Perinatal Providers
Resources for Perinatal Providers
Our brochures are currently unavailable on our website. Please message Cynthia Gutierrez at cynthia.gutierrez@ucsf.edu if you need a copy of a brochure.
Care for Women Living with HIV
Overview
People living with HIV can experience healthy pregnancies and healthy, fulfilling sex lives across the reproductive and sexual lifespan. We providers can help people living with and affected by HIV successfully achieve their family building and sexual health goals by engaging our patients proactively in health promotion and cultivating a trusting and supportive therapeutic alliance. A healthy pregnancy begins with a focus on wellness and risk mitigation prior to conception. The risk of HIV transmission to sexual partners and infants is nearly eliminated with the use of 1) universal preconception and prenatal HIV testing, 2) adherence to fully suppressive antiretroviral therapy, 3) screening and treating sexually transmitted infections, 4) infant post-exposure prophylaxis and 5) safe infant feeding practices, Preconception, pregnancy, and postpartum periods can often prove to be unique opportunities to engage birthing people, their partners, and sometimes other family and community members in health-promoting behavior. Improved birth outcomes and wellness more generally may be promoted with interventions such as adequate birth spacing, immunization, weight optimization, addressing food insecurity, cessation of alcohol, tobacco and substance use, housing stabilization, mental health care including safety planning, and harm reduction approaches such as opiate replacement and syringe exchange
We encourage all providers and institutions to create and promote a non-judgmental, trauma-sensitive, family-inclusive, and resiliency-based approach to reproductive and sexual healthcare for those living with HIV. It is important to recognize that many adults living with HIV have experienced significant stigma in the community and during receipt of healthcare related to their sexual and reproductive desires and behavior. This stigma is fueled by many forms of structural violence including but not limited to racism, classism, sexism, homophobia, transphobia, and anti-immigrant atmosphere and policies. Even with open-minded intentions on the part of individual medical providers, our individual implicit biases and structure of healthcare itself may reinforce trauma, stigma, and health disparities experienced by those living with HIV. As such, we encourage all providers to engage in an iterative and lifelong process of identifying and addressing such sources of trauma and stigma within themselves and the settings in which we work. HIVE stands in solidarity with those individuals and organizations promoting patient autonomy, equity and sexual and reproductive justice.
The DHHS National Perinatal HIV Guidelines (Dec 2018) include recommendations regarding the care of people during the preconception period as well as during pregnancy, intrapartum and postpartum. When language from the DHHS guidelines is copied directly from guidelines, we use italics below. We acknowledge Panel members? generous, voluntary government service in creating these guidelines and contributing to establishing standards of reproductive healthcare for those living with HIV.
Given research findings and national guidelines do not address all elements of clinical care, we also include clinical practices currently followed at HIVE and will do our best to maintain this website content to reflect current practices and up-to-date guidelines.
We encourage providers to use the National Perinatal HIV Hotline (888) 448-8765) ? a 24/7 professional resource for preconception, pregnancy, intrapartum, postpartum and management of HIV exposure in infants.
HIV Testing in Reproductive and Sexual Health Settings
Early identification and diagnosis of HIV through universal testing of sexually active people and of people who inject drugs is a critical step in ensuring optimal health outcomes for people living with HIV, as well as eliminating sexual and perinatal HIV transmission. As with all care provision, HIV testing should be conducted in a confidential setting in the patient?s language of choice with adequate opportunity for patients to ask questions and receive any additional education needed to make an informed choice. Opt-out HIV testing ? in which HIV testing is recommended and performed and patients are given the opportunity to decline ? has been found to be acceptable to patients, including in the perinatal setting, and is the current standard of care.
In 2006, the CDC published Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. In 2018, the American College of Obstetricians and Gynecologists published Prenatal and perinatal human immunodeficiency virus testing. (ACOG Committee Opinion No. 752). The ACOG HIV testing recommendations are listed below in italics.
Preconception/Interconception Care for Those Living with HIV
In 2006, the Centers for Disease Control and Prevention published guidelines for the provision of preconception care for women in the US. The DHHS National Perinatal HIV Guidelines expanded upon these baseline recommendations to include the following preconception goals and practices specific for those living with HIV (italics represent language copied directly from the DHHS guidelines).
- Discuss reproductive options, actively assess women?s pregnancy intentions on an ongoing basis throughout the course of care, and, when appropriate, make referrals to experts in HIV and women?s health, including experts in reproductive endocrinology and infertility when necessary.
- The primary treatment goal for people of childbearing potential who are on ART and planning a pregnancy should be sustained suppression of plasma viral load (below the limit of) detection prior to conception. This is important for the health of the patient and to decrease the risk of both perinatal transmission and sexual transmission to a partner without HIV (see Reproductive Options).
- Counsel patients on safer sex practices (including condoms and ART) that prevent HIV transmission to sexual partners, protect patients from acquiring sexually transmitted infections, and reduce the risk of acquiring resistant strains of HIV (see Reproductive Options).
- Encourage sexual partners to receive HIV counseling and testing so that they can seek HIV care if they have HIV or seek advice about oral pre-exposure prophylaxis (PrEP) and other measures to prevent HIV acquisition if they do not have HIV.
- Counsel people of childbearing potential on eliminating the use of alcohol, tobacco, and other drugs of abuse. Appropriately treat (e.g., with methadone or buprenorphine) and manage (e.g., provide access to syringe services program) the use of these drugs when elimination is not feasible.
- Counsel patients contemplating pregnancy to take a daily multivitamin that contains 400 mcg of folic acid to help prevent certain birth defects. Patients who are at higher risk of having a child with neural tube defects than the baseline population are candidates for higher (1 to 4 mg) dose folic acid supplementation.
- Educate and counsel women about risk factors for perinatal transmission of HIV, strategies to reduce those risks, potential effects of HIV or of antiretroviral (ARV) drugs given during pregnancy on pregnancy course and outcomes, and the recommendation that women living with HIV in the United States not breastfeed because of the risk of transmission of HIV to their infants and the availability of safe and sustainable infant feeding alternatives.
- When prescribing antiretroviral therapy (ART) to women of childbearing age, consider the regimen?s effectiveness, an individual?s hepatitis B virus (HBV) status, the potential for teratogenicity, and possible adverse outcomes for mother and fetus.21-23
- Provide counseling about the potential risk of neural tube defects when dolutegravir is taken during conception to patients who are currently receiving dolutegravir as part of their ARV regimen or who wish to be started on dolutegravir, see Interim Recommendations about the Use of Dolutegravir at the Time of Conception and During Pregnancy in Teratogenicityand Recommendations for the Use of Antiretroviral Drugs During Pregnancy.
- Use the preconception period to modify the ART regimen of women who are contemplating pregnancy to optimize virologic suppression and minimize potential adverse effects, see Recommendations for Use of Antiretroviral Drugs in Pregnancyand Table 7.
- Recognize that women with perinatally acquired HIV may have special needs24 (see Women with Perinatal HIV Infection).
- Evaluate and manage therapy-associated side effects (e.g., hyperglycemia, anemia, hepatotoxicity) that may adversely impact maternal-fetal health outcomes.
- Administer all vaccines as indicated, (see Guidance for Vaccine Recommendations for Pregnant and Breastfeeding Womenand 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host) including vaccines for influenza, pneumococcus, HBV, and tetanus. All women, including those with HIV, should receive Tdap vaccination during each pregnancy.
- Offer all women who do not currently desire pregnancy effective and appropriate contraceptive methods to reduce the likelihood of unintended pregnancy. Women living with HIV can use all available contraceptive methods, including hormonal contraception (e.g., pill, patch, ring, injection, implant) and intrauterine devices (IUDs).25 Providers should be aware of potential interactions between ARV drugs and hormonal contraceptives that could lower contraceptive efficacy (see Table 3 below).
Offer emergency contraception as appropriate
DHHS General Principles Regarding Use of Antiretroviral Drugs during Pregnancy
- Initial evaluation of pregnant women living with HIV should include an assessment of HIV disease status and plans to initiate, continue, or modify antiretroviral therapy (ART) (AI). The National Perinatal HIV Hotline (888-448-8765) provides free clinical consultation on all aspects of perinatal HIV care.
- All pregnant women living with HIV should initiate ART as early in pregnancy as possible, regardless of their plasma HIV RNA copy number or CD4 T lymphocyte count, to prevent perinatal transmission (AI). It is recommended that the HIV viral load be maintained below the limit of detection throughout pregnancy and lifetime of the individual living with HIV (AII).
- To minimize the risk of perinatal transmission, antiretroviral (ARV) drugs should be administered at all time points (including antepartum and intrapartum) to the woman as well as postnatally to the neonate (AI).
- The known benefits and potential risks of all medications, including ARV drugs used during pregnancy and postpartum, should be discussed with all women living with HIV (AIII).
- The importance of adherence to ARV drug regimens should be emphasized during patient counseling (AII).
- ARV drug-resistance genotype studies should be performed before starting ARV drug regimens in women who are ARV-naive (AII) or ARV-experienced (AIII) and before modifying ARV drug regimens (AII) in women whose HIV RNA levels are above the threshold for resistance testing (i.e., >500 to 1,000 copies/mL).
- In pregnant women who are not already receiving ART, ART should be initiated before results of drug-resistance testing are available, because earlier viral suppression has been associated with lower risk of transmission. If ART is initiated before results are available, the regimen should be modified, if necessary, based on resistance assay results (BIII).
- Coordination of services among prenatal care providers, primary care and HIV specialty care providers, and, when appropriate, mental health and drug abuse treatment services, intimate partner violence support services, and public assistance programs is essential to help ensure that women living with HIV adhere to their ARV drug regimens (AII).
- Providers should initiate counseling about key intrapartum and postpartum considerations during pregnancy, including mode of delivery, maternal lifelong HIV therapy, family planning and contraceptive options, infant feeding, infant ARV prophylaxis, timing of infant diagnostic testing, and neonatal circumcision (AIII).
Recommendations for Use of Antiretroviral Drugs During Pregnancy
At HIVE, we engage in a shared decision-making process among pregnant people already taking or considering initiating or restarting Dolutegravir (DTG) during early first trimester pregnancy, prioritizing the autonomy and sovereignty of the pregnant person. We discuss the benefits (e.g. low pill burden, tolerability, potency, high barrier to resistance) and potential risks (specifically, neural tube defects [NTD]), including reviewing the Botswana data showing 0.30% vs. 0.10% risk of NTD among infants born to women taking DTG vs. non-DTG ART at conception. HIVE clinicians also discuss with patients the timing of neural tube closure (i.e. by 4 weeks after conception/6 weeks after last menstrual period). We facilitate with our patients a self-assessment of their priorities, level of risk aversion, and ART options and have had some patients switch to a non-DTG regimen preconception or during early first trimester and have had other patients decide to continue DTG throughout early pregnancy.
DHHS: Table 10. Antiretroviral Drug Use in Pregnant Women with HIV: Pharmacokinetic and Toxicity Data in Human Pregnancy and Recommendations for Use in Pregnancy
Monitoring of the Pregnant Person and Fetus During Pregnancy
In addition to the clinical management described in the DHHS Perinatal HIV Guidelines, HIVE clinicians obtain monthly HIV RNA levels throughout pregnancy even once viral suppression is documented. It is well-documented that self-reported adherence measures are unreliable and viremia near delivery may occur, even among pregnant people who experience viral suppression earlier in pregnancy. If rebound viremia is documented later in pregnancy, clinicians can optimize an ART regimen, assess for HIV resistance, initiate adherence interventions including directly observed therapy as indicated, and obtain more frequent viral load monitoring just prior to delivery in order to minimize the risk of in-utero perinatal HIV transmission and avert the need for a cesarean delivery (see below).
DHHS: Antiretroviral Drug Resistance and Resistance Testing in Pregnancy
- HIV drug-resistance genotype studies should be performed in women living with HIV whose HIV RNA levels are above the threshold for resistance testing (i.e., >500 to 1,000 copies/mL) before:
- Initiating antiretroviral therapy (ART) in antiretroviral (ARV)-naive pregnant women who have not been previously tested for ARV resistance (AII),
- Initiating ART in ARV-experienced pregnant women (AIII), or
- Modifying ART regimens for women who are entering pregnancy while receiving ARV drugs or who have suboptimal virologic response to ARV drugs started during pregnancy (AII).
- ART should be initiated in pregnant women prior to receiving results of ARV-resistance studies; ART should be modified, if necessary, based on the results of the resistance assay (BIII).
- If an integrase strand transfer inhibitor (INSTI) is being considered for an ART-naive patient and INSTI resistance is a concern, providers should supplement standard resistance testing with a specific INSTI genotypic resistance assay (BIII). INSTI resistance may be a concern because:
- A patient received prior treatment that included an INSTI,
- A patient has a history with a sexual partner on INSTI therapy, or
- A patient is starting or changing ART regimen late in pregnancy, in which case an INSTI might be selected because of its ability to rapidly decrease viral load.
- Documented zidovudine resistance does not affect the indications for use of intrapartum zidovudine (BIII).
- Choice of ARV regimen for an infant born to a woman with known or suspected drug resistance should be determined in consultation with a pediatric HIV specialist, preferably before delivery (see Antiretroviral Management of Newborns with Perinatal HIV Exposure or Perinatal HIV) (AIII).
- Pregnant women living with HIV should be given ART to maximally suppress viral replication, which is the most effective strategy for preventing development of resistance and minimizing risk of perinatal transmission (AII).
- All pregnant and postpartum women should be counseled about the importance of adherence to prescribed ARV medications to reduce the potential for development of resistance (AII).
Lack of Viral Suppression
At HIVE, we track HIV viral loads at least monthly during pregnancy and, sometimes, more frequently if consistent viral suppression is not documented, especially close to delivery. The goal is viral suppression throughout pregnancy and, certainly, by the time of delivery given maternal viremia is the strongest predictor of intrapartum HIVE transmission. Viral suppression helps to optimize the pregnant person?s health long-term, decreases the risk of in-utero transmission and enables a trial of labor. If a pregnant person has an HIV RNA level >1,000 copies/mL close to term or just prior to an indicated preterm delivery, HIVE clinicians will typically offer admission to the hospital for directly-observed therapy, with modification of ART regimen if resistance is suspected. If not already prescribed and viremia is documented in the 3rd trimester, an Integrase Inhibitor will be added to the regimen in order to expedite viral decay. We will typically obtain HIV viral loads every few days (asking the laboratory to run the lab ?stat?) after ART modification and/or initiation of directly observed therapy in the late 3rd trimester in order to document viral decay and avert the need for a cesarean delivery done for the purpose of HIV prevention.
DHHS: Intrapartum Antiretroviral Therapy/Prophylaxis
- Women should continue taking their antepartum combination antiretroviral therapy (ART) on schedule as much as possible during labor and before scheduled cesarean delivery (AIII).
- Intravenous (IV) zidovudine:
- Should be administered to women living with HIV if HIV RNA is known or suspected to be >1,000 copies/mL (or if HIV RNA is unknown) near delivery (AI).
- Is not required for women who are receiving ART regimens and who have HIV RNA ?50 copies/mL during late pregnancy and near delivery and no concerns regarding adherence to the ART regimen (BII).
- May be considered for women with HIV RNA between 50 and 999 copies/mL. There are inadequate data to determine whether administration of IV zidovudine to women with HIV RNA levels between 50 and 999 copies/mL provides any additional protection against perinatal transmission. This decision can be made on a case by case basis, taking into consideration the woman’s recent ART adherence, her preferences, and involving expert consultation if needed (CII).
Transmission and Mode of Delivery
At HIVE, when a patient has an HIV RNA > 1000 copies/mL in the late 3rd trimester, as noted in above in Lack of Viral Suppression section we typically offer admission to the Family Birth Center for directly observed therapy and additional wrap-around support including community-based resources. With the use of optimal ART and HIV viral load monitoring every few days, we have helped many patients achieve a viral load < 1000 copies/mL prior to delivery and, thus, undergo a trial of labor. While elective cesarean delivery (i.e. 38 weeks gestation, no labor, no ruptured membranes) appears to minimize the risk of intrapartum HIV transmission in the absence of maternal combination ART and more potent infant post-exposure prophylaxis (PEP) regimens, there are no data demonstrating elective cesarean delivery is protective if a woman is taking combination ART and/or the infant receives more than just prophylactic AZT as PEP. Moreover, elective cesarean delivery among those with HIV is associated with increased maternal and infant morbidity compared to vaginal delivery.
Other Intrapartum Management Considerations
In addition to the DHHS recommendations above, at HIVE we generally avoid artificial rupture of membranes (AROM), regardless of degree of maternal viremia, unless delivery is clearly imminent or we have run out of options for labor induction or augmentation and have one last opportunity to avert a cesarean delivery. This avoidance of AROM is driven by a desire to minimize the risk of chorioamnionitis which is associated with worse maternal and infant outcomes and, in the setting of maternal viremia and/or absence of maternal antiretrovirals, may increase the risk of intrapartum HIV transmission.
- HIVE uses an electronic version of our patients are admitted prior to delivery at the Family Birth Center. We review these orders with the Birth Center team prior to anticipated admission for delivery.
- HIVE uses an electronic version of HIV-Exposed Infant Orderswhen our patients are admitted prior to delivery at the Family Birth Center. We review these orders with the Nursery team prior to anticipated admission for delivery.
- Additional resources include: Pediatric AIDS Chicago Prevention Initiative (PACPI) 24/7 Illinois Perinatal HIV Hotline Best Practices for Caring for Women living with HIV during Labor
Postpartum Follow-Up of Women Living with HIV
Loss to follow-up and challenges with ART adherence postpartum are truly global health crises. While we have been successful at eliminating perinatal HIV transmission in San Francisco since 2005, numerous women living with HIV who received care at HIVE have died within a few years of delivery. Establishing linkage to postpartum and ongoing primary HIV care is ideally achieved early in pregnancy. It is critical to identify and address individual and collective barriers to adherence, including but not limited to stigma-related non-disclosure of HIV status, depression, interpersonal violence, and substance use as well as structural issues such as disjointed healthcare systems, suboptimal communication among prenatal, pediatric, and primary care teams, and implicit bias in healthcare that drives health disparities based on race. It is also critical to identify and celebrate facilitators of adherence, to link people with HIV to promising adherence interventions, and to foster resiliency and community support with the goal of not only encouraging engagement in long-term HIV-specific care but indeed promoting true holistic wellness.
- HIVE uses an electronic version of when our patients are admitted prior to delivery at the Family Birth Center. We review these orders with the Birth Center team prior to anticipated admission for delivery.
- Information about infant feeding may be found
Care for those in HIV-serodifferent relationships
and others potentially at risk of HIV acquisition
Preconception/Interconception Care for those in HIV-serodifferent relationships or those at risk for HIV acquisition
Loss to follow-up and challenges with ART adherence postpartum are truly global health crises. While we have been successful at eliminating perinatal HIV transmission in San Francisco since 2005, numerous women living with HIV who received care at HIVE have died within a few years of delivery. Establishing linkage to postpartum and ongoing primary HIV care is ideally achieved early in pregnancy. It is critical to identify and address individual and collective barriers to adherence, including but not limited to stigma-related non-disclosure of HIV status, depression, interpersonal violence, and substance use as well as structural issues such as disjointed healthcare systems, suboptimal communication among prenatal, pediatric, and primary care teams, and implicit bias in healthcare that drives health disparities based on race. It is also critical to identify and celebrate facilitators of adherence, to link people with HIV to promising adherence interventions, and to foster resiliency and community support with the goal of not only encouraging engagement in long-term HIV-specific care but indeed promoting true holistic wellness.
- HIVE uses an electronic version of when our patients are admitted prior to delivery at the Family Birth Center. We review these orders with the Birth Center team prior to anticipated admission for delivery.
- Information about infant feeding may be found
Antepartum Care for Those in HIV-serodifferent relationships or those at risk for HIV acquisition
Pregnant people who are in HIV-serodifferent relationships or at-risk for HIV acquisition can benefit from HIV-informed prenatal care that is non-judgmental and evidence-based. In addition to routine, comprehensive prenatal care, antepartum management may also include:
- Education about HIV prevention and risk mitigation strategies during pregnancy including:
- Treatment as Prevention (TasP). It is now understood that those living with HIV who have a consistently undetectable HIV viral load and no active sexually transmitted infections do not transmit HIV to sexual partners.
- Pre-exposure/Post-exposure Prophylaxis (PrEP/PEP)
- PleasePrEPMe.org
- HIVE educational material
- DHHS educational material
- Serial HIV testing using a combination antigen/antibody assay. The frequency of testing should be driven by the timing and pattern of exposure (e.g. frequency of condomless sex with partner with HIV, partner HIV viral load) as well as patient request. HIVE offers serial HIV antigen/antibody testing for pregnant patients whose partners are living with HIV and will typically supplement with nucleic acid amplification testing (i.e. HIV RNA), the frequency of which is driven by risk factors for HIV acquisition and timing of exposure.
- Screening for acute HIVincluding education about and evaluation of symptoms and, when clinically indicated, performing nucleic acid amplification testing (e.g. HIV RNA) as noted above.
- Engaging a partner living with HIV in HIV-specific medical care including ART and serial HIV viral load monitoring.
- Consider monthly HIV viral load monitoring of partner with HIV during pregnancy and breastfeeding.
- Obtaining Release of Information in order to access partner?s medication history, viral load results and/or to discuss the case with the partner?s medical provider directly.
- A sample SOAP note for the prenatal care of someone in a serodifferent relationship may be found here: HIVE SOAP Note for Prenatal Care of HIV-negative Women with Sex Partners Living with HIV. Please feel free to use or modify this template to fit your needs.
Intrapartum Care for those in HIV-serodifferent relationships or those at risk of HIV acquisition
The key element that distinguishes intrapartum management for those at risk of HIV acquisition includes a thorough assessment of the likelihood and timing of HIV exposure and management accordingly. Guided by a patient?s particular circumstances, intrapartum management may include:
- Confidential, non-judgmental inquiry about the most recent condomless sex or other exposure risk behavior (e.g. sharing injection drug equipment, occupational exposure to HIV), HIV status of sexual and/or drug-using partners (including timing of most recent test if thought to be HIV-negative), HIV viral load of partner if known to be living with HIV (including timing of most recent viral load)
- Evaluation of acute HIV including a complete review of acute HIV symptoms
- If no documentation of HIV testing to cover the most recent window of exposure, performing rapid HIV antigen/antibody testing done upon admission, with testing available 24/7 with results available within an hour of performing.
- If rapid HIV testing is positive:
- Presumptively initiate oral integrase-inhibitor-based ART (and intravenous AZT if in labor, has ruptured membranes or to undergo cesarean within 3-4 hours) while awaiting confirmatory testing
- Obtain an HIV viral load (e.g. HIV RNA) ? requesting the laboratory to perform the assay as ?STAT.?
- The decision about delivery route may be complex. There is no evidence that cesarean delivery decreases the risk of HIV transmission in the setting of labor or ruptured membranes. If a patient is not yet in labor and has intact membranes, the clinician should consider gestational age, timing of HIV RNA results, and obstetrical indication for delivery to help determine the optimal timing and route of delivery. It is important to involve the patient in this delivery route decision-making.
- The National Perinatal HIV Hotlineis available 24/7 to assist in the management of positive rapid HIV test results and other HIV-related perinatal care. (888) 448-8765
- If rapid HIV testing is negative but a patient endorses symptoms of acute HIV in the setting of very recent known or likely HIV exposure:
- Consider presumptively initiating oral integrase-inhibitor-based ART (and intravenous AZT if in labor, has ruptured membranes or to undergo cesarean within 3-4 hours) while awaiting confirmatory testing including the use of intravenous AZT
- Obtain an HIV viral load or nucleic acid test (e.g. HIV RNA or APTIMA-1) ? requesting the laboratory to perform the assay as ?STAT.?
- The decision about delivery route may be complex. There is no evidence that cesarean delivery decreases the risk of HIV transmission in the setting of labor or ruptured membranes. If a patient is not yet in labor and has intact membranes, the clinician should consider gestational age, timing of HIV RNA results, and obstetrical indication for delivery to help determine the optimal timing and route of delivery. It is important to involve the patient in this delivery route decision-making.
- Given PEP is most effective when initiated as soon as possible after exposure, a patient?s intrapartum status should not influence the initiation of PEP when indicated.
- If there has been a recent exposure to HIV, this information may inform infant feeding recommendations including pumping/saving breast milk while awaiting confirmatory HIV testing that covers the potential window of exposure and/or while awaiting the completion of PEP.
- Patient educational material on the use of PEP during breastfeeding may be found here.
- Evaluation if the patient is a candidate for pre-exposure prophylaxis (PrEP)
- The timing of PrEP initiation may be guided by patient preference and anticipated future HIV exposure.
- Patient educational material on the use of PrEP during breastfeeding may be found here.
- Infant management:
- If the pregnant patient has a documented negative HIV testing without recent HIV exposure that would call these results into question, there is no need to have the infant undergo HIV NAT testing (i.e. HIV RNA or DNA) or receive prophylactic PEP.
- If there is any concern for acute HIV prior to delivery or the pregnant patient?s rapid testing is positive, National Perinatal HIV Hotline is available 24/7 to assist in infant management including the use of PEP and HIV testing. (888) 448-8765
Postpartum Care for Those in HIV-serodifferent relationships or those at risk of HIV acquisition
In addition to standard postpartum management, care for postpartum people in a serodifferent relationship with a partner living with HIV may include discussion about on-going HIV prevention interventions such as PrEP, PEP and treatment as prevention (TasP). PrEP is generally considered safe during breastfeeding. Patient education on the use of PEP and PrEP during and, ideally, clinicians will create an inviting and non-judgmental atmosphere such that patients will feel comfortable sharing honestly about their behavior as well as their infant feeding preferences and concerns.
This page was curated by Karen A. Scott, MD, MPH, FACOG and Deborah Cohan, MD, MPH??
While we have worked hard to include many informative resources, we understand that this is not an exhaustive resource. Thank you for your support of our work. If you have any questions, please contact Caroline at?caroline@hiveonline.org. This page was last updated on 9/23/19.
Guidelines, Recommendations, & Research
What’s New in the Guidelines
“The section now describes how the Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission (the Panel) evaluates the risks and benefits of antiretroviral (ARV) drugs during pregnancy, develops recommendations about the use of ARV drugs in pregnancy, and collaborates with the Panel on Antiretroviral Guidelines for Adults and Adolescents to address concerns related to drug safety in pregnancy.”
HIV/AIDS and Pregnancy
“Some pregnant women with HIV/AIDS may not know that they have it. So it is important that all women who are pregnant or planning to get pregnant have an HIV test as early as possible. Because most pregnant women with HIV/AIDS and their babies take HIV/AIDS medicines, few babies in the United States get HIV.”
Our Gift to You: A Manifesto toward Resilience and Healing
Inspired by a symposium we hosted earlier this year called ?Beyond Compassion: Caring for Women with a History of Trauma,? and driven to spread lessons learned through love and art, we created this manifesto for you.
Birth Outcomes for Pregnant Women with HIV Using Tenofovir?Emtricitabine
“Using data from two U.S.-based cohort studies, we compared the risk of adverse birth outcomes among infants with in utero exposure to ZDV?3TC?LPV/r, TDF?FTC?LPV/r, or TDF?FTC with ritonavir-boosted atazanavir (ATV/r). We evaluated the risk of preterm birth (<37 completed weeks of gestation), very preterm birth (<34 completed weeks), low birth weight (<2500 g), and very low birth weight (<1500 g). Risk ratios with 95% confidence intervals were estimated with the use of modified Poisson models to adjust for confounding."
SEXUAL PLEASURE: The forgotten link in sexual and reproductive health and rights
Talking about sex and sexuality can be difficult for both sexual and reproductive health (SRH) service providers and their clients. Discussions are often limited to a problem and solution approach. Taboos around sexuality can make it difficult even for clients and providers to talk about sexual relationships, sexual wellbeing and pleasure in professional contexts. Establishing sexual pleasure as a starting point can provide a broader and positive focus on sexuality and sexual health, helping people to make informed decisions about sexual relationships and avoid risks. Talking about sexual wellbeing, sexual pleasure and sexual rights is beneficial for clients and should be commonplace in service provision.
PrEP for Women: Engaging Family Planning Providers
Over the past few months, San Francisco based organizations HIVE (formerly BAPAC) and getSFcba, partnered with the National Clinical Training Center for Family Planning (NCTCFP) to help fill a gap ? the slow uptake of PrEP among cis women in the United States.
Breastfeeding Protocol for Mothers with Partners Living with HIV
A 29 year old HIV-negative pregnant woman, with a male partner living with HIV, comes to labor and delivery. A healthy baby girl is born. Postpartum, the mom asks if she is allowed to immediately breastfeed, and wants to know if her newborn is at risk for HIV exposure.
Webinar: Living and Aging with HIV: Policies that Affect Women & Girls
In March 2017, the 30 for 30 Campaign, CHANGE, Advocates for Youth, HIVEonline, and OWEL held a webinar examining how woman and girls across the age spectrum are affected by HIV.
::Hangouts with HIVE:: Offering PrEP in Family Planning Clinics
Watch this Google+ Hangout on Air as we hear from PrEP champions from around the country who shared lessons learned and discuss the way forward for integrating PrEP into family planning services.
Before the Pen hits the Pad: Education for Health Care Providers
Check out the recording of “Before the Pen Hits the Pad: Education for Health Care Providers”!
Hot off the Presses! Use of PrEP In & Around Pregnancy
468,000 women in the U.S. are eligible for pre-exposure prophylaxis (PrEP). Many vulnerable women only access care or increase their access of care in and around pregnancy.
PrEP for US Women: The Role of Women’s Health Practitioners
Worldwide, approximately one million reproductive-aged women were diagnosed with HIV in 2013. 60% of new HIV infections in individuals under age 25 were in women and girls . Globally, 40% of pregnancies are unintended. There is significant overlap between areas with higher rates of HIV and unintended pregnancies.
Rite to Heal: An Inquiry into the Rituals & Practices that Invite Us to Make Meaning and Deepen Our Purpose as Service Providers
Given the prevalence of vicarious trauma among healthcare providers working with women who have experienced trauma, Ms. Kimberly Wylder, MFT, led a breakout session at Beyond Compassion focusing on healing rituals for service providers.
Willingness to Use HIV Prevention Strategies for Conception- Serodifferent Couples
We conducted an online survey of HIV-negative women with HIV-positive partners to evaluate the acceptability of and willingness to use various HIV prevention strategies in order to conceive.
Caring for Survivors: Reducing Anxiety & Pain during Gynecological Exams and Procedures
?Many times the patients that are most ?difficult? are those who?ve had sexual trauma. She isn?t hard, she?s had a hard life?the body of a survivor remembers those traumatic experiences…she knows that other providers have found her to be a hard patient, so if you change the way you see her, then maybe she?ll change the way she sees herself in that dynamic.?
A Shift in Practice: Screening Patients for Intimate Partner Violence
In this 40-minute video, Dr. Leigh Kimberg, a Professor of Medicine in the Division of General Internal Medicine at ZSFG/UCSF, works with a breakout session group to understand best practices for screening patients for intimate partner violence (IPV).
Disclosure, Criminalization and Stigma for Women Living with HIV
?I had a fear of being alone?The stigma was huge. I had more internal stigma than external stigma?I stayed out of relationships because I didn?t want to disclose.?
Violence, Trauma and Healing: A Conversation with Women Living with HIV
This hour-long video tells the story of three women who are national leaders: Ms. Naina Khanna (Executive Director of Positive Women’s Network-USA), Ms. Gina Brown (Coordinator at New Orleans Regional AIDS Planning Council), and Ms. Linda Scruggs (Director of Ribbon Consulting Group).
Trauma-Informed Care: Collaborating to Enhance Safety & Healing
?Trauma has the incredible ability to rupture relationships with ourselves as well as with others, simultaneously.?
Trauma among Women Living with HIV: Understanding its Rates & Impact
?The entire HIV epidemic is fueled by violence and neglect?Far more women living with HIV are dying from the consequences of unaddressed trauma than are dying from HIV itself.?
Do you know your partner’s status?
Dr. Garcia explains what will happen during the prenatal visit, and tells Poppy that, ?Every pregnant woman should know her HIV status.?
Every Pregnant Woman Should Know Her HIV Status
Poppy says that her partner is living with HIV, and Dr. Garcia asks her if they can discuss options to keep Poppy safe during pregnancy.
It?s Hard to Give Him That Information, You Never Really Know
Trigger warning: IPV concerns
Jessica has not disclosed her HIV status to her partner because she is concerned about physical violence and the possibility of her partner leaving the relationship.
Is there any way the baby will catch the virus?
Magic, a man living with HIV, asks Dr. Cori Blum about the risks of having a baby with his HIV negative partner, Annie.
We?ve been seeing if we are ready. Are there any risks involved?
Magic, a man living with HIV, and Annie, his HIV-negative partner, talk with Dr. Cori Blum, a family practice provider, about safer conception. Annie and Magic want to know, ?What can we do to make the risks as little as possible??
It Brings a Little Bit of Hope
Dr. Cori Blum asks Magic, a man living with HIV, if he wants to have a baby.
::Hangouts with HIVE:: PrEP Pharmacokinetics
Dr. Angela Kashuba and Dr. Mackenzie Cottrell along with their colleagues, conducted a pharmacology investigation to determine the number of doses
required for effective HIV pre-exposure prophylaxis (PrEP)
30 for 30 Campaign
Briefing Paper: Integrating HIV and Sexual and Reproductive Health Service Provision: A Proven Strategy for Providing More and Better Health Care to Women Living with and at Risk of HIV/AIDS
Reaching Women in Serodifferent Relationships
Safer conception & contraceptive counseling by providers of men living with HIV
?This might be the only place for those kinds of needs?
A qualitative study of U.S. family planning providers? attitudes towards PrEP for HIV prevention
HIV #LanguageMatters: Addressing Stigma by Using Preferred Language
#NotYourInfection is important to me because people living with HIV deserve respect. A word can be correct, but that doesn?t make it nice. I am living with HIV, not an HIV-infected person.
I am NOT an infection! ?Mina, a teen living with HIV
Integrating Early Treatment and Prevention
Drs. Smith and Grant suggest best practices for HIV testing, PEP, PrEP, and early treatment of HIV ?based on research evidence and existing normative guidelines.?
HIV Providers in 7 U.S. Cities Identify Training Needs for Preconception Care
Poster presentation that Richlyn Yond from Houston presented at the APHA Conference in Chicago.
Engaging PLHIV in Discussions About Conception & Repro Health Intentions Webinar
Learn from people living with HIV and providers about having meaningful discussions with patients, applying reproductive justice frameworks, and using non-stigmatizing language.
A Woman-Centered Approach to Infant Feeding and HIV
For many women living with HIV, learning about the recommendation against breastfeeding is a challenging part of adjusting to her HIV diagnosis and/or her pregnancy.
The PRO Men Initiative Poster
“Reaching women through their HIV-positive male partners: The PRO Men Initiative”:
Lessons learned from Perinatal HIV to Inform Prevention of Sexual HIV Transmission
Dr. Robert Grant and HIVE’s Shannon Weber’s poster on “Lessons learned from Perinatal HIV to Inform Prevention of Sexual HIV Transmisson.”
Juno Obedin-Maliver on Reproductive Health for Trans Men
Shannon Weber and Dr. Obedin-Maliver discuss trans men having babies, contraception, what is happening, research-wise, and what is expected to happen in the future.
Recommendations of the Expert Panel and the EMCT Stakeholders Groups
After the three-day meeting, Mary Jo Hoyt, MSN, Principle Investigator at FXB Center, sent a letter to the Office of National AIDS Policy detailing the groups? recommendations on revisions and updates to the National HIV/AIDS Strategy.
HuffPo: Ending Sexual HIV Transmission: Lessons Learned from Perinatal HIV
In 1991, during the peak of the HIV/AIDS epidemic, 1650 babies were born with HIV in the United States. By 2010, that number had declined to 162.
Understanding Perinatal HIV Service Coordination
Perinatal HIV Service Coordination: closing gaps in the HIV care continuum for pregnant women & eliminating perinatal HIV transmission. This CDC webinar on the elimination of mother to child transmission was presented by Deborah Storm, MSN, PhD, Mary-Margeret...
Dr. Jesleen Rana on Trauma Informed Care
Dr. Jesleen Rana discusses how to serve substance involved women, trauma informed care, and two tips any provider can take away to influence their practice toward being more mindful of women’s prior trauma.
Dazon Dixon Diallo on Language: High Risk Vs. At Risk
Dazon Dixon Diallo and Shannon Weber talk about PrEP for women and language around risk perception.