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Reviewed Ene. 31, 2023

Antepartum Care

Initial Evaluation and Continued Monitoring of HIV-Related Assessments During Pregnancy

Panel’s Recommendations
  • The plasma HIV RNA levels of pregnant people with HIV should be monitored at the initial antenatal visit with a review of prior HIV RNA levels (AI), 2 to 4 weeks after initiating (or changing) antiretroviral therapy (ART) (BI), monthly until RNA levels are undetectable (BIII), and then at least every 3 months during pregnancy (BIII). HIV RNA levels also should be assessed at approximately 36 weeks gestation, or within 4 weeks of delivery, to inform decisions about mode of delivery (see Intrapartum Care for People with HIV) and to inform decisions about optimal management for the newborn (see Antiretroviral Management of Newborns with Perinatal HIV Exposure or HIV Infection) (AIII).
  • CD4 T lymphocyte (CD4) cell count should be measured at the initial antenatal visit with review of prior CD4 counts (AI). Patients who have been on ART for ≥2 years and who have had consistent viral suppression and CD4 counts that are consistently >300 cells/mm3 do not need to have their CD4 counts monitored after the initial antenatal visit during this pregnancy, per the Adult and Adolescent Antiretroviral Guidelines (CIII). Patients who have been on ART for <2 years, patients with CD4 counts <300 cells/mm3, and patients with inconsistent adherence and/or detectable viral loads should have CD4 counts monitored every 3 months during pregnancy (CIII).
  • HIV drug-resistance testing (genotypic testing and, if indicated, phenotypic testing) should be reviewed in conjunction with antiretroviral (ARV) history (if prior results are available) and performed during pregnancy in those whose HIV RNA levels are above the threshold for resistance testing (usually >500 copies/mL to 1,000 copies/mL but may be possible for HIV RNA >200 to ≤500 copies in some laboratories). Testing should be conducted before—
    • Initiating ART in ARV-naive pregnant people who have not been previously tested for ARV drug resistance (AII);
    • Initiating ART in ARV-experienced pregnant people (including those who have received pre-exposure prophylaxis) (AIII); or
    • Modifying ARV regimens for people with HIV who become pregnant while receiving ARV drugs or people who have suboptimal virologic response to ARV drugs that were started during pregnancy (AII). See Antiretroviral Drug Resistance and Drug Resistance Testing in Pregnancy.
  • ART should be initiated in pregnant patients prior to receiving the results of ARV-resistance tests. ART should be modified, if necessary, based on the results of resistance testing (AII).
  • Laboratory testing to monitor complications of ARV drugs during pregnancy should be based on what is known about the adverse effects of the drugs an individual is receiving (AIII).
  • Pregnant people with HIV who are taking ART during pregnancy should undergo standard glucose screening (AIII). Some experts suggest performing glucose screening early in pregnancy for those who may be at high risk for gestational diabetes on protease inhibitor–based ART (BIII). For more information on ART, see Antiretroviral Drug Regimens and Maternal and Neonatal Outcomes.
Rating of Recommendations: A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Viral Load and CD4 Cell Count Testing and Monitoring

Viral loads should be monitored more frequently in pregnant individuals than in nonpregnant individuals because of the importance of rapid and sustained viral suppression in preventing perinatal HIV transmission (see Table 5 below). Individuals who are adherent to their antiretroviral therapy (ART) and who do not harbor resistance mutations to the prescribed drugs should achieve viral suppression within 4 to 12 weeks. Individuals with higher viral loads and lower CD4 T lymphocyte (CD4) cell counts are more likely to require more time to achieve viral suppression1,2 than those with lower viral loads and higher CD4 counts. In addition, those using integrase strand transfer inhibitors (INSTIs) are more likely to achieve suppression in much shorter time frames.3-5 Most patients with adequate viral response at 24 weeks of treatment have had at least a 1 log10 viral load decrease within 1 to 4 weeks after starting therapy.6,7

Viral load should be monitored in pregnant patients with HIV at the initial clinic visit with a review of prior viral load levels, 2 to 4 weeks after initiating or changing ART, monthly until undetectable, and at least every 3 months thereafter. If adherence is a concern, especially during early pregnancy, more frequent monitoring is recommended because of the increased risk of perinatal HIV transmission associated with detectable HIV viremia during pregnancy.8-10 Similarly, pregnancy may reduce the drug exposure levels or the efficacy of some drugs; patients who are taking these drugs may require a change in therapy or more frequent viral load monitoring (see Table 6 and Table 7). More frequent viral load monitoring is recommended for those who are receiving regimens containing rilpivirine or cobicistat-boosted elvitegravir, atazanavir, or darunavir. Although increasing the frequency of viral load monitoring may help detect viral rebound, this may be difficult to implement if visit attendance or access to viral load monitoring is limited. In addition, viremia detected in late pregnancy may be challenging to manage, requiring medication changes shortly before delivery (see Pregnant People With HIV Who Are Currently Receiving Antiretroviral Therapy).

Viral load also should be assessed at approximately 36 weeks gestation, or within 4 weeks of delivery, to inform decisions about the mode of infant delivery and optimal treatment for newborns (see Intrapartum Care for People with HIV).

In pregnant patients with HIV, CD4 count should be measured at the initial clinic visit with a review of prior CD4 counts (see Table 5 below). For patients who have been on ART for ≥2 years, have had consistent viral suppression and CD4 counts that are consistently >300 cells/mm3, and are tolerating ART during pregnancy, CD4 count should be monitored only at the initial antenatal visit; CD4 counts do not need to be repeated for these patients during this pregnancy, per the Adult and Adolescent Antiretroviral Guidelines.6,11,12 Patients who have been on ART for <2 years, patients with CD4 counts of <300 cells/mm3, and those with inconsistent adherence and/or detectable viral loads should have CD4 counts monitored every 3 months during pregnancy. The safety of this approach is supported by research that demonstrates that patients who are stable on ART (defined as patients who have viral load levels <50 copies/mL and CD4 counts >500 cells/mm3 for 1 year) are highly unlikely to experience a CD4 count <350 cells/mm3 in the span of a year.13

HIV Drug-Resistance Testing

HIV drug-resistance testing should be reviewed in conjunction with ARV history if prior results are available and performed in pregnant patients with HIV before starting or modifying ART if HIV RNA levels are above the threshold for standard resistance testing (usually >500 copies/mL to 1,000 copies/mL but may be possible for HIV RNA >200 to ≤500 copies in some laboratories) (see Table 5 below). Genotypic testing should be performed. In cases of treatment-experienced individuals with suspected multidrug resistance on failing regimens, phenotypic testing also should be performed. See Drug-Resistance Testing in the Adult and Adolescent Antiretroviral Guidelines and Antiretroviral Drug Resistance and Resistance Testing in Pregnancy for more information on resistance testing, including considerations regarding INSTI genotypic resistance testing. ART should not be delayed while waiting for resistance test results. If the results demonstrate resistance, then the regimen can be adjusted subsequently. HIV drug-resistance testing also should be performed on patients who are taking ART but who have suboptimal viral suppression (i.e., failure to achieve undetectable levels of virus during an appropriate time frame, as noted above) or who have sustained viral rebound to detectable levels after prior viral suppression on ART (see Pregnant People Who Have Not Achieved Viral Suppression on Antiretroviral Therapy and Antiretroviral Drug Resistance and Resistance Testing in Pregnancy). Drug-resistance testing in the setting of virologic failure is most useful when it is performed while patients are receiving ARV drugs or within 4 weeks after discontinuing drugs. Even if more than 4 weeks have elapsed since the ARV drugs were discontinued, resistance testing can still provide useful information to guide therapy, although it may not detect all resistance mutations that were selected by previous ARV regimens.

Other Laboratory Testing and Monitoring

The laboratory tests that are assessed initially and used to monitor complications of ARV drugs during pregnancy should be chosen based on what is known about the adverse effects of the drugs a patient is receiving (see Table 5 below). For example, HLA-B* 5701 testing should be performed if the use of abacavir is anticipated.14-18 Routine hematologic monitoring is recommended for patients who are receiving zidovudine-containing regimens, and routine renal monitoring is recommended for patients who are receiving tenofovir-containing regimens. Liver function should be monitored in all patients who are receiving ART, ideally within 2 to 4 weeks after initiating or changing ARV drugs and approximately every 3 months thereafter or as needed for other clinical care. Hepatic dysfunction has been observed in pregnant women on protease inhibitors (PIs), and the use of any PI during pregnancy has been associated with higher rates of liver function test abnormalities than the rates observed with non-nucleoside reverse transcriptase inhibitor-based ART. Pregnant women in general are more likely than their nonpregnant counterparts to have elevated levels of liver enzymes.19-21

Pregnancy itself increases the risk of glucose intolerance. In a recent meta-analysis, the pooled prevalence of gestational diabetes among women with HIV was 4.42% (95% confidence interval, 3.48% to 5.35%). These rates do not appear to be higher than those in non-HIV populations.22,23 The majority of studies in pregnant women have not demonstrated an association between HIV infection and gestational diabetes,24-28 although some studies with stringent definitions of gestational diabetes did show an increased risk of gestational diabetes in women who were taking PI-based regimens during pregnancy.29 In addition, one study and several case series in nonpregnant adults with HIV have reported an increased risk for incident diabetes after initiation of INSTIs.30-34 Patients with HIV who are on ART during pregnancy should receive the standard glucose screening that is recommended for all pregnant women. However, some experts would perform glucose screening earlier in pregnancy for patients who are receiving PI-based ART that was initiated before pregnancy, in accordance with recommendations for patients with risk factors for glucose intolerance, such as obesity (see Table 5 below).35

In addition to gestational diabetes risk with some ARV classes, risk for weight gain and obesity both during pregnancy and postpartum may be present with integrase inhibitor use, although existing evidence is somewhat inconclusive, with most published data collected in nonpregnant populations.36-43 Current guidelines from the American College of Obstetricians and Gynecologists as well as the National Academy of Medicine recommend that appropriate weight gain, diet, and exercise during pregnancy should be discussed with patients at initial antenatal visits and regularly thereafter.44,45

Other Laboratory Testing and Monitoring

Table 5. HIV-Related Laboratory Monitoring Schedule for Pregnant People With HIVa
Table 5. HIV-Related Laboratory Monitoring Schedule for Pregnant People With HIVa
   
   
   
   

References

  1. Aziz N, Sokoloff A, Kornak J, et al. Time to viral load suppression in antiretroviral-naive and -experienced HIV-infected pregnant women on highly active antiretroviral therapy: implications for pregnant women presenting late in gestation. BJOG. 2013;120(12):1534-1547. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23924192.
  2. Snippenburg W, Nellen F, Smit C, Wensing A, Godfried MH, Mudrikova T. Factors associated with time to achieve an undetectable HIV RNA viral load after start of antiretroviral treatment in HIV-1-infected pregnant women. J Virus Erad. 2017;3(1):34-39. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28275456.
  3. Kintu K, Malaba TR, Nakibuka J, et al. Dolutegravir versus efavirenz in women starting HIV therapy in late pregnancy (DolPHIN-2): an open-label, randomised controlled trial. Lancet HIV. 2020;7(5):e332-e339. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32386721.
  4. Rahangdale L, Cates J, Potter J, et al. Integrase inhibitors in late pregnancy and rapid HIV viral load reduction. Am J Obstet Gynecol. 2016;214(3):385 e381-387. Available at: http://www.ncbi.nlm.nih.gov/pubmed/26928154.
  5. Joao EC, Morrison RL, Shapiro DE, et al. Raltegravir versus efavirenz in antiretroviral-naive pregnant women living with HIV (NICHD P1081): an open-label, randomised, controlled, phase 4 trial. Lancet HIV. 2020;7(5):e322-e331. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32386720.
  6. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. 2022. Available at: https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf.
  7. 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(9):1095-1103. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22441248.
  8. 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(6):394-402. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10432324.
  9. 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(7):1049-1057. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24566097.
  10. Mandelbrot L, Tubiana R, Le Chenadec J, et al. No perinatal HIV-1 transmission from women with effective antiretroviral therapy starting before conception. Clin Infect Dis. 2015;61(11):1715-1725. Available at: http://www.ncbi.nlm.nih.gov/pubmed/26197844.
  11. Gale HB, Gitterman SR, Hoffman HJ, et al. Is frequent CD4+ T-lymphocyte count monitoring necessary for persons with counts >=300 cells/muL and HIV-1 suppression? Clin Infect Dis. 2013;56(9):1340-1343. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23315315.
  12. Girard PM, Nelson M, Mohammed P, Hill A, van Delft Y, Moecklinghoff C. Can we stop CD4+ testing in patients with HIV-1 RNA suppression on antiretroviral treatment? AIDS. 2013;27(17):2759-2763. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23842127.
  13. Di Biagio A, Ameri M, Sirello D, et al. Is it still worthwhile to perform quarterly CD4+ T lymphocyte cell counts on HIV-1 infected stable patients? BMC Infect Dis. 2017;17(1):127. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28166729.
  14. Hetherington S, Hughes AR, Mosteller M, et al. Genetic variations in HLA-B region and hypersensitivity reactions to abacavir. Lancet. 2002;359(9312):1121-1122. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11943262.
  15. Hetherington S, McGuirk S, Powell G, et al. Hypersensitivity reactions during therapy with the nucleoside reverse transcriptase inhibitor abacavir. Clin Ther. 2001;23(10):1603-1614. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11726000.
  16. Mallal S, Nolan D, Witt C, et al. Association between presence of HLA-B*5701, HLA-DR7, and HLA-DQ3 and hypersensitivity to HIV-1 reverse-transcriptase inhibitor abacavir. Lancet. 2002;359(9308):727-732. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11888582.
  17. Mallal S, Phillips E, Carosi G, et al. HLA-B*5701 screening for hypersensitivity to abacavir. N Engl J Med. 2008;358(6):568-579. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18256392.
  18. Saag M, Balu R, Phillips E, et al. High sensitivity of human leukocyte antigen-B*5701 as a marker for immunologically confirmed abacavir hypersensitivity in white and black patients. Clin Infect Dis. 2008;46(7):1111-1118. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18444831.
  19. Huntington S, Thorne C, Anderson J, et al. Does pregnancy increase the risk of ART-induced hepatotoxicity among HIV-positive women? J Int AIDS Soc. 2014;17(4 Suppl 3):19486. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25393995.
  20. Huntington S, Thorne C, Newell ML, et al. Pregnancy is associated with elevation of liver enzymes in HIV-positive women on antiretroviral therapy. AIDS. 2015;29(7):801-809. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25710412.
  21. Sibiude J, Warszawski J, Tubiana R, et al. Liver enzyme elevation in pregnant women receiving antiretroviral therapy in the ANRS-French Perinatal Cohort. J Acquir Immune Defic Syndr. 2019;81(1):83-94. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30702449.
  22. Biadgo B, Ambachew S, Abebe M, Melku M. Gestational diabetes mellitus in HIV-infected pregnant women: A systematic review and meta-analysis. Diabetes Res Clin Pract. 2019;155:107800. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31362053.
  23. Jiwani A, Marseille E, Lohse N, Damm P, Hod M, Kahn JG. Gestational diabetes mellitus: results from a survey of country prevalence and practices. J Matern Fetal Neonatal Med. 2012;25(6):600-610. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21762003.
  24. Tang JH, Sheffield JS, Grimes J, et al. Effect of protease inhibitor therapy on glucose intolerance in pregnancy. Obstet Gynecol. 2006;107(5):1115-1119. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16648418.
  25. Haeri S, Shauer M, Dale M, et al. Obstetric and newborn infant outcomes in human immunodeficiency virus-infected women who receive highly active antiretroviral therapy. Am J Obstet Gynecol. 2009;201(3):315 e311-315. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19733286.
  26. Jao J, Wong M, Van Dyke RB, et al. Gestational diabetes mellitus in HIV-infected and -‍uninfected pregnant women in Cameroon. Diabetes Care. 2013;36(9):e141-142. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23970721.
  27. Samuels EON, Isah AY, Offiong RA, Ekele BA. Foeto-maternal outcome of HIV-positive pregnant women on highly active antiretroviral therapy. Int J Med Biomed Res. 2014;3(3):202-208. Available at: https://www.ajol.info/index.php/ijmbr/article/download/111608/101385.
  28. Mmasa KN, Powis K, Sun S, et al. Gestational diabetes in women living with HIV in Botswana: lower rates with dolutegravir- than with efavirenz-based antiretroviral therapy. HIV Med. 2021;Epub ahead of print. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34003565.
  29. Soepnel LM, Norris SA, Schrier VJ, et al. The association between HIV, antiretroviral therapy, and gestational diabetes mellitus. AIDS. 2017;31(1):113-125. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27677165.
  30. Hailu W, Tesfaye T, Tadesse A. Hyperglycemia after dolutegravir-based antiretroviral therapy. Int Med Case Rep J. 2021;14:503-507. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34349567.
  31. Hirigo AT, Gutema S, Eifa A, Ketema W. Experience of dolutegravir-based antiretroviral treatment and risks of diabetes mellitus. SAGE Open Med Case Rep. 2022;10:2050313X221079444. Available at: https://www.ncbi.nlm.nih.gov/pubmed/35223037.
  32. Lamorde M, Atwiine M, Owarwo NC, et al. Dolutegravir-associated hyperglycaemia in patients with HIV. Lancet HIV. 2020;7(7):e461-e462. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32105626.
  33. Nolan NS, Adamson S, Reeds D, O'Halloran JA. Bictegravir-based antiretroviral therapy-associated accelerated hyperglycemia and diabetes mellitus. Open Forum Infect Dis. 2021;8(5):ofab077. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33981777.
  34. O'Halloran JA, Sahrmann J, Parra-Rodriguez L, et al. Integrase strand transfer inhibitors are associated with incident diabetes mellitus in people with HIV. Clin Infect Dis. 2022. Available at: https://www.ncbi.nlm.nih.gov/pubmed/35521785.
  35. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 190 summary: gestational diabetes mellitus. Obstet Gynecol. 2018;131(2):406-408. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29370044.
  36. Caniglia EC, Shapiro R, Diseko M, et al. Weight gain during pregnancy among women initiating dolutegravir in Botswana. EClinicalMedicine. 2020;29-30:100615. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33437946.
  37. Bengtson AM, Phillips TK, le Roux SM, et al. Postpartum obesity and weight gain among human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women in South Africa. Matern Child Nutr. 2020;16(3):e12949. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31943774.
  38. Floridia M, Masuelli G, Tassis B, et al. Weight gain during pregnancy in women with HIV receiving different antiretroviral regimens. Antivir Ther. 2021;25(6):315-325. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33459635.
  39. Bourgi K, Rebeiro PF, Turner M, et al. Greater weight gain in treatment naive persons starting dolutegravir-based antiretroviral therapy. Clin Infect Dis. 2019;70(7):1267-1274. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31100116.
  40. Venter WDF, Sokhela S, Simmons B, et al. Dolutegravir with emtricitabine and tenofovir alafenamide or tenofovir disoproxil fumarate versus efavirenz, emtricitabine, and tenofovir disoproxil fumarate for initial treatment of HIV-1 infection (ADVANCE): week 96 results from a randomised, phase 3, non-inferiority trial. Lancet HIV. 2020;7(10):e666-e676. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33010240.
  41. Joseph NT, Satten GA, Williams RE, et al. The effect of antiretroviral therapy for the treatment of HIV-1 in pregnancy on gestational weight gain. Clin Infect Dis. 2021. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34864949.
  42. Leonard MA, Cindi Z, Bradford Y, et al. Efavirenz pharmacogenetics and weight gain following switch to integrase inhibitor-containing regimens. Clin Infect Dis. 2021;73(7):e2153-e2163. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32829410.
  43. Zash R, Caniglia EC, Diseko M, et al. Maternal weight and birth outcomes among women on antiretroviral treatment from conception in a birth surveillance study in Botswana. J Int AIDS Soc. 2021;24(6):e25763. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34176240.
  44. Patient Safety Quality Committee SfM-FME, Gibson KS, Toner LE. Society for Maternal-Fetal Medicine special statement: updated checklists for pregnancy management in persons with HIV. Am J Obstet Gynecol. 2020;223(5):B6-B11. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32861690.
  45. Institute of Medicine (US) and National Research Council (US) Committee to Reexamine IOM Pregnancy Weight Guidelines. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington (DC): 2009. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20669500

Antepartum Care

Initial Evaluation and Continued Monitoring of HIV-Related Assessments During Pregnancy

Panel’s Recommendations
  • The plasma HIV RNA levels of pregnant people with HIV should be monitored at the initial antenatal visit with a review of prior HIV RNA levels (AI), 2 to 4 weeks after initiating (or changing) antiretroviral therapy (ART) (BI), monthly until RNA levels are undetectable (BIII), and then at least every 3 months during pregnancy (BIII). HIV RNA levels also should be assessed at approximately 36 weeks gestation, or within 4 weeks of delivery, to inform decisions about mode of delivery (see Intrapartum Care for People with HIV) and to inform decisions about optimal management for the newborn (see Antiretroviral Management of Newborns with Perinatal HIV Exposure or HIV Infection) (AIII).
  • CD4 T lymphocyte (CD4) cell count should be measured at the initial antenatal visit with review of prior CD4 counts (AI). Patients who have been on ART for ≥2 years and who have had consistent viral suppression and CD4 counts that are consistently >300 cells/mm3 do not need to have their CD4 counts monitored after the initial antenatal visit during this pregnancy, per the Adult and Adolescent Antiretroviral Guidelines (CIII). Patients who have been on ART for <2 years, patients with CD4 counts <300 cells/mm3, and patients with inconsistent adherence and/or detectable viral loads should have CD4 counts monitored every 3 months during pregnancy (CIII).
  • HIV drug-resistance testing (genotypic testing and, if indicated, phenotypic testing) should be reviewed in conjunction with antiretroviral (ARV) history (if prior results are available) and performed during pregnancy in those whose HIV RNA levels are above the threshold for resistance testing (usually >500 copies/mL to 1,000 copies/mL but may be possible for HIV RNA >200 to ≤500 copies in some laboratories). Testing should be conducted before—
    • Initiating ART in ARV-naive pregnant people who have not been previously tested for ARV drug resistance (AII);
    • Initiating ART in ARV-experienced pregnant people (including those who have received pre-exposure prophylaxis) (AIII); or
    • Modifying ARV regimens for people with HIV who become pregnant while receiving ARV drugs or people who have suboptimal virologic response to ARV drugs that were started during pregnancy (AII). See Antiretroviral Drug Resistance and Drug Resistance Testing in Pregnancy.
  • ART should be initiated in pregnant patients prior to receiving the results of ARV-resistance tests. ART should be modified, if necessary, based on the results of resistance testing (AII).
  • Laboratory testing to monitor complications of ARV drugs during pregnancy should be based on what is known about the adverse effects of the drugs an individual is receiving (AIII).
  • Pregnant people with HIV who are taking ART during pregnancy should undergo standard glucose screening (AIII). Some experts suggest performing glucose screening early in pregnancy for those who may be at high risk for gestational diabetes on protease inhibitor–based ART (BIII). For more information on ART, see Antiretroviral Drug Regimens and Maternal and Neonatal Outcomes.
Rating of Recommendations: A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Other Laboratory Testing and Monitoring

Table 5. HIV-Related Laboratory Monitoring Schedule for Pregnant People With HIVa
Table 5. HIV-Related Laboratory Monitoring Schedule for Pregnant People With HIVa
   
   
   
   

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