HIV infection

• Identification of HIV infection in pregnancy is essential for the prevention of perinatal transmission. An opt-out approach has been shown to increase acceptance rates for HIV testing in pregnant women and is the recommended approach to universal prenatal screening.
• Goal of HIV treatment in pregnancy is to prevent vertical transmission primarily by reducing maternal viral load to <1000 copies/mL, and preferably below the limit of detection of the assay (currently <48copies/mL).
• Rate of perinatal transmission is correlated to maternal viral load but many other factors also play a role.
• All HIV positive women should be offered a combination antiretroviral therapy regardless of clinical or immunological diagnosis to maximally suppress viral replication, reduce the risk of perinatal transmission and minimize the risk of development of resistant virus. In women already on HAART, and with low viral load, the regimen is usually continued. In women not on therapy with a CD4 count >350, HAART can be initiated in the second trimester. In women with a CD4 count <=350, HAART should be initiated even in the first trimester.
• A common current regimen for HAART in pregnancy is Combivir and Kaletra.
• Women with CD4 counts <200 should receive bactrim prophylaxis. Women with CD4 counts <100 should receive azythromycin prophylaxis (1200mg weekly)
• Plasma HIV-1 RNA levels should be monitored each trimester.
• Women with a viral load >1000 copies/mL should be counseled regarding the benefit of elective cesarean delivery at 38 weeks to reduce the risk of transmission.
• With effective antiretroviral therapy leading to undetectable viral load, elective cesarean delivery for viral load ≥1000, and formula feeding, the risk of perinatal transmission is reduced to <2%.