HIV in Pregnancy
BHIVA guidelines on the management of HIV in pregnancy and the postpartum period 2025
This article focuses on pregnancy-specific HIV management. For general HIV information, see the Human Immunodeficiency Virus (HIV) and Advanced HIV, AIDS, and HIV-Associated Conditions articles.
Vertical Transmission
Vertical transmission of HIV from a pregnant person to their baby can occur at 3 main stages:
- During pregnancy (in utero) – infected maternal lymphocytes can cross the placenta
- During childbirth (intrapartum) – there is a particularly high risk of HIV transmission
- After birth (postnatal) – through breastfeeding
Due to high uptake of effective ART, the vertical transmission rate in the UK is extremely low (consistently <0.4% since 2012)
The risk of transmission is significantly higher (10-20%) without intervention (i.e. effective ART)
- The most significant risk factor that increases vertical transmission is maternal viral load, which often results from poor ART adherence, late antenatal booking, acquiring HIV infection during pregnancy or breastfeeding period
- Other risk factors for vertical transmission include:
- Vaginal delivery (higher risk than planned Caesarean section)
- Prolonged rupture of membranes
- Invasive monitoring (e.g. fetal scalp electrodes, pH blood sampling)
- breastfeeding
Complications
HIV in pregnancy is associated with an increased risk of:
- Negative impact on mental health (e.g. antenatal and postnatal depression)
- Stillbirth (29% higher risk)
- Preterm birth (risk doubled by the presence of concomitant STIs)
- Fetal growth restriction
- Neonatal HIV infection (vai vertical transmission)
Screening
All pregnant women should be offered HIV screening (4th-generation combination assay) at the booking visit (8-12 weeks)
Infections that are routinely screened for in the UK:
- HIV
- Syphilis
- Hepatitis B
See the Antenatal Care for more information.
Management
Antepartum Management
All women conceiving on an effective ART regimen should continue this treatment
- 1st choice regimen: tenofovir disoproxil / emtricitabine + dolutegravir (in the absence of renal or bone concerns)
- If the patient is on a 2-drug regimen, it should ideally be intensified to 3 drugs
If the patient is not on ART → start ART ASAP (by 24 weeks the very latest)
Mode of Delivery
Measure maternal HIV viral load at 36 weeks to decide the mode of delivery.
| Viral load at 36 weeks (copies / mL) | Mode of delivery |
|---|---|
| <50 | Planned vaginal delivery can be safely supported, assuming there are no other obstetric contraindications |
| 50-399 | Planned Caesarean section is recommended but not absolute (consider the actual viral load, trajectory of the viral load, patient’s adherence, length of time on treatment, and patient’s preference) |
| ≥400 | Planned Caesarean section is strictly recommended |
The women must deliver in a unit with on-site paediatric care to start neonatal PNP within 4 hours.
Intrapartum Management
The mainstay of intrapartum management is IV zidovudine infusion (an NRTI)
Indications are determined by viral load, irrespective of mode of delivery:
| Viral load at 36 weeks (copies / mL) | Intrapartum IV zidovudine infusion |
|---|---|
| <50 | NOT required |
| 50-1000 | Can be considered, along with other medication optimisation |
| >1000 | Strictly recommended |
Timing to commence intrapartum zidovudine (if indicated):
- Planned Caesarean section → commence 4 hours prior
- If the patient presents in labour or with spontaneous rupture of membranes → commence immediately
Postpartum Management
| Maternal management | The mother should continue lifelong ART |
| Neonatal management | PNP should start ASAP, latest within 4 hours
Risk-stratified management:
|
| Advise on breastfeeding | All women should be advised NOT to breastfeed.
Exclusive formula feeding is recommended. |