All pregnant people should be counseled on the importance of knowing their HIV status. In Illinois, state law requires that all pregnant people be counseled and offered an opt-out HIV test twice during pregnancy. This counseling and testing should ideally take place during the first prenatal visit and again during the third trimester, ideally by the 36th week of pregnancy. In Illinois, people who do not have documentation of HIV testing during the third trimester of pregnancy are counseled and offered opt-out rapid HIV testing upon presentation to labor and delivery. All preliminary positive rapid HIV tests must then be confirmed by a subsequent supplemental HIV test different from the initial test.
FAQs
Is there a risk for transmission if a person is negative for HIV and the partner is living with HIV?
If a person is negative for HIV and their partner is living with HIV, there is no risk of perinatal transmission to the baby. However, pregnant people are at an increased risk for contracting HIV and a person who acquires HIV while pregnant has a greater chance of transmitting the virus to their baby. People who are negative for HIV and in a serodifferent relationship should seek counseling on the multiple measures that can be taken to prevent HIV acquisition, including ensuring their partner keeps their virus suppressed by taking HIV medications, taking a medication called pre-exposure prophylaxis (PrEP), and consistently using condoms with each episode of intercourse. Because of the ongoing risk of HIV acquisition, all people in Illinois are required to be counseled and offered an HIV test both at the initial prenatal visit and again in their third trimester of pregnancy.
Integrated HIV/OB care is essential for the best treatment of a person who is pregnant and living with HIV. Both obstetric and infectious disease issues must be considered when recommending an antiretroviral regimen. A regimen needs to be followed and adjusted throughout pregnancy to achieve the goal of viral suppression at delivery. Ideally, infectious disease and obstetrical visits can be scheduled together to make it easier for the patient to make all appointments.
If possible, prenatal care for all pregnant people living with HIV should be provided by an obstetrician experienced in the care of patients with HIV. If this is not possible, physicians caring for these patients should request a consultation with a physician experienced in the care of pregnant patients with HIV who can assist with mapping out an appropriate care plan for the patient.
Infectious disease specialists are imperative when it comes to prescribing medications which can help to achieve rapid and sustained viral suppression. Infectious disease specialists are experienced in identifying possible drug interactions, monitoring for signs of drug toxicity and managing the troubling side effects which sometimes hinder medical compliance with antiretroviral therapies. Finally, it is important that persons living with HIV who have severely compromised immune systems be monitored by infectious disease specialists for the possible development of opportunistic infections and to receive appropriate prophylactic medications.
A combination of antiretroviral medications should be taken as prescribed during pregnancy in order to achieve an undetectable viral load and reduce the risk of vertical transmission. A multi-drug regimen is the only therapy which has been shown to achieve effective and sustained viral suppression for those living with HIV. It is important to realize that certain medications are contraindicated during pregnancy and that some medications require alterations in dosing during pregnancy. For this reason, people living with HIV and contemplating pregnancy as well as those who become pregnant should have their drug regimen reviewed by an infectious disease specialist. People who are inadvertently exposed to certain contraindicated medications during pregnancy may require additional surveillance. Please contact the Illinois Perinatal HIV Hotline for additional information or specific questions.
The Illinois Perinatal HIV Hotline recommends intravenous AZT to be given during labor and delivery (See Best Practices: Labor & Delivery Care for Pregnant People with HIV and Care of Infants with Perinatal Exposure to HIV). Ideally, this should be started at the onset of uterine contractions with a goal of completing at least a 3 hour course prior to delivery in order to achieve adequate maternal and neonatal serum levels. AZT is given as an intravenous 2mg/kg load infusion given over the first hour followed by 1mg/kg/hour intravenously until delivery. Other antiretroviral medications should be continued during labor to ensure that their normal antiretroviral regimen is uninterrupted.
The best decisions about route of delivery are made together between a patient and their doctor. Obstetric indications regarding previous pregnancies and the current pregnancy (non-HIV related) must be factored into this decision. The Department of Health and Human Services Perinatal Guidelines cover this topic. The general summary of these recommendations on route of delivery are:
Vaginal delivery is safe if viral load is less than 1000 copies/ml at 36 weeks of pregnancy and the patient reports recent good adherence with antiretroviral medications. Physicians delivering people living with HIV should avoid all invasive monitoring devices including fetal scalp electrodes. Every attempt should be made to delay artificial rupture of membranes. Instrumental vaginal delivery with forceps should be avoided due to the potential to introduce fetal trauma and potentially increase viral exposure.
C-Section delivery is recommended if the viral load is unknown or is greater than 1000 copies/ml at 36 weeks of pregnancy. In these instances, delivery should be scheduled for 38 weeks gestation prior to the onset of labor and spontaneous rupture of membranes in order to achieve maximum benefit.
Any patient who presents to labor and delivery without prenatal care should be offered and recommended rapid HIV testing. People with a preliminary positive rapid HIV test who are in active labor should be counseled on the test result, the risk of vertical transmission, and the potential benefit of a cesarean delivery in reducing that risk. The patient should receive treatment appropriate for HIV in a laboring patient, until confirmatory tests prove otherwise.
Intravenous Zidovudine (AZT) should be initiated immediately and blood sent for a supplemental HIV test to confirm the positive rapid HIV result. The neonate should also be managed as though the birthing parent is positive until confirmatory tests prove otherwise. See the Illinois Perinatal HIV Hotline’s Best Practices: Labor & Delivery Care for Pregnant People with HIV and Care for Infants with Perinatal Exposure to HIV including those with a positive rapid HIV test.
If the patient is not in labor, and delivery is not imminent, confirmatory testing should be conducted and the patient managed accordingly. Expedited confirmatory HIV testing is available through the Illinois Perinatal HIV Hotline with results generally obtained within 24 hours. Please call 1-800-439-4079 for additional information or specific questions.
Patients with a preliminary positive rapid HIV test who are in active labor should be counseled on the test result, the risk of vertical transmission, and the potential benefit of a cesarean delivery in reducing that risk. The birthing patient should be treated as positive, until confirmatory tests prove otherwise. The Department of Health and Human Services Perinatal Guidelines indicate that intravenous zidovudine (AZT) should be initiated immediately and that blood be sent for a supplemental HIV test to confirm the positive rapid HIV result. If needed, expedited confirmatory HIV testing is available through the Illinois Perinatal HIV Hotline with results generally obtained within 24 hours. Please call 1-800-439-4079 for additional information or specific questions. The neonate should also be managed as though the birthing parent is positive, until confirmatory tests prove otherwise. See the Illinois Perinatal HIV Hotline’s Best Practices: Labor & Delivery Care for Pregnant People with HIV and Care of Infants with Perinatal Exposure to HIV including those with a positive rapid HIV test.
