Case 38 - A 30-Year-Old at 10 Weeks’ Gestation with a New Positive HIV Test

Summary

Caring for patient with HIV in pregnancy requires additional compassion and attention to recent developments. The CDC maintains a website with up-to-date recommendations to guide care. Prognosis for women with HIV in pregnancy is good, with a vertical transmission rate of 0.09% if viral load was <50 copies/mL. In those successfully achieving an undetectable HIV RNA by 36 weeks, cesarean delivery has not been shown to further reduce the vertical transmission risk. Delivery timing for patients with HIV and an undetectable HIV RNA should be per usual obstetric indications and timing. However, if the HIV RNA is >1,000 copies/mL, cesarean delivery prior to labor is performed at 38 weeks. HIV RNA that is detectable, but <1,000 copies/mL should raise concern that there are issues with compliance and patient counseling and repeat testing before 38 weeks should be considered. Oral antiviral medications are continued throughout labor and delivery. Adding intravenous zidovudine at least 3 hours prior to delivery (2 mg/kg load over first hour, then 1 mg/kg/hour until delivery) for patients with HIV RNA >1,000 copies/mL further reduces the risk of transmission. In HIV discordant couples, condoms are recommended during pregnancy. If viral suppression is unable to be maintained, a partner’s HIV status is unknown, or condoms are not able to be negotiated, consider the addition of preexposure prophylaxis with tenofovir/emtricitabine.