REVIEW

Management of HIV infection persons carrying the virus enabling appropriate clinical decisions
to be made. The aim of these testing campaigns is to reduce the

in pregnancy proportion of people (approximately one quarter) who are un-

aware of their HIV status. A third of all new HIV diagnoses are
defined as late presenters ie they have a CD4 count of below 200
Lauren Bull
cells/ml at the time of diagnosis which has a negative effect on
Abdul W Khan clinical outcomes. The majority of women who are unaware of
Simon Barton their status are from sub-Saharan Africa. With the HIV epidemic
maturing, there are now cases of women who acquired HIV
vertically themselves now becoming mothers.
Abstract
Advances in the management of HIV positive patients combined with up Natural history
to date research, collaborative guidelines and routine antenatal screening HIV 1 is responsible for the majority of HIV infections worldwide
has meant that the transmission of HIV-1 from mother to child is now a whilst HIV 2 is generally confined to West Africa and has a much
rare occurrence in the UK. Globally women equally share the burden of lower virulence and transmission.
HIV associated morbidity and mortality with men, however in the devel- After infection, viral replication and integration results in a
oped world, women represent a minority of those with new HIV infection. gradual loss of the CD4 lymphocyte count causing immune
The clinical intricacies associated with the management of pregnancy and deficiency, indicated by a cell count less than 350 cells/mm3.
childbirth necessitates specialist care across multidisciplinary teams, thus This can make a patient vulnerable to a variety of opportunistic
ensuring optimal outcomes for mothers and their babies. The global infections or subsequently a risk of developing AIDS. The time
target of eliminating mother to child transmission MTCT requires a taken to develop AIDS from seroconversion is very variable,
major and sustained effort to improve access to testing, antiretroviral ranging from months to more than a decade. The development of
therapy and expert multidisciplinary care. The following article highlights anti-retroviral drugs has transformed the management of HIV. In
the latest research and guidelines applicable to HIV positive expectant fact the initial effects were so impressive it led to the term highly
mothers in the UK. active antiretroviral therapy (HAART) to come into existence.
Keywords antiretrovirals; breastfeeding; epidemiology; hepatitis co- Now that these effects are widely accepted it is more commonly,
infection; HIV; point-of-care testing; pre-labour caesarean section; and herein referred to as antiretroviral therapy (ART). By
pregnancy enabling restoration of immune function and in doing so
increasing life expectancy, ART also renders viral loads unde-
tectable and thus reduces infectivity.
Introduction
Mother to child transmission (MTCT)
Globally, approximately 35 million people are infected with HIV
In 2011, the WHO unveiled a campaign “No child born with HIV”
and almost half of them are women. The overwhelming majority
outlining the goals and plans to decrease worldwide MTCT rates.
of women living with HIV are in resource poor countries. In the
In the UK, in 2011, the estimated HIV prevalence of HIV infection
UK, there has been a concerted effort to increase HIV testing
amongst women giving birth was 2.2 per 1000 women The ma-
uptake both in traditional settings such as Genitourinary Medi-
jority of these women are from sub-Saharan Africa The rate of
cine clinics and antenatal clinics and novel settings such as Dean
HIV MTCT has significantly decreased from 25.6% in 1993 to an
Street Express a walk in service which provides rapid results for
estimated 0.57% in 2007e2011. The risk of transmission is
all sexual infections, as well as making HIV testing part of routine
highly dependent on the viral load (VL). At a viral load of
investigations in settings such as Accident & Emergency and
>100,000 copies/ml there is a 40% risk of transmission. This
general practice. Additionally, the widespread availability of
falls to 1% at 1000 copies/ml and less than 1% at undetectable
point of care tests (POCT) for HIV enable rapid identification of
VL (<50 copies/ml). Management also considers the mode of
delivery, appropriate and timely intervention of post exposure
prophylaxis (PEP) for the infant and avoidance of breast feeding.
Lauren Bull MSc MRCP is a Specialist Registrar in Genitourinary Medicine It must be noted that in the UK, over half of pregnant women
and HIV at Chelsea and Westminster Hospital, London, UK. Conflicts of with HIV present late for antenatal care. Late presentation and
interest: I have received funding from Gilead and Janssen to attend later booking has adverse consequences for both mother and
conferences. child, with a small proportion of HIV positive women remaining
undiagnosed at the point of delivery. Obtaining the best possible
Abdul W Khan MSc MBBS is an Associate Specialist in Genitourinary
outcome for all HIV positive women including late presenters
Medicine and HIV at Chelsea and Westminster Hospital, London, UK.
requires a dedicated and flexible team of specialist midwifes,
Conflicts of interest: none declared.
obstetricians and HIV physicians.
Simon Barton BSc MD FRCOG FRCP is a Consultant Physician in HIV and
Genitourinary Medicine at Chelsea and Westminster Hospital, and Methods of MTCT
Adjunct Professor at Imperial College, London, UK. Conflicts of interest: There are three established ways of MTCT:
Received honoraria and travel funding from ViiV and Gilead for  In utero transmission is a less common mode of trans-
delivering educational lectures at conferences. Trustee of St Stephens mission as an intact placenta acts as a very effective barrier
AIDS Trust a registered Charity. to the transfer of HIV. Placental transfer of virus can

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:10 273 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW

happen with an extremely high viral load which is com- counselling. POCT’s have a window period of 6 weeks, i.e. in-
mon in seroconversion illness where transmission rates forms us of the patient’s status 6 weeks before and have a false
can be as high as 30%, advanced late stage disease with reactive rate of less than 1%. Any reactive result undergoes a
very low CD4 and in the presence of opportunistic in- confirmatory test of a different type of POT to confirm the results.
fections which can up regulate the viral load. In normal
circumstances a viral load of above 100,000 copies/ml is Screening of HIV positive pregnant women
high enough to facilitate in utero transmission with a risk The British HIV Association (BHIVA) guidelines recommend STI
of about 2%. The placental barrier can be compromised screening on a yearly basis in HIV positive individuals. Women
with severe systemic infections like milliary tuberculosis, need to be educated about preventing onward HIV transmission
falciparum malaria and secondary syphilis where inflam- and STI’s. Any pregnant woman at risk should also be screened
matory endarteritis can distort the integrity of the placenta. for other sexual infections that could potentially be transmitted
Con-comittant use of crack and cocaine can also impair to the unborn child including chlamydia, syphilis, hepatitis,
placental function and may increase the risk of MTCT. gonorrhoea and herpes. Screening for STI’s should be performed
 MTCT at the point of delivery is the commonest mode of twice during pregnancy, once in the first trimester and again in
transmission, and can occur as a result of high viral load at the third trimester. Test of cure should be performed following
delivery, prolonged rupture of membranes, prematurity, treatment for any bacterial STI’s.
vaginal laceration, vaginal ulceration due to herpes sim- Recurrent herpes simplex (HSV) type 2 infection is common in
plex infection or syphilitic ulcers, episiotomy, invasive HIV positive women and all women should have type specific
fetal monitoring and instrumental delivery. HSV serology if they have no previous diagnosis of genital herpes
 Post-partum MTCT is almost exclusively due to breast and present with symptoms of genital ulcers. HSV recurrence will
feeding and accounts for up to 40% of transmissions in increase the local HIV replication and may play a role in MTCT
undiagnosed women. There are reports that for some especially when vaginal delivery is anticipated. Prophylactic
women there may be a lot of stigma around being unable treatment with aciclovir 400 mg TDS should be offered from 32
to breastfeed. This is especially among communities in weeks especially where vaginal delivery is planned. Appropriate
parts of Africa and migrants living in the UK from these partner notification should be performed. HIV positive women
areas, where it may be viewed as a disclosure of their HIV with primary genital HSV in the last trimester should be managed
status to friends, families and even partners. as per HIV negative women. There is currently no evidence to
support HIV positive women who are HSV antibody positive but
with no history of genital ulceration to have aciclovir
Antenatal management
prophylaxis.
Antenatal testing
Prior to 2005, the majority of women diagnosed with HIV ante- Vaccinations: whooping cough vaccine and vitamin D should be
natally were not aware of their diagnosis however the majority offered to women regardless of their HIV status.
are now already aware, many diagnosed in a previous preg-
nancy. The UK introduced routine ‘opt out’ antenatal HIV testing ART in pregnancy
in 1999; the uptake in 2008 was 92e95%. Testing is performed at Antiretroviral drugs have been used extensively in HIV positive
booking (12e14 weeks) and no further HIV tests are routinely women in order to control virus levels and thus reduce MTCT.
offered. However the National Screening Committee has The repertoire of antiretroviral agents is expanding and there is
emphasised that any woman declining the initial test should be better understanding about the mode of action, toxicity and in-
reoffered screening at 28 weeks’ gestation. Additionally, given teractions of these agents. Very little data have arisen from ani-
the risk of seroconversion during pregnancy as outlined above, mal studies for these drugs and most of the experience of use in
any woman considered to be at ongoing risk should be reoffered pregnancy comes from observational studies, pregnancy drug
screening particularly if presenting with symptoms consistent registry and yellow card reporting.
with seroconversion. Up until the late 1990’s the standard of care for HIV positive
Robust policies should exist in every antenatal unit offering pregnant women was to take Zidovudine, a nucleoside analogue
HIV tests, with clear records of uptake and the reasons for inhibitor, orally in the second trimester, followed by an intra-
declining a test. Reasons for declining should be further explored venous infusion during labour and then given orally to new
through a meeting with a dedicated HIV midwife and the born for first six weeks. This was called the 076 protocol after
obstetrician in charge, with repeat offering of the test. All rele- the major study that proved its efficacy. This reduced the MTCT
vant healthcare staff should have the skills and knowledge to from 27.7% to 7.9%; importantly women did not breast feed.
deal with these situations comfortably and receive regular The 076 protocol in conjunction with a bloodless planned lower
training, peer support and audit in their units. Additionally, segment caesarean section further reduced the risk of MTCT to
training in the use of point of care tests (POCT) should be 2%. In the late 1990s, introduction of triple combination anti-
considered. Given the advances in HIV management, counselling retroviral or ART changed clinical practice. ART’s ability to
prior to testing should not be seen as the daunting task it once lower plasma viral load to undetectable levels improves survival
was. It is based around a discussion of risk and the likely and reduces morbidity. All children born to mothers who had
outcome of the result and is always performed with the notion exposure to antiretrovirals in the UK are followed up for any
that it is better to know the result and act on it accordingly. future potential adverse effects and are placed on the pregnancy
Serology tests are taken routinely as part of screening with no registry.

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 REVIEW

Timing and type of ART and transmission pregnant women if possible given the small chance of bleeding and
A high viral load is the most important risk factor for MTCT; thus of HIV transmission; however this risk has to be weighed
mothers with a viral load of less than 50 copies/ml (undetect- against the benefit of performing the procedure. The French Pae-
able) and who do not breast feed have a 0.5% chance of trans- diatric HIV Infection Study Group observed a relative risk of HIV
mitting the virus. Some women will require initiation of ART transmission of 1.9 with antenatal procedures including amnio-
whilst pregnant for their own health, i.e. a CD4 <350, others will centesis, cerclage, laser therapy and amnioscopy. However, this
conceive whilst already on ART and others will only require to study was conducted between 1985 and 1993 and only a minority
start ART to minimise MTCT. had received zidovudine. Current guidelines recommend that if the
Maternal baseline viral load is an important factor to take into procedure cannot be delayed until viral suppression is achieved, an
consideration when deciding the time to initiate treatment in ART regimen including raltegravir (associated with rapid viral load
pregnant women. All women should commence ART by 24 weeks suppression) should be given along with single dose of nevirapine
of pregnancy. A longer duration of ART is associated with reduced 2e4 hours prior to the procedure.
MTCT and rates of MTCT are lower in women who became
pregnant on ART, compared to those who start ART during Hepatitis co-infection: hepatitis B and/or C co-infection is rela-
pregnancy; each week of ART reduces the odds of transmission by tively common within the HIV positive cohort in the UK, although
8%. It is important to start ARV earlier than 20e24 weeks when less so in pregnant women. HIV can have deleterious impact on
the base line viral load is high, the CD 4 count is low, in the hepatitis with lower rates of spontaneous clearance and faster rate
presence of co-morbidities like hepatitis B/C infection or recurrent of progression to cirrhosis. It is recommended that any abnormal
genital HSV, and in high risk obstetrics patients such as those with liver function tests are investigated with hepatitis co-infection in
a history of premature delivery. ART should be started as soon as mind and that co-infected patient are co-managed by clinicians
possible if the viral load is higher than 100,000 and in some with expertise in treating both conditions. Particular attention
special circumstances, for example seroconversion illness. must be paid to antiviral agents used for treatment of hepatitis B
Studies have shown the different types of ART used do not and C. Patients need to have close monitoring of liver function
influence the rate of MTCT. There are increasing amount of data tests if starting HIV antiviral therapy due to the risk of hepato-
to guide the use of ARV during pregnancy however there have toxicity or immune reconstitution inflammatory syndrome. For
been many newer agents developed in recent years for which both infections, in the absence of obstetric complications, vaginal
such data is not yet available. As a general rule, if a woman delivery can be anticipated if HIV viral load is suppressed on ART.
conceives on an effective ART regime she should continue on
this, one exception is a patient on protease inhibitor mono- Management of labour
therapy as this requires intensification with additional anti ret-
Mode of delivery (Figure 1)
rovirals to maintain viral suppression. See Table 1 for an outline
Historically a planned elective caesarean section was the method
of the major classes of antiretroviral therapy.
of choice for delivery in HIV positive women. However effective
Antiretroviral toxicity control of viral load with ART has led to more and more women
The fetus is most vulnerable to toxic drug effects in the first 12 having vaginal deliveries. For women taking ART, a decision
weeks of gestation. Previous guidelines had advised that efavir- regarding mode of delivery should be made after review of viral
enz should not be used in pregnancy. However, systematic re- load at 36 weeks.
view and meta-analysis indicates that there is no additional BHIVA guidelines state that a planned vaginal delivery is
teratogenicity with efavirenz compared to other drugs; indeed it recommended for women on ART with an undetectable viral
can be both continued and commenced in pregnancy. Zidovu- load in the absence of obstetric complications. In these women,
dine, lamivudine and ritonavir have been shown to have obstetric management should follow the same guidelines as for
congenital malformation rates within the expected range. Simi- the uninfected population. Published cohort data from the UK
larly, an excess in congenital malformations has been excluded and other European countries have shown MTCT rates of <0.5%
with abacavir, tenofovir, emtricitabine, lopinavir, atazanavir in women with plasma viral load <50 cpml taking ART, irre-
nevirapine. Newer agents such as raltegravir, etravirine, mar- spective of mode of delivery.
aviroc, rilpivirine, elvitegravir and dolutegravir do not have In circumstances when the viral load is greater than 400
sufficient reported outcomes of first trimester exposure to copies/ml at 36 weeks a planned caesarean section is recom-
exclude such risk. Ongoing surveillance of all children exposed to mended regardless of the ART agents, additionally when the pa-
ART is through the RCOG/NSPH and the international Anti- tient is on zidovudine monotherapy regardless of the viral load.
retroviral Pregnancy Registry. For women who have a viral load between 50 and 399 copies/ml
There is no evidence to suggest that the pharmacokinetics of current recommendations are to consider caesarean section taking
most ARV are altered in pregnancy if used at adult license doses. into account the actual viral load, the trajectory for the viral load,
length of treatment, obstetric factors and the woman’s views. This
Antenatal ultrasound and invasive procedures is based on unpublished European and NHSPC UK cohort data
Fetal ultrasound imaging should be performed as per national which show the risk of MTCT in this group is double for women
guidelines regardless of maternal HIV status. Prenatal diagnostic intending vaginal delivery. Although this was not a significant
testing should not be performed until HIV status of the woman has finding given the small number of events.
been determined and ideally deferred until viral load is suppressed. The timing of caesarean section is a balance between the risks
Most invasive procedures should be avoided in HIV positive of transient tachypnoea of the newborn and the likelihood of

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:10 275 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW

Outlining the main classes of antiretroviral therapy, mechanism of action and use in pregnancy
Class of drug Mechanism of action Use in pregnancy

Nucleoside reverse transcriptase inhibitors Competes with natural substrates for HIV Two drugs from this class form the backbone
(NRTI) e.g. Zidovudine, tenofovir, reverse transcriptase and inhibits its DNA of the majority of ART regimens. Well used in
emtricitabine, lamivudine polymerisation pregnancy.
Non-nucleoside reverse transcriptase Bind directly to reverse transcriptase inhibit its Normally used in addition to 2 NRTI’s.
inhibitors (NNRTI) e.g. nevirapine, efavirenz, function Experience and studies show that nevirapine
etravirine, rilpivirine and efavirenz are safe to use in pregnancy. No
data to support the newer agents such as
etravirine and rilpivirine. However if a woman
conceives on an effective regimen containing
these agents may be able to continue.
Protease inhibitors (PI’s) e.g. lopinavir, Substrate analogues for an HIV protease Normally used in addition to 2 NRTI’s.
atazanavir, darunavir, ritonavir enzyme. Blocks enzyme’s activity resulting in Lopinavir, atazanavir and ritonavir shown to
lack of virion formation have congenital malformation rates within
expected range and well used in pregnancy.
Integrase inhibitors (INI) e.g. raltegravir, Target the HIV enzyme integrase which is Normally used in addition to 2 NRTI’s. Not yet
elvitegravir, dolutegravir responsible for integration of viral genetic sufficiently studied to exclude increased risk
material into human DNA of congenital malformation in the first
trimester. Although if a woman conceives on
an effective regime containing one of these
drugs may be able to continue.

Table 1

labour occurring before the scheduled caesarean section. Where women on ART who ruptures her membranes at term with a viral
the indication is to prevent MTCT, caesarean section at 38e39 load of <50 copies/ml and who does not have an obstetric
weeks is considered; the earlier timing reflects the importance of contra-indication to vaginal delivery, a caesarean section is not
avoiding the onset of labour. recommended.
In the pre-ART era, several studies suggested that prolonged Studies have shown an association between both acute/
duration of ruptured membranes, usually analysed as greater chronic chorioamnionitis and perinatal transmission. Although
than 4 hours, in women who were either untreated or receiving these studies were largely performed in the pre-ART era, it is
ZDV monotherapy, resulted in a significantly increased risk of recommended that labour should be expedited for all women
MTCT. The few studies available from the ART era do not sup- with rupture of membranes at term. Therefore women with an
port this. According to BHIVA guidelines therefore, for any undetectable viral load and ROM at term should have immediate

Mode of delivery for different HIV viral loads

Review of HIV viral load at 36 weeks

40 400
(Undetectable) copies/ml
50–399
copies/ml
In the absence of Planned Caesarean
obstetric complications section
planned vaginal delivery

Consider Caesarean section

taking into account actual viral load,
the trajectory for the viral load,
length of treatment, obstetric factors
and the woman’s views

Figure 1

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 REVIEW

induction of labour with a low threshold for the treatment of adjusted according to further information available about the
intrapartum pyrexia. maternal pre-natal viral load. In preterm labour where the infant
Women in whom difficult labour/obstetric complications are is unlikely to be able to absorb oral therapy the addition of
anticipated should be considered for referral to a tertiary centre. double dose tenofovir to the mother can ensure ARV’s reach the
Additionally women who opt for a vaginal birth after caesarean baby as soon as possible.
should be allowed to proceed if they have an undetectable viral load.
Home birthing and the use of birth pools is not commonly Preterm delivery
routine in HIV positive labouring women, and there is no evi- There is a large amount of conflicting evidence as to whether
dence to inform guidelines at present. This situation requires the ART is associated with preterm delivery. The ART implicated
view of the MDT taking into account all relevant factors. predominantly are the protease inhibitors. Observational and
There is a lack of current data since the introduction of ART on cohort data are mixed as to the association with pre term delivery
the use of fetal scalp electrodes/fetal blood sampling. However it is and RCT data from Africa is also mixed. A current trial-PROMISE
felt that these are unlikely to confer an increased risk of trans- study (NCT01061151) will likely provide some more answers
mission in a woman who has an undetectable viral load. In a around the use of PI’s in pregnancy.
woman for whom vaginal delivery has been recommended and Decisions regarding the optimum treatment of preterm ROM
labour has commenced, obstetric management should follow the necessitate assessment of exact gestation, maternal viral load and the
same principles as for the uninfected population. There are theo- presence of other co-morbidities as well as the facilities available.
retical reasons why a low traction forceps may be preferred to a Consideration of corticosteroids to improve fetal lung matu-
ventouse delivery (with potential lower rates of fetal trauma) ration and oral erythromycin should be given as per the RCOG
however there are no data to inform this. In a woman with an guidelines. The viral load should be optimised, if it is not un-
undetectable viral load it is unlikely that the type of instrument will detectable. A concern that the pre-term infant may not be able to
affect MTCT therefore the most appropriate for the situation should tolerate oral therapy may make it more desirable to load the
be used. infant through the transplacental route with maternal therapy.

Late booking or women presenting in labour who are Post-partum management

untested
Neonatal post exposure prophylaxis
Late booking or presentation in labour, prior to adequate treat-
Antiretroviral treatment to the newborn is an example of pre-
ment with ART (and thus likely detectable viraemia) can lead to
exposure prophylaxis and should be decided before the delivery.
MTCT. A national audit of pregnant women with HIV revealed
The choice of the drugs given to the baby depends on the mother’s
that women who received ART for fewer than 2 weeks were more
antiretroviral drug history and known resistance mutations. This
likely to be first diagnosed with HIV, during their pregnancy. The
treatment should be planned in a multi-disciplinary setting with a
most common reason for not receiving ART were late booking, a
paediatrician with interest in HIV disease, obstetrician and HIV
denial of HIV diagnosis and refusal of treatment. Children born to
physician; there may be need for advice from a virologist.
these women had a higher rate of MTCT (13.4%).
Monotherapy (usually AZT) is usually sufficient where there
If a woman presents after 28 weeks and is subsequently found
is a very low risk of transmission to the newborn, i.e. when the
to be infected with HIV she should start treatment without delay.
mother is on combination ART with an undetectable viral load.
The ART regimen selected is normally based on a resistance test;
There are however two situations where triple combination (i.e.
however, if this is not rapidly available a PI- based regimen
ART) neonatal post-exposure prophylaxis is advised: where the
(either ritonavir-boosted atazanavir, lopinavir or darunavir)
mother is found to be HIV positive after delivery (whereby
should be initiated immediately. Where the viral load is un-
treatment needs to be given within 72 hours), when there is
known or >100,000 copies/ml, a fourth drug, raltegravir, may be
detectable maternal viraemia at birth. Choices for newborn are
added to this regimen.
fairly limited given the toxicities of many drugs. Neonatal PEP
If a woman presents in labour and is untested or had signifi-
should be given for 4 weeks. In addition Pneumocystis pneu-
cant risk since previous testing an urgent point of care test should
monia (PCP) prophylaxis should be started at 4 weeks in: all HIV
be performed. These widely available near patient tests provide
infected infants, infants with an initial positive HIV DNA/RNA
an accurate view of the patient’s status from 6 weeks prior to the
test, infants whose mothers viral load at 36 weeks or delivery is
test (the window period for antibody formation that the test is
>1000 copies/ml.
detecting). If a woman presents in labour and is not on treat-
ment, she should be given a stat dose of nevirapine as this
rapidly crosses the placenta (effective concentrations are ach- Breast feeding in HIV positive women
ieved within 2 hours and then maintained in the neonate for up Women who breast feed may transmit HIV by this route, espe-
to 10 days). Obstetric emergency management is the priority, cially if the viral load in plasma and breast milk is high, delivery
however if time permits prior to caesarean section, attending is premature, breastfeeding is prolonged, or if nipples are
staff should also commence potent therapy which crosses the cracked. The current standard of care in the UK is to avoid
placenta and results in rapid reduction of viral load, such as an breastfeeding in HIV positive mothers. There may be wide vari-
oral combination of zidovudine, lamivudine and raltegravir, with ations between plasma and breast milk viral load, which is why
intravenous zidovudine being administered throughout labour. breast feeding should be avoided even in the presence of an
The newborn should then initiate a combination of three drugs, undetectable serum viral load. Intestinal permeability is a
usually zidovudine, lamivudine and nevirapine for four weeks, possible entry site for the virus and mixed feeding is thought to

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:10 277 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW

double the risk of HIV transmission secondary to inflammation. FURTHER READING

It should be noted that in a mother who chooses to breastfeed Antiretroviral Pregnancy Registry Steering Committee. Antiretroviral
when on ART with an undetectable viral load this does not pregnancy register international interim report for 1 January 1989
constitute an automatic referral to child protection teams how- through 31 January 2011. Antiretroviral pregnancy registry. 2011
ever feeding whilst not on ART or with detectable viraemia does (accessed 22 Dec 2011), www.APRegistry.com.
constitute a potential child protection issue. BHIVA. Guidelines for the management of HIV infection in
pregnant women 2012. 2012, http://www.bhiva.org/documents/
Testing of infants Guidelines/Treatment/2012/120430PregnancyGuidelines.pdf.
All infants born to HIV positive mothers should be tested for HIV. HPA, HIV in the United Kingdom: November 2011 report. http://www.hpa.
HIV DNA PCR (or HIV RNA testing however this may require org.uk/webc/HPAwebFile/HPAweb_C/1317131685847.
more blood volume to test) should be performed during the first Induction of Labour: NICE guideline. National institute of health and
48 hours and prior to hospital discharge, 2 weeks post infant clinical excellence. 2008, http://www.nice.org.uk/CG70 (accessed Feb
prophylaxis (6 weeks of age), 2 months post infant prophylaxis 2012).
(12 weeks of age), HIV antibody testing for seroreversion (loss of Modestini C, Roedling S, French C, Martin N, Tookey P, Burns F. HIV
maternal antibodies) should be performed at age 18 months. positive pregnant women who receive less than two weeks of anti-
Diagnosis of in utero transmission can be made by the identifi- retroviral therapy before delivery: why does it occur? HIV Med 2012;
cation of proviral DNA through amniocentesis or from the cord 13(suppl 1): 1e11.
blood/newborns blood sample at birth. National study of HIV in pregnancy and childhood (NSHPC)/CHIVA. 2007,
www.nshpc.ud.ac.uk.
Stigma and mental health conditions in HIV positive Royal College of Obstetricians and BASHH. Management of genital herpes
pregnant women in pregnancy. 2014, http://www.rcog.org.uk/en/guidelines-research-
Chronic HIV infection, subsequent opportunistic infections, services/guidelines/genital-herpes.
homelessness, stigma, poverty, immigration, disclosure, family de Ruiter A, Mercey D, Anderson J, et al. British HIV Association
and peer pressure and drug use can all contribute to complex and Children’s HIV Association Guidelines for the management of
mental illness. Mental health issues can affect engagement with HIV infection in pregnant women 2008. HIV Med 2008; 9:
community care, midwifery, obstetricians and HIV clinicians. 452e502.
Additionally, fears around accessing NHS care and entitle- Taylor GP, Anderson J, Clayden P, et al. British HIV Association and Chil-
ment to health and social care can limit engagement. It has been dren’s HIV Association position statement on infant feeding in the UK
clarified that HIV care is provided to all people who have resi- 2011. HIV Med 2011; 12: 389e93.
dency in the UK and those who have applied for residency Townsend CL, Cortina-Borja M, Peckham CS, de Ruiter A, Lyall H,
however there remains uncertainty about antenatal care and this Tookey PA. Low rates of mother-to-child transmission of HIV
requires clarification with commissioners. following effective pregnancy interventions in the United
Many HIV positive women are unable to disclose the diag- Kingdom and Ireland, 2000e2006. AIDS 2008 May 11; 22:
nosis to their partners as they fear violence; separation and 973e81.
rejection. Furthermore, studies from around the world show
significant intimate partner violence in pregnancy which seems
to be greater in women who are HIV positive. Women may
depend on their partners for financial support, right to remain in
the UK and accommodation. Antenatal HIV are should be Practice points
delivered by an MDT with every effort to involve the woman’s
GP and health visitor. Additionally trained peer-support workers C MTCT of HIV has dramatically decreased in the UK in the last 20
can be invaluable. years
C A high viral load is the most important risk factor for MTCT;
Conclusion mothers with a viral load of less than 50 copies/ml (undetectable)
and who do not breast feed have a 0.5% chance of transmitting
HIV remains one of the most important diseases in the UK despite the virus
remarkable improvements in treatment and reduction in C A planned vaginal delivery is recommended for women on ART
morbidity and mortality. Delays in diagnosis and their subse- with an undetectable viral load in the absence of obstetric
quent costs and complex treatment and care continue to need complications
specialist support. Advances in the management of HIV infection C In circumstances when the viral load is >400 copies/ml at 36
have led to changes in how HIV infection is managed in preg- weeks a planned caesarean is recommended
nancy. With undetectable viral loads, antenatal procedures and C For women who have a viral load between 50 and 399 copies/ml
instrumentation have become safer and vaginal deliveries are a current recommendations are to consider caesarean section tak-
viable first line management option. As more data becomes ing into account the actual viral load, the trajectory for the viral
available, better informed drug choices can be made. The over- load, length of treatment, obstetric factors and the woman’s views
riding issue when dealing with HIV in pregnancy is to have clear C If a woman presents in labour and is untested or had significant
lines of communication with input from the multidisciplinary risk since previous testing an urgent point of care test should be
team and to ensure continuity of care for the woman, her family performed
and her baby. A

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:10 278 Ó 2015 Elsevier Ltd. All rights reserved.