstetrical team, including the doctors, nurses, midwives, or physician’s assistants managing their labor, to facilitate actions that will reduce the risk of MTCT. (AIII)

Timely identification of HIV infection and initiation of antiretroviral therapy (ART) that contains at least 3 active agents, prescribed as soon as possible after diagnosis, are crucial to reducing the risk of mother-to-child transmission (MTCT) of HIV. Women who are actively engaged in their medical care with both the obstetrical team and HIV care providers, and who adhere to their ART regimens, will significantly reduce the risk of HIV transmission to their infants and will improve their own health.

For additional information regarding New York State Public Health Law and NYSDOH-specific recommendations regarding HIV testing during pregnancy, see HIV Testing in Labor and Delivery Guideline.

Acute HIV Infection in Pregnancy

RECOMMENDATION
  • Clinicians should include acute HIV infection in the differential diagnosis for any pregnant woman presenting with a rash and/or flu-like symptoms or other symptoms compatible with acute HIV infection. (AIII)

Acute infection confers a significantly high risk of MTCT of HIV [1-7]. Factors that may contribute to the increased risk of transmission during acute infection include:

  • Hyperinfectivity associated with both markedly increased viral loads (> 1 million viral copies/mm3) and increased infectiousness of the virus early in infection [8,9].
  • Missed HIV diagnosis because nonspecific flu- or mono-like symptoms may not be recognized as symptoms of acute HIV infection [10].

Early diagnosis of HIV infection is an important intervention that allows providers to recommend treatment to reduce viral loads and to offer counseling for women with high-risk behaviors to reduce transmission risk to their partners [11-13]. For additional information, see Acute HIV Infection in Pregnancy Guideline and Diagnosis and Management of Acute HIV Infection Guideline.

NYSDOH data demonstrate the role of acute HIV infection in the increased risk of MTCT [14,15]. Repeat testing in women who test negative for HIV early in pregnancy, as well as assessment for acute infection during pregnancy, is crucial to reducing the risk of MTCT (see HIV Testing During Pregnancy and at Delivery Guideline). Between 2007 and 2015, 9 (21.4%) of 42 perinatal transmissions to infants in New York State occurred among women who acquired HIV during pregnancy [14].

Maternal ART

RECOMMENDATIONS
  • Clinicians should:
    • Recommend an ART regimen, using at least 3 fully active antiretroviral agents (AII), for all pregnant HIV-infected women regardless of gestational age
    • Prescribe ART for pregnant women with the goal of suppressing viral load to below detection as early as possible in pregnancy (AII)
    • Counsel HIV-infected women about the importance of taking and adhering to ART to prevent MTCT and maintain maternal health (AIII)
  • Clinicians should recommend that women receiving antepartum ART continue their regimens throughout labor, delivery, and after delivery, maintaining the prescribed schedule. (AII)

ART with at least 3 fully active agents that is initiated early and maintains a fully suppressed viral load in pregnant women is critical to decreasing the risk of MTCT of HIV. A high maternal plasma HIV RNA level significantly increases the risk of MTCT [16-20]. In the AIDS Clinical Trials Group Protocol 076 (ACTG 076) [16] and Women and Infants Transmission Study (WITS) [19], the highest risk of transmission was among women with the highest HIV viral loads. The likelihood of an HIV-infected pregnant woman achieving an undetectable viral load by the time of delivery is dependent on the baseline viral load and the length of time taking and adhering to ART. In one study, timing of initiation of ART at up to 26.3 gestational weeks did not affect probability of reaching undetectable viral loads at delivery in women who had baseline viral loads <10,000 copies/mL. However, for women with viral loads >10,000 copies/mL, deferral of ART beyond 20.4 weeks reduced the probability of reaching <50 copies/mL by the time of delivery. For women with baseline viral loads >100,000 copies/mL, the probability of reaching <50 copies/mL by the time of delivery was low and dependent on the length of time the women were taking ART [21].

Importantly, transmission can occur in the setting of a low maternal viral load, even among women with HIV viral loads <1,000 copies/mL [18,21,22]. Women with suboptimal viral suppression include not only those with HIV-1 RNA levels >1,000 copies/mL in late pregnancy but also those who have not received or are not receiving antenatal ART at or before labor, those who have not been adherent to their ART regimens, or those who have resistant virus. One study reported that 0.1% (3 of 2117) of infants born to women on ART with viral loads <50 copies/mL became infected [22].

More recent data have shown that a fully active, three-drug ART regimen is most effective for preventing MTCT, with reported transmission rates of <0.5% [23]. The recent PROMISE study also strongly supports the use of a three-drug regimen for all HIV-infected women during pregnancy [24]. For information regarding prescribing maternal ART, see Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States [17].

Earlier data demonstrated that the incidence of MTCT during pregnancy was 20.0% to 22.6% when women received no ART agents [16,25], 7.6% to 10.4% when women received zidovudine (ZDV) single-drug prophylaxis [16,25], 3.8% when women received two-drug ART [25], and 1.2% when women received ART containing three or more ART agents [25].

For women already taking ART before pregnancy, continuation of therapy throughout pregnancy plays an important role in reducing the risk of HIV transmission. Data demonstrate that treatment interruption early or late in pregnancy is associated with higher risk of MTCT [26]. In one study, MTCT did not occur among women who were taking ART before pregnancy, had viral loads <500 copies/mL early in their pregnancy, and had viral loads <500 copies/mL at delivery [27]. In another study, the risk of MTCT was reduced by 8% for each additional week during pregnancy that ART was taken [28].

KEY POINT
  • No viral load threshold has been established below which the risk of MTCT is eliminated [29], underscoring the importance of continued use of ART throughout pregnancy to maintain viral suppression that is beneath the lower limit of detection by standard quantitative HIV RNA testing.

Avoidance of Invasive Obstetrical Procedures

RECOMMENDATIONS
  • Invasive procedures should be avoided unless the pregnant woman and her healthcare provider decide that the benefits of performing the procedure outweigh the potential risk of MTCT and the patient is aware of the theoretical increased risk of perinatal transmission associated with the procedure. (AIII)
  • HIV-infected women who elect to undergo amniocentesis or chorionic villus sampling should be receiving effective ART at the time of the procedure and, ideally, should have an undetectable viral load. (BIII)

Data are limited regarding MTCT associated with invasive diagnostic procedures such as amniocentesis and chorionic villus sampling in HIV-infected women. In the largest case series conducted during the era of combination antenatal ART, no perinatal HIV transmission occurred among 81 mothers who received amniocentesis while using effective ART [30]. Other, smaller studies have had similar results. Transplacental amniocentesis should be avoided if possible. Although no data exist regarding the risk of chorionic villus sampling in HIV-infected women, MTCT may be increased because of the likelihood of comingling of maternal and fetal blood with this procedure. Intrapartum fetal scalp blood sampling, the use of fetal scalp electrodes for fetal heart rate monitoring, and intrauterine pressure catheters to monitor contractions may increase the risk of MTCT and should be avoided if possible [17].

CD4 Cell Count

Low CD4 cell count is not an independent risk factor for MTCT [31]. Conversely, a high CD4 cell count does not confer protection from MTCT. ART with three fully active antiretroviral agents for the prevention of MTCT is recommended for all pregnant HIV-infected women, regardless of CD4 count.

Maternal Co-Infections

Herpes simplex virus (HSV): Although some data suggest that risk of MTCT may be increased in women who are co-infected with HIV/genital HSV and particularly in the presence of genital HSV viral shedding [32,33], no data support the use of HSV-suppressive medication to prevent perinatal HIV transmission. However, HSV-suppressive therapy during pregnancy has been shown to decrease the risk of HSV recurrence at the time of delivery by 75% and hence to reduce the rate of cesarean delivery for recurrent genital herpes lesions by 40% [34].

Other coinfections: Results from some studies have shown that chorioamnionitis and placental inflammation are associated with perinatal transmission of HIV [35,36]. Maternal co-infections with syphilis [37], gonorrhea [38], chlamydia [38], and hepatitis C virus (HCV) [39] are also associated with an increased risk of HIV transmission, and women with HIV/HCV co-infection have a significantly higher risk of perinatal HCV transmission [40]. However, no proven benefit to cesarean delivery has been demonstrated for preventing perinatal HCV transmission among these patients [41,42]. Cesarean delivery solely for the presence of other STIs, excluding HSV, is also not warranted. For additional information, see Routine Monitoring of HIV-Infected Women During Pregnancy.

References:
  1. Brenner BG, Roger M, Routy JP, et al. High rates of forward transmission events after acute/early HIV-1 infection. J Infect Dis 2007;195:951-959. [PubMed]
  2. Yerly S, Vora S, Rizzardi P, et al.; Swiss HIV Cohort Study. Acute HIV infection: Impact on the spread of HIV and transmission of drug resistance. AIDS 2001;15:2287-2292. [PubMed]
  3. Cohen MS, Pilcher CD. Amplified HIV transmission and new approaches to HIV prevention. J Infect Dis 2005;191:1391-1393. [PubMed]
  4. Wawer MJ, Gray RH, Sewankambo NK, et al. Rates of HIV-1 transmission per coital act, by stage of HIV-1 infection in Rakai, Uganda. J Infect Dis 2005;191:1403-1409. [PubMed]
  5. Remien RH, Higgins JA, Correale J, et al. Lack of understanding of acute HIV infection among newly-infected persons: Implications for prevention and public health: The NIMH Multisite Acute HIV Infection Study: II. AIDS Behav 2009;13:1046-1053. [PubMed]
  6. Marinda ET, Moulton LH, Humphrey JH, et al. In utero and intrapartum HIV-1 transmission and acute HIV-1 infection during pregnancy: Using the BED capture EIA as a surrogate marker for acute infection. Int J Epidemiol 2011;40:945-954. [PubMed]
  7. Taha TE, James MM, Hoover DR, et al. Association of recent HIV infection and in utero HIV-1 transmission. AIDS 2011;25:1357-64. [PubMed]
  8. Ma ZM, Stone M, Piatak M Jr, et al. High specific infectivity of plasma virus from the pre-ramp-up and ramp-up stages of acute simian immunodeficiency virus infection. J Virol 2009;83:3288-3297. [PubMed]
  9. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med. 2000;342:921-929. [PubMed]
  10. Chin T, Hicks C, Samsa G, et al. Diagnosing HIV infection in primary care settings: missed opportunities. AIDS Patient Care STDS 2013;27:392-97. [PubMed]
  11. Fonner VA, Denison J, Kennedy CE, et al. Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries. Cochrane Database Syst Rev 2012;9:CD001224. [PubMed]
  12. Steward WT, Remien RH, Higgins JA, et al. Behavior change following diagnosis with acute/early HIV infection-a move to serosorting with other HIV-infected individuals. The NIMH Multisite Acute HIV Infection Study: III. AIDS Behav. 2009;13:1054-1060. [PubMed]
  13. Colfax GN, Buchbinder SP, Cornelisse PG, et al. Sexual risk behaviors and implications for secondary HIV transmission during and after HIV seroconversion. AIDS 2002;16:1529-35. [PubMed]
  14. New York State Department of Health AIDS Institute. Unpublished data.
  15. Patterson KB, Leone PA, Fiscus SA, et al. Frequent detection of acute HIV infection in pregnant women. AIDS 2007;21:2303-2308. [PubMed]
  16. Sperling RS, Shapiro DE, Coombs RW, et al. Maternal viral load, zidovudine treatment, and the risk of transmission of human immunodeficiency virus type 1 from mother to infant. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1996;335:1621-9. [PubMed]
  17. Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. 2016 Oct 26. Available at: https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0/#
  18. Duri K, Gumbo FZ, Kristiansen KI, et al. Antenatal HIV-1 RNA load and timing of mother to child transmission: A nested case-control study in a resource poor setting. Virol J 2010;7:176;1-9. [PubMed]
  19. Garcia PM, Kalish LA, Pitt J, et al. Maternal levels of plasma human immunodeficiency virus type 1 RNA and the risk of perinatal transmission. Women and Infants Transmission Study Group. N Engl J Med 1999;341:394-402. [PubMed]
  20. Mofenson LM, Lambert JS, Stiehm ER, et al. Risk factors for perinatal transmission of human immunodeficiency virus type 1 in women treated with zidovudine. Pediatric AIDS Clinical Trials Group Study 185 Team. N Engl J Med 1999;341:385-393. [PubMed]
  21. Read PJ, Mandalia S, Khan P, et al. When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery? AIDS 2012;26:1095-1103. [PubMed]
  22. Townsend CL, Cortina-Borja M, Peckham CS, et al. Low rates of mother-to-child transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000-2006. AIDS 2008;22:973-981. [PubMed]
  23. Townsend CL, Byrne L, Cortina-Borja M, et al. Earlier initiation of ART and further decline in mother-to-child HIV transmission rates, 2000-2011. AIDS 2014;28:1049-57. [PubMed]
  24. Fowler MG, Qin M, Fiscus SA, et al. PROMISE: Efficacy and Safety of 2 Strategies to Prevent Perinatal HIV Transmission. Abstract 31LB. Conference on Retroviruses and Opportunistic Infections (CROI); 2016 Feb 22-25; Boston, MA. [Abstract]
  25. Cooper ER, Charurat M, Mofenson LM, et al. Combination antiretroviral strategies for the treatment of pregnant HIV-1 infected women and prevention of perinatal HIV-1 transmission. J Acquir Immune Defic Syndr 2002;29:484-494. [PubMed]
  26. Galli L, Puliti D, Chiappini E, et al. Is the interruption of antiretroviral treatment during pregnancy an additional major risk factor for mother-to-child transmission of HIV type 1? Clin Infect Dis 2009;48:1310-1317. [PubMed]
  27. Tubiana R, Le Chenadec J, Rouzioux C, et al. Factors associated with mother-to-child transmission of HIV-1 despite a maternal viral load <500 copies/ml at delivery: A case-control study nested in the French perinatal cohort (EPF-ANRS CO1). Clin Infect Dis 2010;50:585-596. [PubMed]
  28. Hoffman RM, Black V, Technau K, et al. Effects of highly active antiretroviral therapy duration and regimen on risk for mother-to-child transmission of HIV in Johannesburg, South Africa. J Acquir Immune Defic Syndr 2010;54:35-41. [PubMed]
  29. Arvold ND, Ngo-gian-Huong N, McIntosh K, et al. Perinatal HIV Prevention Trial (PHPT-1), Thailand: Maternal HIV-1 DNA load and mother to child transmission. AIDS Patient Care STDs 2007;21(Suppl 9):638-643. [PubMed]
  30. Mandelbrot L, Jasseron C, Ekoukou D, et al. Amniocentesis and mother-to-child human immunodeficiency virus transmission in the Agence Nationale de Recherches sur le SIDA et les Hepatites Virales French Perinatal Cohort. Am J Obstet Gynecol 2009;200:160.e1-9. [PubMed]
  31. Goetghebuer T, Haelterman E, Marvillet I, et al. Vertical transmission of HIV in Belgium: A 1986-2002 retrospective analysis. Eur J Pediatr 2009;168:79-85. [PubMed]
  32. Bollen LJ et al. Maternal herpes simplex type 2 coinfection increases the risk of perinatal HIV transmission: Possibility to further decrease transmission. AIDS 2008;22:1169-76. [PubMed]
  33. Drake AL, John-Stewart GC, Wald A, et al. Herpes simplex type 2 and risk of intrapartum HIV transmission.  Obstet Gynecol 2007;109:403-409. [PubMed]
  34. Sheffield JS, Hollier LM, Hill JB, et al. Acyclovir prophylaxis to prevent herpes simplex virus recurrence at delivery: A systematic review. Obstet Gynecol 2003;102:1396-1403. [PubMed]
  35. Bhoopat L, Khunamornpong S, Sirivatanapa P, et al. Chorioamnionitis is associated with placental transmission of human immunodeficiency virus-1 subtype E in the early gestational period. Mod Pathol 2005;18:1357-1364. [PubMed]
  36. Mwanyumba F, Gaillard P, Inion I, et al. Placental inflammation and perinatal transmission of HIV-1. J Acquir Immune Defic Syndr 2002;29:262-269. [PubMed]
  37. Yeganeh N, Watts HD, Camarca M, et al. Syphilis in HIV-infected mothers and infants: Results from the NICHD/HPTN 040 study. Pediatr Infect Dis J 2015;34:e52-e57. [PubMed]
  38. Adachi K, Klausner JD, Bristow CC, et al. Chlamydia and gonorrhea in HIV-infected pregnant women and infant HIV transmission. Sex Transm Dis 2015;42:554-565. [PubMed]
  39. Hershow RC, Riester KA, Lew J, et al. Increased vertical transmission of human immunodeficiency virus from hepatitis C virus-coinfected mothers. Women and Infants Transmission Study. J Infect Dis 1997;176:414-420. [PubMed]
  40. Ngo-Giang-Huong N, Jourdain G, Sirirungsi W, et al. Human immunodeficiency virus-hepatitis C virus coinfection in pregnant women and perinatal transmission to infants in Thailand. Int J Infect Dis 2010;14:e602-e607. [PubMed]
  41. Cottrell EB, Chou R, Wasson N, et al. Reducing risk for mother to infant transmission of hepatitis C virus: A systematic review for the US Preventive Services Task Force.  Ann Intern Med 2013;158:109-113. [PubMed]
  42. Ghamar Chereh ME, Tabatabei SV, Khazanehdari S, et al. Effect of cesarean delivery on the risk of perinatal transmission from HCV+/HIV- mothers: A meta-analysis.  Arch Gynecol Obstet 2011;283:255-260. [PubMed]

Management During Labor and Delivery

RECOMMENDATIONS
  • Clinicians should educate HIV-infected women about the benefits and risks of available modes of delivery and their effects on rates of MTCT and should provide the information:
    • As early as possible during pregnancy (AII)
    • In the context of maternal viral load (AII)
    • With the understanding that some women are from cultures in which vaginal delivery is expected (AII)
  • Clinicians should recommend a scheduled cesarean delivery at 38 weeks’ gestation, prior to the onset of active labor and before rupture of membranes (AII), for women:
    • With viral load >1,000 copies/mL within 4 weeks of expected date of delivery (AII) or
    • Who report consistent nonadherence to prenatal ART or missed multiple medical visits within 4 weeks of expected date of delivery (AIII) or
    • Who present without documentation of a recent HIV RNA level within 4 weeks of expected date of delivery (AIII)
  • Clinicians should recommend cesarean delivery when all of the following criteria are met:
    • The patient is not virally suppressed according to the criteria above and
    • Duration of ruptured membranes is <4 hours (BII) and
    • The patient is not in active labor (AII)
  • For women who 1) report adherence to their prenatal ART, 2) consistently attend their medical appointments, and 3) have documented HIV RNA levels ≤1,000 copies/mL within 4 weeks of onset of labor, clinicians should:
    • Refer to established guidelines for standard obstetrical indications for vaginal vs. scheduled cesarean delivery (AII)
    • Perform a cesarean delivery that is being scheduled for standard obstetrical indications at 39 weeks’ gestation (AII)
  • Clinicians should expedite delivery for women who present with either ruptured membranes or chorioamnionitis, a condition that may be associated with increased risk for MTCT. (AIII)
  • For women whose viral load is not fully suppressed, clinicians should delay rupture of membranes as long as possible to decrease the risk of MTCT. (BIII)
  • For women with full viral suppression, clinicians should follow standard obstetrical indications for rupture of membranes for all pregnant women. (AII)

Mode of Delivery: Vaginal vs Cesarean Delivery

With fully suppressive maternal ART, a low incidence of MTCT can be achieved regardless of mode of delivery. In a European surveillance study, no statistically significant difference was found in transmission rates between women taking ART during pregnancy who had a scheduled cesarean delivery and those who had a planned vaginal delivery [1].

A meta-analysis of 15 cohort studies of perinatal HIV transmission in which women received either no ART or received ZDV monotherapy prophylaxis reported that scheduled cesarean delivery before the onset of labor or rupture of membranes was associated with an approximately 50% decrease in transmission regardless of whether ZDV was given during delivery [2]. The rate of HIV transmission for scheduled cesarean delivery without the use of ZDV prophylaxis was 10.4%, and the rate of transmission for other modes of delivery without the use of ZDV prophylaxis was 19.0%. Among all mother-child pairs given ZDV prophylaxis during the prenatal, intrapartum, and neonatal periods, 13.5% had scheduled cesarean deliveries and 86.5% had other modes of delivery. The incidence of transmission was 2.0% for those with cesarean deliveries and 7.3% for those who had other modes of delivery.

Currently, both the American College of Obstetricians and Gynecologists [3] and the US Department of Health and Human Services [4] recommend that HIV-infected pregnant women with suboptimal viral suppression (>1,000 copies/mL) should be counseled regarding the benefits of a scheduled cesarean delivery and that scheduled cesarean deliveries should be performed at 38 weeks’ gestation. This Panel also recommends cesarean delivery for patients who have missed multiple medical visits or report nonadherence to antiretroviral medications during the 4 weeks prior to delivery.

Patients who meet all of the criteria for optimal viral suppression have a very low risk of MTCT. Studies do not indicate that cesarean delivery confers significant additional benefit for prevention of MTCT in this group compared with vaginal delivery [5-7]. Scheduled cesarean delivery is not routinely recommended [3,4]. Mode of delivery should be determined by the woman in consultation with her obstetrical care provider and should be based on the benefits for prevention of MTCT and the potential risks associated with cesarean delivery.

KEY POINT

A cesarean delivery that is being performed on the basis of inadequate viral suppression requires that:

  • The duration of ruptured membranes is <4 hours
  • The patient is not in active labor

An association between cesarean delivery and reduction in the incidence of MTCT has not been demonstrated after the onset of labor or duration of ruptured membranes ≥4 hours. When a provider anticipates a long period of labor after the rupture of membranes, the use of adjuvant therapy, such as oxytocin, to reduce the length of labor should be considered.

For women who report adherence to their prenatal ART and have documented HIV RNA levels ≤1,000 copies/mL within 4 weeks of delivery, the decision to perform a cesarean delivery is based on standard obstetrical indications. If vaginal delivery is chosen, invasive fetal/uterine monitoring should be avoided.

In the pre-combination ART era, several perinatal transmission studies reported a positive association between transmission risk and duration of ruptured membranes prior to delivery [8,9]. For women whose viral load is not fully suppressed, clinicians should delay rupture of membranes as long as possible to decrease the risk of MTCT. However, no association has been established between duration of membrane rupture and MTCT in virally suppressed women receiving combination ART [10-12]. Standard obstetrical indications for rupture of membranes for all pregnant women are appropriate in the setting of full viral suppression.

Management of Maternal ART Medications During Labor and Delivery

RECOMMENDATIONS
  • Birth facilities should maintain a stock of intravenous (IV) ZDV that is available for immediate use in labor and delivery settings. (AIII)
  • For HIV-infected pregnant women receiving antepartum maternal ART at the time of scheduled cesarean delivery or onset of labor, clinicians should:
    • Prescribe the current ART regimen as scheduled during labor and before scheduled cesarean delivery (AII)
    • Stop oral ZDV when intrapartum IV ZDV is indicated (AII)
    • Stop and restart all drugs simultaneously if it becomes necessary to interrupt the mother’s ART regimen during the peripartum period (AII)
  • IV ZDV should be administered to HIV-infected pregnant women during labor and delivery under the following conditions*:
    1. The patient’s viral load has been >1,000 copies/mL late in pregnancy and near the time of delivery (AII) or
    2. The most recent viral load was measured more than 4 weeks prior to onset of labor (AIII) or
    3. The patient has missed doses of ART during the 4 weeks prior to onset of labor  (AIII) or
    4. The patient has missed medical visits during the 4 weeks prior to onset of labor (AIII)

*Although additional IV ZDV is not harmful to HIV-infected pregnant women who do not meet the criteria above, it is not required because it does not confer additional benefit in prevention of MTCT [13,14].

  • When IV ZDV administration is indicated at the time of labor and delivery for an HIV-infected pregnant woman, clinicians should:
    • Administer a loading dose of ZDV 2 mg/kg IV infusion over 1 hour upon the patient’s arrival in the labor and delivery unit (AII)
    • Administer IV ZDV 1 mg/kg per hour by continuous infusion after the loading dose and until delivery (AII)
  • Ensure that a total of at least 3 hours of IV ZDV has been given prior to delivery unless either maternal or fetal clinical circumstances dictate the need for delivery before the 3 hours of IV ZDV is complete (AII)
  • For women receiving oral ZDV as part of their antepartum ART regimen and for whom administration of IV ZDV is indicated during labor and delivery:
    • The oral ZDV component should be temporarily stopped while IV ZDV is administered (AIII)
    • ZDV-containing fixed-dose combination products, including lamivudine/ZDV (Combivir) or abacavir/lamivudine/ZDV (Trizivir), should be discontinued prior to administration of IV ZDV; individual dosing of non-ZDV components should be continued (AIII)
    • The oral ZDV component of the mother’s regimen can be restarted at the regularly scheduled dosing interval after delivery and the IV ZDV has been discontinued (AIII)
AVOID USE IN PREGNANCY AND LABOR
  • Nevirapine:  Single-dose maternal nevirapine is no longer recommended as part of MTCT prophylaxis for women in New York State.
  • Stavudine or didanosine: The combination of stavudine and didanosine is contraindicated during both pregnancy and labor. Fatal lactic acidosis and pancreatitis have been reported in pregnant women who received combination stavudine/didanosine with other ART agents [4,15-17]. These drugs are rarely prescribed, and neither agent should be initiated in ART-naïve HIV-infected patients.

The purpose of IV infusion of ZDV is to ensure adequate infant drug levels when exposure to HIV occurs during the birth process. ZDV rapidly crosses the placenta to the infant, and IV infusion ensures that drug levels in the mother and the fetus do not fluctuate as they may with oral administration.

In the ACTG 076 trial, IV ZDV during labor and delivery for all pregnant HIV-infected women, along with oral antepartum ZDV administration to the mother and postpartum administration to the infant, reduced perinatal transmission by 68% [18]. Further reductions in perinatal transmission have been achieved with the use of maternal ART regimens that include at least three active antiretroviral agents [5]. Such combination antiretroviral agents are recommended for treatment and prevention of MTCT for all HIV-infected pregnant women (see Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States [4]).

IV ZDV should be available for immediate use in all labor and delivery settings to ensure sufficient levels of prophylaxis during delivery. Based on data demonstrating a reduction of MTCT with the use of IV ZDV in women with HIV RNA viral loads >1,000 copies/mL [10,13,14], this Panel and other guideline committees [4] recommend IV ZDV during labor and delivery for HIV-infected pregnant women with any factor associated with suboptimal viral suppression. This prophylaxis is especially important for women who did not receive ART during pregnancy or who received ART but did not achieve complete viral suppression by the time of delivery.

INTRAPARTUM IV ZDV DOSING
  • Initial loading dose: 2 mg/kg IV over 1 hour, then
  • Continuous infusion: 1 mg/kg/hour until delivery

Most MTCT occurs during labor and delivery [19]. Although intrapartum IV ZDV will not prevent MTCT before labor, ZDV crosses the placenta rapidly and may provide sufficient systemic drug levels in the infant to prevent infection during labor and delivery [20-22].

IV ZDV is most effective in reducing MTCT when it is administered to the mother continuously for at least 3 hours prior to delivery; if labor lasts longer than 3 hours, IV ZDV should be administered for the entire duration. Nonemergency cesarean deliveries should be scheduled to begin after 3 hours of IV ZDV administration. However, maternal or fetal clinical circumstances may dictate the need for delivery before the 3 hours of IV ZDV administration is complete.

KEY POINT

Although IV ZDV is not harmful for women receiving antepartum ART who routinely have viral loads ≤1,000 copies/mL, it is not required for these patients provided all of the following criteria are met:

  • The patient’s viral load has been consistently ≤1,000 copies/mL late in pregnancy and near the time of delivery
  • The last viral load was obtained within 4 weeks of onset of labor
  • The patient confirms that she has not missed any doses of ART during the 4 weeks prior to onset of labor
  • The patient has attended all medical appointments during the 4 weeks prior to onset of labor
References:
  1. Townsend CL, Cortina-Borja M, Peckham CS, et al. Low rates of mother-to-child transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000-2006. AIDS 2008;22:973-981. [PubMed]
  2. International Perinatal HIV Group. The mode of delivery and the risk of vertical transmission of human immunodeficiency type-1—a meta-analysis of 15 prospective cohort studies. The International Perinatal HIV Group. N Engl J Med 1999;340:977-987. [PubMed]
  3. American College of Obstetricians and Gynecologists. ACOG committee opinion-scheduled Cesarean delivery and the prevention of vertical transmission of HIV infection. Number 234, May 2000 (replaces number 219, August 1999). Int J Gynaecol Obstet 2001;73:279-281. [PubMed]
  4. Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. 2016 Oct 26. Available at: https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0/#
  5. Townsend CL, Byrne L, Cortina-Borja M, et al. Earlier initiation of ART and further decline in mother-to-child HIV transmission rates, 2000-2011. AIDS 2014;28:1049-57. [PubMed]
  6. Briand N, Jasseron C, Sibiude J, et al. Cesarean section for HIV-infected women in the combination antiretroviral therapies era, 2000-2010. Am J Obstet Gynecol 2013;209:335.e1-12. [PubMed]
  7. Boer K, Nellen JF, Patel D, et al. The AmRo study: pregnancy outcome in HIV-1 infected women under effective highly active antiretroviral therapy and a policy of vaginal delivery. BJOG 2007;114:148-155. [PubMed]
  8. Garcia-Tejedor A, Perales A, Maiques V. Duration of ruptured membranes and extended labor are risk factors for HIV transmission. Int J Gynaecol Obstet 2003;82:17-23. [PubMed]
  9. International Perinatal HIV Group. Duration of ruptured membranes and vertical transmission of HIV-1: A meta-analysis from 15 prospective cohort studies. AIDS 2001;15:357-368. [PubMed]
  10. Cotter AM, Brookfield KF, Duthely LM, et al. Duration of membrane rupture and risk of perinatal transmission of HIV-1 in the era of combination antiretroviral therapy. Am J Obstet Gynecol 2012;207:482.e1-5. [PubMed]
  11. Mark S, Murphy KE, Read S, et al. HIV mother-to-child transmission, mode of delivery, and duration of rupture of membranes: experience in the current era. Infect Dis Obstet Gynecol 2012;2012:267969. [PubMed]
  12. Peters H, Byrne L, De Ruiter A, et al. Duration of ruptured membranes and mother-to-child HIV transmission: a prospective population-based surveillance study. BJOG 2016;123:975-981. [PubMed]
  13. Briand N, Warszawski J, Mandelbrot L, et al. Is intrapartum intravenous zidovudine for prevention of mother-to-child HIV-1 transmission still useful in the combination antiretroviral therapy era? Clin Infect Dis 2013;57:903-914. [PubMed]
  14. Wong VV. Is peripartum zidovudine absolutely necessary for patients with a viral load less than 1,000 copies/ml? J Obstet Gynaecol 2011;31:740-742. [PubMed]
  15. Bristol-Myers Squibb Company. Healthcare Provider Important Drug Warning Letter. 2001 Jan 5. Available at: http://i-base.info/htb/4145
  16. Sarner L, Fakoya A. Acute onset lactic acidosis and pancreatitis in the third trimester of pregnancy in HIV-1 positive women taking antiretroviral medication. Sex Transm Infect. 2002;78:58-59. [PubMed]
  17. Mandelbrot L, Kermarrec N, Marcollet A, et al. Case report: Nucleoside analogue-induced lactic acidosis in the third trimester of pregnancy. AIDS 2003;17:272-273. [PubMed]
  18. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1994;33:1173-1180. [PubMed]
  19. Sturt AS, Dokubo EK, Sint TT. Antiretroviral therapy (ART) for treating HIV infection in ART-eligible pregnant women. Cochrane Database Syst Rev 2010;CD008440. [PubMed]
  20. Petra Study Team. Efficacy of three short-course regimens of zidovudine and lamivudine in preventing early and late transmission of HIV-1 from mother to child in Tanzania, South Africa, and Uganda (Petra study): A randomised, double-blind, placebo-controlled trial. Lancet 2002; 359:1178-1186. [PubMed]
  21. Gray GE, Urban M, Chersich MF, et al. A randomized trial of two postexposure prophylaxis regimens to reduce mother-to-child HIV-1 transmission in infants of untreated mothers. AIDS 2005;19:1289-1297. [PubMed]
  22. Jackson JB, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: 18-month follow-up of the HIVNET 012 randomised trial. Lancet 2003;362:859-863. [PubMed]

Infant Prophylaxis

RECOMMENDATIONS
  • Clinicians should administer infant prophylaxis for prevention of MTCT to all HIV-exposed infants as soon as possible after birth, and within 12 hours [1,2] (AII) but preferably within 6 hours (for regimen and dosing information, see Care of the HIV-Exposed Infant with Indeterminate Status and [1]).
  • Clinicians managing HIV-infected pregnant women should always consult with an experienced pediatric HIV provider as soon as possible, preferably prior to delivery or immediately after delivery, to determine the regimen for infant antiretroviral prophylaxis. (AIII)

The addition of ART agents to an infant’s postnatal ZDV regimen can further reduce MTCT for infants born to mothers who received no antepartum antiretroviral drugs or who had suboptimal virologic suppression [2].

KEY POINTS
  • Consultation with an experienced pediatric HIV provider as soon as possible, preferably before labor, enables determination of an effective regimen for infant antiretroviral prophylaxis. This is particularly crucial when the woman: 1) is diagnosed with HIV infection during labor, or 2) did not have prenatal care or antenatal ART prior to presenting in labor, or 3) has unsuppressed virus, or 4) has ART-resistant virus.
  • Clinicians in communities without an experienced pediatric HIV provider can obtain free expert consultation from the National Perinatal HIV Hotline (1-888-448-8765) 24 hours/7 days a week or from the NYSDOH AIDS Institute Clinical Education Initiative (CEI) Line (1-866-637-2342) during regular business hours.

For further information about antiretroviral prophylaxis and care for infants, see Care of the HIV-Exposed Infant with Indeterminate Status and Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States [1].

References:
  1. Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. 2016 Oct 26. Available at: https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0/#
  2. Nielsen-Saines K, Watts DH, Veloso VG, et al. Three postpartum antiretroviral regimens to prevent intrapartum HIV infection. N Engl J Med 2012;366:2368-2379. [PubMed]

Postpartum Management and Breastfeeding

RECOMMENDATIONS
  • For HIV-infected women:
    • Breastfeeding, in both New York State and elsewhere in the United States, is not recommended. (AI)
    • HIV-infected women should formula feed exclusively. (AI)
    • For an HIV-infected woman who expresses concern that family members or acquaintances who are unaware of her infection status may ask about a decision not to breastfeed, clinicians should encourage her to develop an acceptable explanation for the decision that may enable her to avoid disclosing her HIV status under such circumstances. (AIII)
  • For women at risk for acquiring HIV:
    • Clinicians should recommend that the following women should delay breastfeeding until HIV infection has been excluded:
      • Women who have no documentation of a negative HIV test result (AII)
      • Women who have symptoms that are suggestive of acute HIV infection since their last HIV test (AII)
    • Clinicians should recommend that women with current or ongoing high-risk factors, such as a new diagnosis of a sexually transmitted infection, injection drug use, or a partner known to be infected with HIV, should not breastfeed until an HIV risk-reduction plan is in place, including the use of PrEP. (AII)
    • Clinicians should include acute HIV infection in the differential diagnosis for any breastfeeding mother presenting with a rash and/or flu-like symptoms or other symptoms compatible with acute HIV infection. (AIII)

In the United States, breastfeeding by HIV-infected women is not recommended, even when the mother is taking combination ART and/or her viral load is undetectable [1]. Although preliminary data support that maternal ART used during breastfeeding decreases MTCT, the data have not been fully analyzed and additional research is needed [2]. Increased risk of HIV transmission via breastfeeding is associated with higher levels of HIV RNA in breast milk [3,4], with inflammation of the breast (mastitis) [4], longer duration of breastfeeding as the infant ages [3,4], and resumption of feeding after abrupt weaning [4].

Breast milk HIV RNA is higher in women with higher viral loads, particularly during acute infection. A breastfeeding woman with previously negative HIV test results should be assessed for acute HIV infection when presenting with symptoms suggestive of acute retroviral syndrome (see the Acute HIV Infection in Pregnancy Guideline and the Diagnosis and Management of Acute HIV Infection Guideline).

HIV RNA is also higher in colostrum than in mature breast milk, and HIV RNA increases in the setting of low CD4 counts. Nevertheless, breast milk transmission of HIV may occur at any time during breastfeeding [5]. Several studies have shown that the longer an infant breastfeeds, the greater the risk of transmission [6,7]. Although the risk of MTCT is significantly lower with the use of combination ART and an undetectable viral load, neither infant antiretroviral prophylaxis nor suppressive maternal postpartum ART completely eliminates the risk of HIV transmission through breast milk [1].

KEY POINTS
  • Even when plasma viral load is undetectable, viral load variation in breast milk is unknown. Therefore, HIV-infected mothers in the United States should not breastfeed, regardless of maternal viral load or ART regimen [8].
  • A risk-reduction plan is essential for women who have high-risk factors for acquiring HIV infection but wish to breastfeed.
  • Women in whom breastfeeding should be delayed may temporarily pump and discard breast milk to maintain lactation. Once HIV infection is definitively excluded, or once a risk-reduction plan is in place for those at current high risk for HIV acquisition, breastfeeding may be initiated.

For some HIV-infected women who have not disclosed their HIV status to family members or friends but are from cultures in which breastfeeding is customary or have been educated that breastfeeding is essential for the health of their infants, lack of disclosure presents a challenge when explaining the choice not to breastfeed [9]. Encouraging a new mother to develop, in advance, an explanation for not breastfeeding may help her to avoid disclosing her HIV status.

Risk Reduction and Use of PrEP During Breastfeeding for Non-HIV-Infected Women at Risk for HIV

Breastfeeding mothers who develop acute HIV infection are at high risk for transmitting HIV to their infants because of the elevated viral load associated with acute HIV infection [8,10,11]. To reduce the incidence of acute infection in breastfeeding mothers, and subsequent transmission to their infants, a risk-reduction plan should be in place for those who have current high-risk factors for HIV acquisition, such as a new diagnosis of a sexually transmitted infection, injection drug use, or a partner known to be infected with HIV. Appropriate follow-up and, when possible, involvement of the woman’s partner and others in her support network are necessary before breastfeeding can be recommended. Development of a risk-reduction plan also offers the opportunity to discuss the use of PrEP with tenofovir disoproxil fumarate/emtricitabine (TDF/FTC).

PrEP is an intervention for non-HIV-infected individuals that is used to reduce their risk of acquiring HIV infection by using antiretroviral medications. PrEP has been shown to be effective in significantly decreasing the risk of HIV transmission in heterosexual serodiscordant couples [12]. Data also demonstrate a 92% to 96% reduction in HIV transmission risk in serodiscordant heterosexual relationships when the HIV-infected partner has been virally suppressed for at least 6 months [13,14].

PrEP drug exposure to the infant though breastmilk is much lower compared with exposures that occur in utero; evidence to date suggests that use of TDF is safe during breastfeeding [15,16]. Longer-term follow-up studies of TDF-exposed infants are ongoing and will provide further information to guide clinicians and women on the use of PrEP in this setting. TDF/FTC is commonly prescribed as part of an ART regimen before, during, and after pregnancy. Although limited data on breastfeeding effects exist, the benefit of preventing MTCT among women at high risk for HIV infection outweighs the theoretical concerns associated with prescribing TDF/FTC as PrEP during breastfeeding. Information regarding medications used during breastfeeding is available through the LactMed database.

For more information regarding the use of PrEP, see Guidance for the Use of PrEP to Prevent HIV Transmission.

Infant Exposure

Other than discontinuing breastfeeding, optimal strategies have yet to be defined for managing breastfeeding infants born to mothers with previously undiagnosed HIV infection, including women who acquired their infection late in pregnancy or after delivery [17]. Some experts would consider the use of three-drug post-exposure prophylaxis (PEP) in infants for 4 to 6 weeks after breastfeeding is discontinued and after an initial diagnostic test is obtained to determine the infant’s HIV infection status. However, in comparison with other types of non-occupational exposures, PEP is less likely to be effective in this setting because the exposure to breast milk is likely to have occurred over an interval of time rather than after a single exposure [17]. To determine whether PEP is indicated for an infant who is exposed to HIV through breast milk, clinicians should consult with a pediatric  provider who has experience with HIV treatment and management.

References:
  1. Committee on Pediatric AIDS. Infant feeding and transmission of human immunodeficiency virus in the United States. Pediatrics 2013;131;391-396. [PubMed].
  2. Taha T, Flynn P, Cababasay M, et al.; the PROMISE Team. Maternal triple antiretrovirals (mART) and infant nevirapine (iNVP) prophylaxis for the prevention of mother-to-child transmission (MTCT) of HIV during breastfeeding (BF). Abstract O_18. 8th International Workshop on HIV Pediatrics; 2016 Jul 15-16; Durban, South Africa. [Abstract]
  3. Kuhn L, Reitz C, Abrams EJ, et al. Breastfeeding and AIDS in the developing world. Curr Opin Pediatr 2009;21:83-93. [PubMed]
  4. Bulterys M, Ellington S, Kourtis AP. HIV-1 and breastfeeding: Biology of transmission and advances in prevention. Clin Perinatol 2010;37:807-824. [PubMed]
  5. Rousseau CM, Nduati RW, Richardson BA, et al. Longitudinal analysis of human immunodeficiency virus type 1 RNA in breast milk and of its relationship to infant infection and maternal disease. J Infect Dis 2003;187:741-747. [PubMed]
  6. Nduati R, Grace J, Mbori-Ngacha D, et al. Effect of breastfeeding and formula feeding on transmission of HIV-1: A randomized clinical trial. JAMA 2000;283:1167-1174. [PubMed]
  7. Shapiro RL, Hughes MD, Ogwu A, et al. Antiretroviral regimens in pregnancy and breast-feeding in Botswana. N Engl J Med 2010;362:2282-2294. [PubMed]
  8. Humphrey JH, Marinda E, Mutasa K, et al. Mother to child transmission of HIV among Zimbabwean women who seroconverted postnatally: Prospective cohort study. BMJ 2010;341:c6580. [PubMed]
  9. Greene S, Ion A, Elston D, et al. “Why aren’t you breastfeeding?”: How mothers living with HIV talk about infant feeding in a “breast Is best” world. Health Care Women Int 2016;36:883-901. [PubMed]
  10. Liang K, Gui X, Zhang YZ, et al. A case series of 104 women infected with HIV-1 during blood transfusion postnatally: High rate of HIV-1 transmission to infants through breastfeeding. J Infect Dis 2009;200:682-686. [PubMed]
  11. Committee on Pediatric AIDS. Infant feeding and transmission of human immunodeficiency virus in the United States. Pediatrics 2013;131;391-396. [PubMed]
  12. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med 2012;367:399-410. [PubMed]
  13. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: A prospective cohort analysis. Lancet 2010;375:2092-2098. [PubMed]
  14. Cohen MS, Chen YQ, McCauley M, et al.; HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365:493-505. [PubMed]
  15. Liotta G, Floridia M, Andreotti M, et al. Growth indices in breastfed infants pre and postnatally exposed to tenofovir compared with tenofovir-unexposed infants. AIDS 2016;30:525-527. [PubMed]
  16. Ehrhardt S, Xie C, Guo N, et al. Breastfeeding while taking lamivudine or tenofovir disoproxil fumarate: a review of the evidence. Clin Infect Dis 2015;60:275-278. [PubMed]
  17. Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. 2016 Oct 26. Available at: https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0/#

All Recommendations

Perinatal Transmission Prevention Guideline Committee, February 2017

ALL RECOMMENDATIONS

See HIV Testing in Pregnancy and at Delivery for recommendations on the following:

Antenatal Management

  • Clinicians should educate women about the importance of disclosing their HIV status to their obstetrical team, including the doctors, nurses, midwives, or physician’s assistants managing their labor, to facilitate actions that will reduce the risk of MTCT. (AIII)
  • Clinicians should include acute HIV infection in the differential diagnosis for any pregnant woman presenting with a rash and/or flu-like symptoms or other symptoms compatible with acute HIV infection. (AIII)
  • Clinicians should:
    • Recommend an ART regimen, using at least three fully active antiretroviral agents (AII), for all pregnant HIV-infected women regardless of gestational age
    • Prescribe ART for pregnant women with the goal of suppressing viral load to below detection as early as possible in pregnancy (AII)
    • Counsel HIV-infected women about the importance of taking and adhering to ART to prevent MTCT and maintain maternal health (AIII)
  • Clinicians should recommend that women receiving antepartum ART continue their regimens throughout labor, delivery, and after delivery, maintaining the prescribed schedule. (AII)
  • Invasive procedures should be avoided unless the pregnant woman and her healthcare provider decide that the benefits of performing the procedure outweigh the potential risk of MTCT and the patient is aware of the theoretical increased risk of perinatal transmission associated with the procedure. (AIII)
  • HIV-infected women who elect to undergo amniocentesis or chorionic villus sampling should be receiving effective ART at the time of the procedure and, ideally, should have an undetectable viral load. (BIII)

Management During Labor and Delivery

  • Clinicians should educate HIV-infected women about the benefits and risks of available modes of delivery and their effects on rates of MTCT and should provide the information:
    • As early as possible during pregnancy (AII)
    • In the context of maternal viral load (AII)
    • With the understanding that some women are from cultures in which vaginal delivery is expected (AII)
  • Clinicians should recommend a scheduled cesarean delivery at 38 weeks’ gestation, prior to the onset of active labor and before rupture of membranes (AII), for women:
    • With viral load >1,000 copies/mL within 4 weeks of expected date of delivery (AII) or
    • Who report consistent nonadherence to prenatal ART or missed multiple medical visits within 4 weeks of expected date of delivery (AIII) or
    • Who present without documentation of a recent HIV RNA level within 4 weeks of expected date of delivery (AIII)
  • Clinicians should recommend cesarean delivery when all of the following criteria are met:
    • The patient is not virally suppressed according to the criteria above and
    • Duration of ruptured membranes is <4 hours (BII) and
    • The patient is not in active labor (AII)
  • For women who 1) report adherence to their prenatal ART, 2) consistently attend their medical appointments, and 3) have documented HIV RNA levels ≤1,000 copies/mL within 4 weeks of onset of labor, clinicians should:
    • Refer to established guidelines for standard obstetrical indications for vaginal vs. scheduled cesarean delivery (AII)
    • Perform a cesarean delivery that is being scheduled for standard obstetrical indications at 39 weeks’ gestation (AII)
  • Clinicians should expedite delivery for women who present with either ruptured membranes or chorioamnionitis, a condition that may be associated with increased risk for MTCT. (AIII)
  • For women whose viral load is not fully suppressed, clinicians should delay rupture of membranes as long as possible to decrease the risk of MTCT. (BIII)
    • For women with full viral suppression, clinicians should follow standard obstetrical indications for rupture of membranes for all pregnant women. (AII)
  • Birth facilities should maintain a stock of intravenous (IV) ZDV that is available for immediate use in labor and delivery settings. (AIII)
  • For HIV-infected pregnant women receiving antepartum maternal ART at the time of scheduled cesarean delivery or onset of labor, clinicians should:
    • Prescribe the current ART regimen as scheduled during labor and before scheduled cesarean delivery (AII)
    • Stop oral ZDV when intrapartum IV ZDV is indicated (AII)
    • Stop and restart all drugs simultaneously if it becomes necessary to interrupt the mother’s ART regimen during the peripartum period (AII)
  • IV ZDV should be administered to HIV-infected pregnant women during labor and delivery under the following conditions*:
    1. The patient’s viral load has been >1,000 copies/mL late in pregnancy and near the time of delivery (AII) or
    2. The most recent viral load was measured more than 4 weeks prior to onset of labor (AIII) or
    3. The patient has missed doses of ART during the 4 weeks prior to onset of labor (AIII) or
    4. The patient has missed medical visits during the 4 weeks prior to onset of labor (AIII)

*Although additional IV ZDV is not harmful to HIV-infected pregnant women who do not meet the criteria above, it is not required because it does not confer additional benefit in prevention of MTCT.

  • When IV ZDV administration is indicated at the time of labor and delivery for an HIV-infected pregnant woman, clinicians should:
    • Administer a loading dose of ZDV 2 mg/kg IV infusion over 1 hour upon the patient’s arrival in the labor and delivery unit (AII)
    • Administer IV ZDV 1 mg/kg per hour by continuous infusion after the loading dose and until delivery (AII)
  • Ensure that a total of at least 3 hours of IV ZDV has been given prior to delivery unless either maternal or fetal clinical circumstances dictate the need for delivery before the 3 hours of IV ZDV is complete. (AII)
  • For women receiving oral ZDV as part of their antepartum ART regimen and for whom administration of IV ZDV is indicated during labor and delivery:
    • The oral ZDV component should be temporarily stopped while IV ZDV is administered (AIII)
    • ZDV-containing fixed-dose combination products, including lamivudine/ZDV (Combivir) or abacavir/lamivudine/ZDV (Trizivir), should be discontinued prior to administration of IV ZDV; individual dosing of non-ZDV components should be continued (AIII)
    • The oral ZDV component of the mother’s regimen can be restarted at the regularly scheduled dosing interval after delivery and the IV ZDV has been discontinued (AIII)

Infant Prophylaxis

  • Clinicians should administer infant prophylaxis for prevention of MTCT to all HIV-exposed infants as soon as possible after birth, and within 12 hours (AII) but preferably within 6 hours (for regimen and dosing information, see Care of the HIV-Exposed Infant with Indeterminate Status and AIDSinfo).
  • Clinicians managing HIV-infected pregnant women should always consult with an experienced pediatric HIV provider as soon as possible, preferably prior to delivery or immediately after delivery, to determine the regimen for infant antiretroviral prophylaxis. (AIII)

Postpartum Management and Breastfeeding

  • For HIV-infected women:
    • Breastfeeding, in both New York State and elsewhere in the United States, is not recommended. (AI)
    • HIV-infected women should formula feed exclusively. (AI)
    • For an HIV-infected woman who expresses concern that family members or acquaintances who are unaware of her infection status may ask about a decision not to breastfeed, clinicians should encourage her to develop an acceptable explanation for the decision that may enable her to avoid disclosing her HIV status under such circumstances. (AIII)
  • For women at risk for acquiring HIV:
    • Clinicians should recommend that the following women should delay breastfeeding until HIV infection has been excluded:
      • Women who have no documentation of a negative HIV test result (AII)
      • Women who have symptoms that are suggestive of acute HIV infection since their last HIV test (AII)
    • Clinicians should recommend that women with current or ongoing high-risk factors, such as a new diagnosis of a sexually transmitted infection, injection drug use, or a partner known to be infected with HIV, should not breastfeed until an HIV risk-reduction plan is in place, including the use of PrEP. (AII)
    • Clinicians should include acute HIV infection in the differential diagnosis for any breastfeeding mother presenting with a rash and/or flu-like symptoms or other symptoms compatible with acute HIV infection. (AIII)