Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States

Antepartum Care for Individuals with HIV

Overview

In addition to the standard antepartum assessments for all pregnant people, the initial evaluation of people with HIV should include an assessment of HIV disease status and recommendations for HIV-related medical care (see Recommendations for the Use of Antiretroviral Drugs During Pregnancy: Overview). See Initial Evaluation and Continued Monitoring of HIV-Related Assessments During Pregnancy and Laboratory Testing for Initial Assessment and Monitoring of People with HIV Receiving Antiretroviral Therapy for the recommended schedule of HIV-related laboratory tests during pregnancy. Initial assessment and ongoing care for pregnant individuals with HIV should include the following items (see Table 4. Antepartum Screenings and Assessments for Pregnant People With HIV):

• Review of prior HIV-related illnesses and past CD4 T lymphocyte (CD4) cell counts and plasma HIV RNA levels;
• Current CD4 count;
• Current plasma HIV RNA level;
• Assessment of the need for prophylaxis against opportunistic infections, such as Pneumocystis jirovecii pneumonia (see the Adult and Adolescent Opportunistic Infections Guidelines);
• Screening for hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), and tuberculosis (see Hepatitis B Virus/HIV Coinfection and Hepatitis C Virus/HIV Coinfection);
• Screening for and treatment of sexually transmitted infections (STIs), such as syphilis, Chlamydia trachomatis, Trichomonas vaginalis, and Neisseria gonorrhea^1-4; Repeat STI testing in the third trimester may be indicated based on individual risk factors or as required by state laws;
• Assessment of the need for HAV, HBV, influenza, pneumococcus, Tdap (tetanus, diphtheria, acellular pertussis), or SARS-CoV-2 immunizations (including boosters). Counseling on the importance of vaccinations for all pregnant individuals, and specifically for people with HIV, should be addressed and vaccinations provided when indicated^5-8; consideration of other vaccinations, such as for meningococcus, may be warranted based on individual patient considerations. Human papillomavirus vaccination may be indicated postpartum if not previously vaccinated;
• Complete blood cell count and renal and liver function testing;
• HLA-B*5701 testing, if the use of abacavir is anticipated (see Table 14. Antiretroviral Drug Use in Pregnant People With HIV: Pharmacokinetic and Toxicity Data in Human Pregnancy and Recommendations for Use in Pregnancy);
• History of prior or current antiretroviral (ARV) drug use or experience with adverse events or toxicities. Counseling should also address prior or anticipated challenges with adherence;
• Screening for depression and anxiety (see Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum), as well as for substance use disorders, and referral for mental health care services if indicated⁹;
• Assessment of the need for supportive care (e.g., social services, mental health services, substance use disorder treatment services, smoking cessation services, other community-based resources) for pregnancy-specific needs, as well as to help ensure lifelong adherence to antiretroviral therapy (ART);
• Screening for intimate partner violence (IPV) and assessment of the need for referrals for supportive care;
• Assessment of gender identity, pronouns used, desired terminology for anatomy, and use of testosterone or other gender-affirming hormonal therapy^10,11 (see Perinatal HIV Prevention for Transgender and Gender-Diverse People Assigned Female Sex at Birth and Transgender People with HIV);
• Assessment of the HIV status of sexual partner(s) and referral of partner(s) for HIV testing and ART or prophylaxis as needed (see Pre-Exposure Prophylaxis [PrEP] to Prevent HIV During Periconception, Antepartum, and Postpartum Periods);
• Referral of children for HIV testing if HIV status is unknown; and
• Counseling about key intrapartum and postpartum considerations, including mode of delivery, lifelong HIV therapy, family planning and contraceptive options, infant feeding choices, infant ARV prophylaxis, and timing of infant diagnostic testing.

Prenatal Screening, Diagnosis, and Therapy

According to the American College of Obstetricians and Gynecologists (ACOG), prenatal genetic screening and diagnostic testing options should be discussed and offered to all pregnant people regardless of age or risk of chromosomal abnormality. After review and discussion, every patient has the right to pursue or decline prenatal genetic screening and diagnostic testing.¹² Prenatal screening for aneuploidy should be offered using noninvasive methods with high sensitivity and low false-positive rates, as recommended by ACOG. Counseling on noninvasive genetic screening options is no different for people with HIV than for those without HIV. Noninvasive screening can be accomplished using either of the following:

• Cell-free DNA screening with or without nuchal translucency; or
• Serum analyte screening alone or combined with nuchal translucency (sequential or integrated).

Patients with HIV who desire or have indications for diagnostic testing during pregnancy (e.g., abnormal ultrasound or aneuploidy screening) should be counseled about the potential risk of perinatal HIV transmission, along with other risks of the procedure so that they can make informed decisions about invasive testing. Although the data on women who are receiving ART are limited, the risk of perinatal HIV transmission does not appear to increase with the use of amniocentesis or other invasive diagnostic procedures in women who have virologic suppression on ART.^13,14 This is in contrast to the era before effective ART, during which invasive procedures, such as amniocentesis and chorionic villus sampling, were associated with a twofold to fourfold increase in the risk of perinatal transmission of HIV.^15-18 Although no transmissions occurred among 159 reported cases of amniocentesis or other invasive diagnostic procedures performed in women who were on effective ART, a small increase in the risk of transmission cannot be ruled out.^19-22

At a minimum, it should be recommended that pregnant patients receive effective ART before undergoing any invasive prenatal testing. Patients ideally should have undetectable HIV RNA levels at the time of the procedure, and every effort should be made to avoid inserting the needle through, or very close to, the placenta. Families often make complex personal decisions about continuing a pregnancy after a prenatal diagnosis, and those decisions are made even more complex by evolving state laws regarding access to abortion. A patient-centered discussion regarding delaying diagnostic procedures to allow for viral suppression should also consider the impact of that delay on the options available to a patient for terminating a pregnancy, if that is something they are considering. If a patient with detectable HIV RNA levels requires invasive prenatal testing, consultation with an expert in the management of HIV during pregnancy should be considered (see Intrapartum Care for People with HIV).

Fetal therapy is an area of maternal-fetal medicine in which insufficient data exist about the risk of HIV transmission through such procedures as selective fetoscopic laser photocoagulation, vesicoamniotic or thoracoamniotic shunts, intrauterine transfusions, in utero repair of neural tube defects, and other invasive procedures. In the absence of evidence to guide these decisions, it is recommended that patients with HIV who may require advanced care for fetal abnormalities receive consultation at specialized centers where they can receive coordinated, multidisciplinary counseling. As with the above discussion regarding prenatal diagnosis, it is recommended that individuals have achieved viral suppression prior to procedures.

The National Perinatal HIV Hotline

The National Clinical Consultation Center Perinatal HIV hotline (1-888-448-8765) is a federally funded service that provides free clinical consultation to providers who are caring for pregnant people with HIV and their infants.

ART Adherence Support During Pregnancy

In general, the recommendations for the use of ART in people who are pregnant are the same as for those who are not pregnant. However, the Perinatal Guidelines do differ from the Adult and Adolescent Antiretroviral Guidelines in some instances where regimen selection has been modified based on concerns about specific drugs or limited experience with newer drugs during pregnancy (see Table 6. What to Start: Initial Antiretroviral Regimens During Pregnancy for People Who Are Antiretroviral-Naive and Table 7. Situation-Specific Recommendations for Use of Antiretroviral Drugs in Pregnant People and Nonpregnant People Who Are Trying to Conceive and Recommendations for Use of Antiretroviral Drugs During Pregnancy: Overview).

Clinicians and patients should discuss the substantial benefits of ARV drugs for health of the pregnant person and for reducing the risk of HIV transmission to infants; this helps put the potential risks of using these drugs into perspective (see Table 14. Antiretroviral Drug Use in Pregnant People With HIV: Pharmacokinetic and Toxicity Data in Human Pregnancy and Recommendations for Use in Pregnancy and Appendix B: Supplement: Safety and Toxicity of Individual Antiretroviral Agents in Pregnancy). Counseling of pregnant patients about ARV drug use should be directive and noncoercive, and providers should help patients make informed decisions regarding the use of ARV drugs.

Counseling about regimens should include information about the following:

• The risk of HIV disease progression and the benefits and risks of therapy for the health of the pregnant person²³;
• The benefits of ART for preventing perinatal transmission of HIV²⁴;
• The benefits of using ART to achieve and maintain viral suppression, which reduces the risk of sexual transmission of HIV to partners who do not have HIV²⁵;
• The need for strict adherence to the prescribed ARV drug regimen to avoid drug resistance, optimize health outcomes, and minimize the risk of perinatal HIV transmission;
• The potential adverse effects of ARV drugs for pregnant people, fetuses, and infants, including potential interactions with other medications the patient may already be receiving (see Recommendations for Use of Antiretroviral Drugs During Pregnancy: Overview)^26-29;
• The limited long-term outcome data for infants who were exposed to ARV drugs in utero, especially for newer ARV drugs; and
• The importance of considering pregnancy-specific challenges to adherence, such as nausea and vomiting or adverse social determinants of health. Patients should be advised to remain in close communication with their providers about these challenges.

Counseling at the onset of antepartum care and at each subsequent visit should emphasize the importance of adherence to the ARV drug regimen to minimize the development of resistance and support the effectiveness of ART in achieving viral suppression. Patients with poor adherence during pregnancy are more likely to have detectable viral loads at delivery.³⁰ In addition, multiple adverse social determinants of health, including housing instability,³¹ nondisclosure of HIV status,^32,33 lack of social support,³⁴ and other factors—are known to affect adherence. As a result, adherence counseling should include careful attention to the patient’s social needs, social support, and mental health.

Patient Counseling and Coordination of Care

Coordination of services among antepartum care providers, primary care and HIV specialty care providers, mental health and substance use disorder treatment services, social services, and public assistance programs is essential to ensure that patients with HIV are well supported during all stages of their pregnancies and the postpartum period. Medical care of pregnant people with HIV requires coordination and communication between HIV specialists and obstetric providers.

Anticipatory guidance provided during pregnancy for people with HIV is generally similar to counseling that is recommended for individuals without HIV.³⁵ However, HIV-specific antepartum counseling should include current knowledge about risk factors for perinatal HIV transmission. Risk of perinatal transmission of HIV has been associated with potentially modifiable factors, including tobacco use, substance use disorders, alcohol consumption, and genital tract infections. In addition to improving health of the pregnant person and their offspring, cessation of tobacco and drug use and treatment of STIs and other genital tract infections may reduce the risk of perinatal transmission. Other risk factors for ART nonadherence, such as housing instability, food insecurity, mental health disorders,³⁶ and IPV,³⁷ also require particular attention for patients with HIV. Patients should be screened for mental health conditions, assessed for the risk of IPV, and counseled about disclosure of their HIV status when needed.³⁸

Fears of stigma and violence that could result from undesired HIV status disclosure require comprehensive, culturally informed services to assist pregnant and postpartum patients who are planning to disclose their status,^39,40 and patients who have not disclosed their status require support to maintain privacy during health care encounters (including telemedicine visits and in-person care).⁴¹ Transgender and gender-diverse individuals may have specific concerns and needs for added support related to receiving services in settings designed for the care of cisgender women and pregnant women (see Perinatal HIV Prevention for Transgender and Gender-Diverse People Assigned Female at Birth).

In addition, providers should counsel patients with HIV about what to expect during labor, delivery, and the postpartum period. This counseling should include discussing the mode of delivery and the possible use of intrapartum zidovudine, as well as unique disclosure circumstances that may occur in the context of intrapartum care. Guidance must also address reproductive choice and postpartum contraceptive options. Providers also should discuss the possibility of simplifying a patient’s ARV regimen after delivery, which can help promote long-term adherence to ART. Discussions regarding the prevention of postnatal transmission to the neonate also should include recommendations about infant feeding, neonatal ARV prophylaxis, infant diagnostic HIV testing, and the avoidance of premastication of food(see Infant Feeding for Individuals with HIV in the United States). Anticipatory guidance about postpartum care also must include plans for transitioning health care from the obstetric team to the long-term health care team.

References

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