Prevention of Mother-to-Child HIV Transmission

Introduction to Prevention Strategies

The American College of Obstetricians and Gynecologists recommends that all HIV-infected pregnant women should receive combination antiretroviral therapy (HAART) as early as possible in pregnancy, ideally containing zidovudine, with continuation through labor and delivery, followed by 6 weeks of zidovudine prophylaxis for the infant 1, 2, 3

The American Academy of Pediatrics recommends performing documented, routine HIV testing for all pregnant women using "opt-out" consent, and repeat HIV testing in the third trimester for women at high risk of HIV acquisition 2, 4
For women in labor with undocumented HIV status, the American Academy of Pediatrics recommends performing rapid HIV antibody testing immediately, with results available within 12 hours of birth 2, 4

The American College of Obstetricians and Gynecologists recommends continuing current HAART regimen throughout pregnancy for women already on HAART when pregnancy is discovered, and discontinue teratogenic drugs immediately 1, 5
For treatment-naive women requiring HAART, the American College of Obstetricians and Gynecologists recommends a preferred regimen of zidovudine + lamivudine + nevirapine, and an alternative regimen of zidovudine + lamivudine + lopinavir/ritonavir 6, 7, 8

The American College of Obstetricians and Gynecologists recommends administering intravenous zidovudine as continuous infusion during labor for all HIV-infected women, and elective cesarean delivery at 38 weeks is recommended if plasma HIV RNA remains >1000 copies/mL at 34-36 weeks gestation or viral load is unknown 1, 5, 9

The American Academy of Pediatrics recommends zidovudine for 6 weeks starting within 6-12 hours after birth for infants born to HIV-infected mothers who received adequate antenatal ART with viral suppression 2, 4, 3, 5
For high-risk infants, the American Academy of Pediatrics recommends single-dose nevirapine (2 mg/kg) at birth plus zidovudine for 6 weeks 5

The American Academy of Pediatrics recommends that HIV-infected mothers should not breastfeed in the United States and resource-rich settings, regardless of maternal ART use, as formula feeding eliminates postnatal transmission risk 3, 5, 9

The American College of Obstetricians and Gynecologists recommends evaluating the need for continued therapy after delivery, and if the woman does not meet criteria for treatment in nonpregnant adults, consider discontinuing therapy after delivery 1, 5

Without intervention, the transmission risk is 15-45%, but with effective ART, the transmission risk is <5% (as low as 1-2% with combined interventions) 3

Failure to test pregnant women for HIV is the most significant missed prevention opportunity, and delayed initiation of antiretroviral therapy significantly reduces effectiveness 3
Stopping antiretroviral drugs during the first trimester in women requiring treatment increases transmission risk, and using nevirapine in women with CD4 >250 cells/mm³ risks severe hepatotoxicity 1, 6, 5

Close blood count monitoring is essential, especially for patients with advanced disease, as neutropenia and anemia are the major toxicities of zidovudine, and monitor liver function closely in women receiving nevirapine, particularly those with CD4 >250 cells/mm³ 5