Perinatal Providers

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. 

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

• 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).

DHHS recommendations

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. 

Table 10. Antiretroviral Drug Use in Pregnant Women with HIV: Pharmacokinetic and Toxicity Data in Human Pregnancy and Recommendations for Use in Pregnancy 

DHHS Guidelines

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).

• 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).

DHHS Guidelines

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. 

• 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).

DHHS Guidelines

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. 

DHHS Guidelines

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

DHHS Guidelines

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 

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. 
    • CDC has publishedthe relative advantages and disadvantages of different HIV testing assays. 
    • DHHS patient HIV testing educational materialmay be found here.
  • 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.

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

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. 

• Breastfeeding Protocol for HIV? Mothers if Sex Partner is HIV+