🧬 HIV in Pregnancy

1. Screening

  • All pregnant women should be offered HIV testing at the booking visit (ideally <10 weeks).

  • If declined, offer again later in pregnancy.

  • Repeat testing if high risk (e.g. new partner, IV drug use, STI).

Reference: NICE NG204; UKHSA; RCOG GTG No. 39.

2.

2. Maternal Management

Antiretroviral Therapy (ART)

Key Principles

  • All HIV-positive pregnant women should commence combination ART (cART) as early as possible, regardless of viral load or CD4 count.

  • Aim for plasma HIV-RNA <50 copies/mL by 36 weeks gestation to minimize the risk of vertical transmission.

  • If the woman is already on ART before conception, continue her regimen unless contraindicated or poorly tolerated.

  • It is recommended that ART should be started in the first trimester, especially if the viral load is
    >100,000 copies/mL and/or CD4 count is <200 cells/mm3 (Grade 1C).
    • If the pregnancy is complicated by significant nausea and vomiting that impacts the ability to
    adhere to treatment, the aim should be to establish consistent ART by 18–20 weeks’ gestation
    (Grade 1C).

  • It is also recommended that all pregnant women/people should have commenced ART by week 24 of
    pregnancy at the very latest (Grade 1C)

Choice of ART Regimen (BHIVA 2024)

Preferred combinations:

  • Two NRTIs (backbone):

    • Tenofovir disoproxil fumarate (TDF) + emtricitabine (FTC), or

    • Abacavir (ABC) + lamivudine (3TC)

  • Third agent (anchor drug):

    • Integrase inhibitor (first choice): Dolutegravir (DTG) or Raltegravir (RAL)

    • NNRTI: Efavirenz (EFV) – acceptable in all trimesters

    • PI: Darunavir/ritonavir (DRV/r) – alternative if integrase inhibitors not suitable

🔹 BHIVA 2024: Dolutegravir-based regimens are now first-line in pregnancy (safe and rapidly suppress viral load).

Monitoring

  • Viral load:

    • At booking

    • At 36 weeks

    • 2–4 weeks after any treatment change

  • CD4 count: every 3–6 months.

3. Mode of Delivery

Maternal Viral Load (at 36 weeks)Recommended Delivery
<50 copies/mLVaginal delivery
50–399 copies/mLConsider individual case; vaginal possible
≥400 copies/mLElective C-section at 38 weeks

Note: Avoid invasive procedures (FBS, scalp electrodes, instrumental delivery unless essential).

4. Intrapartum Management

  • Continue ART during labour.

  • IV Zidovudine: if viral load >1000 copies/mL or unknown.

  • Minimize rupture of membranes duration and instrumentation.

5. Postpartum / Neonatal Care

For the Neonate

  • Antiretroviral prophylaxis:

    • If maternal VL undetectable: Zidovudine for 2–4 weeks.

    • If maternal VL detectable/high: Triple therapy for 4 weeks.

  • Testing for HIV:

    • At birth

    • 6 weeks

    • 12 weeks

    • 18 months (confirmatory)

6. Breastfeeding

  • In the UK & RCOG settings:

    • If viral load undetectable and ART adherence excellent, breastfeeding can be considered with close monitoring.

    • Otherwise, formula feeding recommended.

  • In low-resource settings (WHO): exclusive breastfeeding preferred if replacement feeding is unsafe or unavailable.

7. Postnatal Maternal Care

  • Continue ART lifelong.

  • Contraception: discuss before discharge (avoid enzyme-inducing ART with CHC).

  • Ensure partner testing and counselling.

8. Risk of Transmission

  • Without ART: ~25–30%

  • With effective ART & undetectable VL: <0.5%

⚕️ TOACS Scenario

Station Type:

Counselling / Management / Communication skills

🩺 Scenario Example

You are the obstetric registrar in antenatal clinic.
A 28-year-old woman, 16 weeks pregnant, has just received her antenatal blood results.
Her HIV test is positive.
She is upset and anxious.
The examiner asks you to counsel her regarding the diagnosis and management in pregnancy.

🎯 Objectives

  • Communicate diagnosis empathetically

  • Explain implications for mother and baby

  • Outline management and multidisciplinary approach

  • Discuss prevention of mother-to-child transmission (MTCT)

  • Reassure about good outcomes with treatment

🗣️ Counselling Flow

1. Introduction & Environment

  • Ensure privacy and confidentiality

  • Sit down, maintain eye contact

  • “I understand this is difficult news. I’m here to explain and support you.”

  • Obtain consent to discuss results

2. Breaking the News (SPIKES approach)

S – Setting: quiet, private room
P – Perception: “Do you have any idea why your test was done?”
I – Invitation: “Would you like me to share the result with you now?”
K – Knowledge: “Your blood test shows that you are HIV positive.”
E – Empathy: “I can see this is upsetting; many women feel shocked at first.”
S – Support: “You are not alone. Effective treatment allows healthy pregnancy and baby.”

3. Key Points to Explain

A. About HIV

  • HIV = Human Immunodeficiency Virus → affects immune system

  • Can be managed well with medication (ART)

  • Not the same as AIDS (advanced stage, preventable with treatment)

B. Transmission Risks

  • Without treatment: risk of mother-to-child transmission ≈ 25–40%

  • With proper management: <1% risk

  • Transmission can occur:

    • During pregnancy

    • During labour and delivery

    • Through breastfeeding

C. Management in Pregnancy

  • Immediate referral to multidisciplinary team:

    • Obstetrician (high-risk clinic)

    • Infectious disease specialist / HIV physician

    • Paediatrician / neonatologist

    • Counsellor / social worker

D. Antiretroviral Therapy (ART)

  • Start combination ART as soon as possible, regardless of CD4 count

  • Continue throughout pregnancy and labour

  • Safe and effective for both mother and baby

  • Monitor viral load and CD4 counts regularly

E. Mode of Delivery

  • If viral load <50 copies/ml at 36 weeks → vaginal delivery acceptable

  • If viral load >50 copies/ml → elective caesarean at 38 weeks

F. Intrapartum Care

  • Avoid:

    • Artificial rupture of membranes

    • Fetal scalp electrodes / sampling

    • Instrumental delivery (unless unavoidable)

G. Postnatal Management

  • Baby:

    • Receive antiretroviral prophylaxis (e.g., zidovudine)

    • HIV testing at birth, 6 weeks, and 18 months

  • Mother:

    • Continue ART lifelong

    • Contraceptive counselling

H. Feeding Advice

  • In resource-limited settings: WHO now allows exclusive breastfeeding for 6 months if mother on ART

  • In settings where formula is safe and feasible → formula feeding preferred

I. Partner Management

  • Offer partner testing and counselling

  • Emphasize safe sex (condoms) even if both are positive

4. Address Emotions

  • “It’s understandable to feel scared or confused.”

  • “You can have a normal pregnancy and a healthy baby.”

  • “We’ll support you with medical, emotional, and social help.”

5. Summarize

  • Diagnosis confirmed → treatment available

  • Early ART = very low risk to baby

  • Close monitoring and safe delivery plan

  • Support for partner and future pregnancies

🧾 Examiner’s Marking Checklist

DomainKey Points
CommunicationEmpathy, clarity, reassurance
KnowledgeCorrect management steps, MTCT prevention
TeamworkReferral to multidisciplinary care
SafetyART, delivery mode, feeding guidance
EthicsConfidentiality, partner notification, informed consent

💡 Common Traps

  • Saying “the baby will get HIV” (→ incorrect & distressing)

  • Not mentioning ART safety and effectiveness

  • Forgetting partner testing

  • Ignoring emotional support aspect

🩸 Mnemonic for Quick Recall — HIV CARE

H – Human touch & empathy
I – Immediate ART
V – Viral load guides delivery mode
C – Caesarean if viral load high
A – Avoid invasive procedures
R – Reduce transmission (ART + safe feeding)
E – Engage partner & follow-up

📖 A complete overview of screening, diagnosis, and management following current RCOG, BHIVA, and NICE guidelines

Click below to get ready-to-practice role-play dialogue for TOACS: HIV in Pregnancy — written exactly how you’d perform it in exam (10-minute counselling station) 👇🏼

Click here

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