In Practice

Photo iStock Collection / thinkstockphotos.com

Imagine this scenario: You are working on a Saturday afternoon when a woman comes into the
obstetrics triage unit. She is pregnant for the
fourth time and has had three term births, zero
preterm births, zero abortions/miscarriages, and
three living children. She presents at approximately 28 to 32 weeks gestation, and in early labor. She states that she has had no prenatal care

HIV in Pregnancy
Cheryl Roth
Pauline F. Hrenchir
Christine J. Pacheco
and that her water broke about an hour ago. A
urine drug screening result is positive for cocaine and group B streptococci, and test results
for chlamydia and gonorrhea are negative. The

Abstract In the United States, women with HIV have the ability to make informed choices relating to their reproductive
lives more now than ever before. The increasing availability of antiretroviral therapy has spurred renewed interest among
many HIV-positive women in their decisions about whether to have children. It is important for perinatal nurses to understand the maternal and fetal implications of HIV in pregnancy, including parameters for treatment and the drug regimens
typically used during the antepartum, intrapartum, and postpartum periods. http://dx.doi.org/10.1016/j.nwh.2015.12.010
Keywords antiretroviral therapy | HIV | human immunodeficiency virus | pregnancy

nwhjournal.org

2016, AWHONN

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In Practice

laboratory has just called to notify you that her

human immunodeficiency virus (HIV) screening result is positive.

What Is HIV?
HIV is a virus spread through bodily fluids that
affects specific cells of the immune system called

Undiagnosed maternal HIV infection

before conception, unplanned
pregnancies, delays in accessing
antenatal care, and lack of
education are the most significant
risk factors associated with womanto-fetus transmission of the virus
CD4+ cells, which are a type of T cell. Over
time, the HIV virus can destroy so many T cells
that the body cannot fight off infections and
disease. When this happens, the HIV infection
leads to acquired immunodeficiency syndrome
(AIDS). Although there is no cure for HIV, disease progression to AIDS is no longer inevitable (Centers for Disease Control and Prevention
[CDC], 2014).
Undiagnosed maternal HIV infection before
conception, unplanned pregnancies, delays in accessing antenatal care, and lack of education are

the most significant risk factors associated with

woman-to-fetus transmission of the virus (CDC,
2014). Early intervention with initialization and
compliance with antiretroviral therapy improves
life expectancy and quality of life. Antiretroviral
therapy has decreased the risk of woman-to-fetus
(vertical) transmission of HIV (CDC, 2014).
Most vertical transmission occurs close to or during labor and birth, at the onset of placental separation and/or rupture of membranes (Mnyani, Simango, Murphy, Chersich, & McIntyre, 2014).
In the United States, women with HIV have
the ability to make informed choices relating
to their reproductive lives more now than ever
before. The increasing availability of antiretroviral therapy makes for a renewed interest in
some womens decisions to have children and to
engage in preconception counseling (FranoisXavier Bagnoud Center, 2012). The number of
newborns infected with HIV born each year in
the United States has fallen from approximately 1,750 in the mid-1990s to approximately 143
in 2010 (CDC, 2010). The CDC states that perinatal HIV transmission rates are less than 1%
(0.19.9 in 100,000 births) when antiretroviral
therapy is initiated and adhered to during pregnancy (CDC, 2014). When antiretroviral therapy
is begun intrapartum, the rate of transmission is
approximately 10%, compared with a transmission rate of 25% among infants born to women
receiving no preventive treatment (Beigi, 2013).

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Photo Antonio Diaz / thinkstockphotos.com

Cheryl Roth, PhD, WHNPBC, RNC-OB, RNFA, is a

nurse practitioner in Labor
& Delivery; Pauline F.
Hrenchir, MSL, MSN, RN,
RNFA, is the director of
the Womens Service Line;
Christine J. Pacheco, MSN,
RN, is a staff nurse; all
authors are at HonorHealth
Scottsdale Shea in
Scottsdale, AZ. The authors
report no conflicts of
interest or relevant financial relationships. Address
correspondence to: Cheryl
.Roth@honorhealth.com.

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Antiretroviral Therapy
During Pregnancy
Triple therapy combination regimens of antiretroviral drugs (also known as combination antiretroviral therapy, or cART) are generally used
during pregnancy to keep the viral load suppressed. The most common triple therapy regimen is zidovudine plus lamivudine plus lopinavir/ritonavir or atazanavir/ritonavir (Hughes
& Cu-Uvin, 2015). These medications are given
orally. Additional administration of intrapartum

intravenous zidovudine depends on a womans

HIV viral load at the time of birth.
Zidovudine crosses the placenta rapidly and
can provide pre-exposure prophylaxis to the fetus (Hughes & Cu-Uvin, 2015). Other drugs or
combinations of drugs may also be used, depending on an individuals disease course and
the recommendations of the infectious disease
clinician. Tenofovir is preferred instead of zidovudine for pregnant women with a co-infection
of HIV and hepatitis B. Efavirenz, which is generally not used in pregnancy, is a first-line nonnucleoside reverse transcriptase inhibitor with
potential teratogenic risks, including neural tube
defects, facial clefts, and anophthalmia, when
used in the first 8 weeks of pregnancy. Raltegravir has been used in late pregnancy among
women with high viral loads because of its ability to rapidly decrease viral load within 2 weeks,
although the efficacy and safety of this have not
been evaluated (Hughes & Cu-Uvin, 2015).

In Practice

The CDC (2014) recommend HIV testing for all pregnant women in routine prenatal tests and routine third-trimester screening
for women with high-risk behaviors or who are
displaying signs or symptoms of HIV. Although
a woman can decline testing for HIV, receiving
education from clinicians about HIV and about
the importance of knowing their HIV status can
help women make more informed decisions.

Box 1.

Antepartum Considerations
All pregnant HIV-infected women should receive cART to prevent perinatal transmission regardless of plasma HIV RNA copy number or CD4 T lymphocyte count. The goal of cART is to maintain a viral load below the limit of detection throughout pregnancy (AIDSinfo, 2015, p. 3). This
is usually triple therapy and based on what a patient has taken before.
Laboratory test results (HIV RNA, CD4 T lymphocytes, initial genotyping of HIV virus) should
be monitored per CDC protocol, the goal being a viral load of <1,000 copies/ml (Pennsylvania/
MidAtlantic AIDS Education and Training Center, 2014).
Potential teratogenic effects of antiretroviral prophylaxis may be avoided when delayed until
after completion of the first trimester (Pennsylvania/MidAtlantic AIDS Education and Training
Center, 2014).

Photo iStock Collection / thinkstockphotos.com

Note. cART = combination antiretroviral therapy.

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Box 2.

Intrapartum Considerations
Scheduled cesarean birth at 38 weeks gestation to minimize perinatal
transmission of HIV is recommended for women with HIV RNA levels
>1,000 copies/ml or unknown HIV levels near the time of birth, irrespective of administration of antepartum antiretroviral drugs (Aberg et al.,
2013).
It is not clear whether cesarean birth after spontaneous rupture of membranes or onset of labor provides benefit in preventing perinatal transmission (Pennsylvania/MidAtlantic AIDS Education and Training Center,
2014).
Because there is insufficient evidence to determine whether cesarean
delivery after rupture of membranes or onset of labor reduces the risk of
perinatal HIV transmission, management of women originally scheduled
for cesarean delivery who present with ruptured membranes or in labor
must be individualized at the time of presentation. In these circumstances,
consultation with an expert in perinatal HIV (e.g., telephone consultation
with the National Perinatal HIV/AIDS Clinical Consultation Center at (888)
448-8765) may be helpful in rapidly developing an individualized plan
(AIDSinfo, 2015, p. 14).
Intravenous (IV) zidovudine should be administered to HIV-infected
women with HIV RNA >1,000 copies/ml (or unknown HIV RNA) near
delivery, but is not required for HIV-infected women receiving cART regimens who have HIV RNA 1,000 copies/ml during late pregnancy and
near delivery and no concerns regarding adherence to the cART regimen
(AIDSinfo, 2015, p. 13).
Women whose HIV status is unknown who present in labor should
undergo expedited HIV antibody testing. If the results are positive, a
confirmatory HIV test should be done as soon as possible and maternal
IV zidovudine and infant (combination antiretroviral prophylaxis) drugs
should be initiated pending results of the confirmatory test (AIDSinfo,
2015, p. 13).
Repeat HIV testing in the third trimester is recommended for pregnant
women with initial negative HIV antibody tests who are known to be at
risk of acquiring HIV, are receiving care in facilities that have an HIV incidence in pregnant women of at least 1 per 1,000 per year, are incarcerated, or who reside in jurisdictions with elevated HIV incidence (AIDSinfo,
2015, p. 14).
Note. cART = combination antiretroviral therapy; IV = intravenous.

Practice Considerations
Practice considerations for antepartum, intrapartum, postpartum women,
and postpartum neonates are shown in
Boxes 1, 2, 3, and 4, respectively.

The Rest of the Story . . .

Returning to our scenario, the woman denied knowledge that she was HIV

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positive. Confirmatory tests were ordered, and zidovudine was given intravenously pending test results. Because
the womans viral load was unknown,
the obstetric provider recommended
birth via cesarean. After birth, it was
confirmed that the woman had HIV,
with a viral load >1,000. Combination
antiretroviral therapy was initiated with

zidovudine, lamivudine, and lopinavir/ritonavir, and the woman was referred to an infectious disease specialist
for follow-up. Her neonate was treated
with prophylactic combination antiretroviral therapy. The case manager and
child life specialist were very involved
in the care of the woman and newborn
before discharge, and referrals were
made to the appropriate social services. Final HIV status of the newborn
was unfortunately unknown because of
loss to follow-up; the woman did not
bring the child in for pediatric or pediatric infectious disease appointments.
NWH

References
Aberg, J. A., Gallant, J. E., Ghanem, K.
G., Emmanuel, P., Zingman, B. S., &
Horberg, M. A. (2013). Primary care
guidelines for the management of
persons infected with HIV: 2013 update
by the HIV Medicine Association of the
Infectious Diseases Society of America.
Clinical Infectious Diseases, 58(1), 110.
doi:10.1093/cid/cit757
AIDSinfo. (2015). Recommendations for
use of antiretroviral drugs in pregnant
HIV-1-infected women for maternal
health and interventions to reduce
perinatal HIV transmission in the
United States. Bethesda, MD: National
Institutes of Health. Retrieved from:
aidsinfo.nih.gov/contentfiles/
lvguidelines/Peri_Recommendations.pdf
Beigi, R. (2013). Test everyone and test
early. Atlanta, GA: Centers for Disease
Control and Prevention. Retrieved from
http://www.cdc.gov/actagainstaids/
campaigns/ottl/clinicians/beigi.html
Centers for Disease Control and Prevention. (2010). HIV Surveillance Report,
2010 (Vol. 22). Atlanta, GA: Author.
Retrieved from www.cdc.gov/hiv/topcs/
surveillance/resources/reports/
Centers for Disease Control and Prevention. (2013). Eliminating perinatal HIV
transmission: A curriculum for OB/
GYN Resident and Midwifery Programs
[slides]. Atlanta: GA: Author. Retrieved
from www.cdc.gov/primarycare/
materials/hivtransmission/docs/
hivtransmission.pdf

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Centers for Disease Control and Prevention. (2014). HIV among pregnant
women, infants, and children. Atlanta,
GA: Author. Retrieved from www.cdc
.gov/hiv/risk/gender/pregnantwomen/
facts/index.html
Franois-Xavier Bagnoud Center. (2012).
Are you HIV-positive and thinking about
having a baby? A guide to preconception health for women living with HIV.
Newark, NJ: Author. Retrieved from
www.womenandhiv.org/sites/default/
files/pdf/Client%20informational%20
brochure.pdf
Hughes, B., & Cu-Uvin, S. (2015). Use of
antiretroviral medications in pregnant
HIV-infected patients and their infants
in resource-rich settings. Retrieved
from www.uptodate.com/contents/
antiretroviral-treatment-of-pregnant
-hiv-infected-women-and-antiretroviral
-prophylaxis-of-their-infants-in
-resource-rich-settings
Mnyani, C., Simango, A., Murphy, J.,
Chersich, M., & McIntyre, J. (2014).
Patient factors to target for elimination
of mother-to-child transmission of
HIV. Globalization and Health, 10, 36.
doi:10.1186/1744-8603-10-36
Pennsylvania/MidAtlantic AIDS
Education and Training Center. (2014).
Guidelines for use of HIV combination
antiretroviral therapy in the perinatal
period. Pittsburgh, PA: Author.
Retrieved from www.aidsetc.org/sites/
default/files/resources_files/ART%20
in%20Preg%20Clinical%20Card%2010
-13-14%20FINAL%20%283%29.pdf

Box 3.

Postpartum Considerations (Women)

Decisions regarding continuing combination antiretroviral therapy after
birth should be made in consultation with a woman and her HIV health
care provider, ideally before birth.
Combination antiretroviral therapy is currently recommended for all HIVinfected individuals to reduce the risk of disease progression and to prevent HIV sexual transmission, although the strength and evidence for this
recommendation varies by pretreatment CD4+ T lymphocyte count (Pennsylvania/MidAtlantic AIDS Education and Training Center, 2014).
Decisions should take into account current recommendations for initiation
of combination antiretroviral therapy in adults, pretreatment CD4+ cell
counts and trajectory, HIV RNA levels, adherence issues, whether a woman
has an HIV-uninfected partner, and patient preference (CDC, 2014).
For women continuing combination antiretroviral therapy postpartum,
arrangements for new or continued supportive services should be made
before hospital discharge, because the immediate postpartum period
poses unique challenges to adherence.
Contraceptive counseling should be a critical aspect of postpartum care.
Women with a positive rapid HIV antibody test during labor require immediate linkage to HIV care and comprehensive follow-up, including confirmation of HIV infection. If infection is confirmed, a full health assessment is
warranted, including evaluation for associated medical conditions, counseling related to newly diagnosed HIV infection, and assessment of need for
cART and opportunistic infection prophylaxis (AIDSinfo, 2015, p. 16).
It is recommended that women with HIV infection in the United States
should not breastfeed and that women considering breastfeeding should
know their HIV status (CDC, 2014).
Note. cART = combination antiretroviral therapy.

Box 4.

Postpartum Considerations (Neonates)

Newborns exposed to HIV in utero should receive antiretroviral postexposure prophylaxis and undergo HIV virologic
diagnostic testing at 1421 days of life, at 12 months of age, and at 46 months of age (Aberg et al., 2013, p. 25).
Infant ZDV dosing: 4 mg/kg/dose every 12 hours or 2 mg/kg/dose every 6 hours for 6 weeks. ZDV for 4 weeks may
be considered if maternal viral load was suppressed with consistent cART use during pregnancy (Pennsylvania/
MidAtlantic AIDS Education and Training Center, 2014, p. 2).
Zidovudine, at gestational-age-appropriate doses, should be initiated as close to the time of birth as possible, preferably within 6 to 12 hours of delivery (AIDSinfo, 2015, p. 17).
An additional 15% to 29% of infants will be infected if there is breastfeeding (CDC, 2013, slide 95).
It is important to provide additional support to a woman who is counseled against breastfeeding because of her
HIV status, especially in situations when breastfeeding would be expected by those in her immediate support group
(Hughes & Cu-Uvin, 2015).
Note. cART = combination antiretroviral therapy; ZDV = zidovudine.

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