Heterosexual acquisition and injection drug use are the principal identified modes of HIV infection in women. Asymptomatic HIV infection is associated with a normal pregnancy rate and no increased risk of adverse pregnancy outcomes. There is no evidence that pregnancy causes AIDS progression.
Previously, two-thirds of HIV-positive neonates acquired their infection close to, or during, the time of delivery. Routine HIV screening in pregnancy, including the use of rapid HIV tests in Labor and Delivery units, and using antiretroviral drugs has markedly reduced this transmission risk to approximately 1%. In an HIV-positive pregnant woman, a CD4 count, plasma RNA level, and resistance testing (if virus is detectable, and the patient has not already had this) should be obtained at the first prenatal visit. Treatment should not be delayed while waiting for the results of resistance testing. Prior or current antiretroviral use should be reviewed. The patient should be tested for HLA-B*5701 if abacavir may be prescribed; HLA-B*5701 positivity puts the patient at risk for a serious hypersensitivity reaction and its use is contraindicated.
A woman already taking and tolerating an acceptable antiretroviral regimen need not discontinue it in the first trimester. Patients should also be tested for hepatitis A, hepatitis C, tuberculosis, toxoplasmosis, and cytomegalovirus.
Women not taking medication should be offered combination antiretroviral therapy (commonly a dual nucleoside reverse transcriptase inhibitor combination and either a ritonavir-boosted protease inhibitor or an integrase strand transfer inhibitor) after counseling regarding the potential impact of therapy on both mother and fetus (see Chapter 31). Antiretroviral therapy should be offered regardless of viral load and CD4 count. Whether to start in the first or second trimester should be determined on a case-by-case basis, but it should be started as early as reasonably possible. It can be started in the first trimester after explanation of risks and benefits, provided the mother is not experiencing nausea and vomiting. Most medications used to treat HIV/AIDS have thus far proven to be safe in pregnancy with an acceptable risk/benefit ratio. The physiologic changes that occur during pregnancy may alter the effect of some medications. Before starting any regimen, the safety and efficacy of the medications selected should be reviewed. Standard of care also includes administration of intravenous zidovudine (2 mg/kg intravenously over 1 hour followed by 1 mg/kg/hour intravenously) begun 3 hours before cesarean delivery and continued through the surgery until cord clamping in women whose viral load near delivery (after 34–36 weeks’ gestation or within 4–6 weeks of delivery) is more than 1000 copies/mL or unknown. Antiretroviral therapy on the patient’s usual schedule should be continued in labor. Intravenous zidovudine is not required for antiretroviral therapy–compliant women whose viral load is less than or equal to 50 copies/mL near delivery; data are limited in cases where the viral load is between 50 copies/mL and 1000 copies/mL.
The use of prophylactic elective cesarean section at 38 weeks’ gestation (before the onset of labor ...