Maternal‐to‐Child‐Transmission of Human Immunodeficiency Virus in Maternal Preterm Premature Rupture of the Membranes: A Systematic Review

ABSTRACT

Aim

Preterm premature rupture of membranes (PPROM) in the context of maternal human immunodeficiency virus (HIV) infection poses a significant clinical dilemma, as clinicians must balance the risks of prematurity with the risks of delaying delivery and potentially increasing the chance of mother‐to‐child transmission (MTCT) of HIV. This review aimed to identify the rate of MTCT in HIV‐positive pregnant individuals with PPROM and assess neonatal outcomes.

Methods

A systematic search strategy following PRISMA guidelines, developed by an information specialist, was applied across seven online databases from inception to 2023. Prospective and retrospective cohort studies of HIV‐positive patients with PPROM in which rates of MTCT were reported were included. Case reports and case series were eligible for inclusion. Data were extracted by two independent reviewers, and meta‐analysis was performed when possible.

Results

Of 312 screened articles, three studies from the USA and one from South Africa met inclusion criteria, representing 58 pregnancies. The crude rate of MTCT was 6.9% (n = 4). Unadjusted logistic regression in two studies revealed no association between MTCT and antiretroviral use, CD4 count, gestational age, or length of PPROM. There was, however, a trend toward increased MTCT risk with elevated viral load (p = 0.09) or spontaneous vaginal delivery (p = 0.06).

Conclusions

The crude rate of MTCT of HIV in women with PPROM was approximately 6.9%, albeit in a heterogeneous population with variable antiretroviral use. More recent data reflecting contemporary HIV management are needed to better inform counseling and decision making in this challenging clinical scenario.

1. Introduction

Approximately 3% of all pregnancies are complicated by preterm premature rupture of membranes (PPROM)—the rupture of membranes before the start of labor at a gestational age under 37 weeks [1]. PPROM remains a significant obstetrical challenge, underlying 40% of all preterm births, and consequently plays a significant role in perinatal morbidity and mortality [1, 2, 3].

Although current guidelines for clinically stable parturients with PPROM generally recommend expectant management (including a course of antenatal corticosteroids if below 34 weeks, prophylactic antibiotics, and admission to the hospital), the coexistence of maternal HIV infection poses an important dilemma in the management of PPROM [4]. Whereas efforts toward delaying delivery may offset the morbidity of prematurity, prolonged exposure of the fetus to ruptured membranes may increase the risk of MTCT of HIV.

The question remains whether conservative management or immediate delivery is the optimal choice for HIV‐positive women with PPROM. The goal of this study is thus to assess the management and clinical outcomes of PPROM for HIV‐positive patients as reported in the literature comparing early to delayed delivery.

2. Methods

2.1. Search Strategy and Information Sources

We performed a systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines. The search was performed from inception to January 2023 without restriction on language or geographic origin. The study protocol was registered on an online database, PROSPERO, prior to initiation of the literature search (ID# CRD42022351681). See Appendix SI for search strategy and Appendix SII for PRISMA checklist.

2.2. Study Selection and Data Extraction

Randomized controlled studies, observational trials (prospective/retrospective cohorts, case controls), case series, and case reports were included; however, review articles were excluded. Eligible studies investigated a population of HIV‐positive women who experienced PPROM (defined as rupture of membranes without labor at a gestational age less than 37 weeks and 0 days) in whom MTCT was reported. Screening and data extraction were performed by two independent reviewers (S.I. and A.D.C.), with conflicts resolved through discussion or, if needed, by third‐party team members (A.Z.). Pretested data collection forms were used to extract data such as gestational age at time of PPROM, viral load (VL), use of antiretroviral therapy, antibiotics, obstetrical, and neonatal outcomes including MTCT.

2.3. Eligibility Criteria for Primary and Secondary Outcomes of Interest

The primary outcome of interest was the rate of MTCT of HIV, defined as detectable neonatal infection with HIV within 6 months of delivery, as well as the characteristics of these cases of vertical transmission. Secondary outcomes included duration of pregnancy following PPROM (i.e., latency period from rupture of membranes to delivery), VL at time of PPROM and/or delivery, use of antiretroviral therapy, mode of delivery, and neonatal outcomes such as birthweight, incidence of sepsis, intrauterine fetal demise (IUFD), respiratory distress syndrome (RDS), and admission to the neonatal intensive care unit (NICU) when available.

2.4. Risk of Bias

Risk of bias was determined using the Cochrane risk of bias tool for RCTs and a modified Newcastle–Ottawa scale for assessment of cohort studies. Studies were evaluated for overall quality on the basis of three criteria: selection, comparability, and outcome. These scores were then reported according to the Agency for Healthcare Research and Quality (AHRQ) standards on ethics and integrity to rate studies as either poor, fair, or good quality. In the case of case series or case reports, the Joanna Briggs Institute (JBI) tool for critical appraisal checklist was used.

2.5. Strategy for Data Synthesis

Quantitative results such as incidence of MTCT, gestational age, latency between rupture and delivery, length of stay in hospital or NICU were synthesized when possible, using means or medians as appropriate and reported with associated ranges. Weighted means were used to synthesize data regarding birthweight, gestational age, VL, or length of admission, with corresponding ranges.

2.6. Statistical Analysis

Data were descriptively analyzed for qualitative results (i.e., baseline demographic features, medical, and obstetrical features of the pregnancies of interest such as preexisting diagnosis of HIV, use of antiretroviral therapy, mode of delivery, etc.). Available data regarding primary and secondary outcomes were extracted and synthesized, and if possible, meta‐analyzed to produce odds ratios and p‐values (significance set at 0.05) to determine the association between relevant variables and risk of MTCT. Unadjusted logistic regression analysis was performed to assess for associations between potential risk factors for MTCT of HIV and the rate of vertical transmission.

3. Results

3.1. Study Selection

The initial search yielded 312 articles, of which 54 were duplicates. Title and abstract screening excluded 218 results, leaving 40 studies for full text review; of these, two articles could not be retrieved, and 34 articles were excluded due to ineligibility.

The remaining four studies included in the analysis varied in year of publication from 1996–2020. Three studies compared HIV‐positive patients with PPROM to HIV‐positive patients without PPROM [1, 2, 3], and one study compared HIV‐positive PPROM to HIV‐negative PPROM [5]. The included studies were all observational in design (one prospective, three retrospective), and were performed in the United States [1, 2, 3] and South Africa [5].

See Figure 1 for Prisma flow diagram.

FIGURE 1.

PRISMA flow diagram of methodology.

3.2. Patient Characteristics

Across the four studies, there were a total of 60 HIV‐positive patients with PPROM, with a mean age of 27. At time of PPROM, 32 patients were on antiretroviral medication (either nevirapine and/or zidovudine), whereas 12 were not, and the remaining 16 patients had no reported information regarding antiretroviral use. At the time of delivery, antiretroviral use was reported in an additional 12 patients.

See Table 1 for baseline characteristics and further details.

TABLE 1.

Baseline characteristics of patients included from the selected articles.

Author	Year	Study design	Patients	Co‐infections	Antibiotics	ART at PPROM	ART at delivery	Mean VL at delivery (copies/mL)	Mean CD4 at delivery (abs/mm3)	Mean duration of PPROM (h)	Mean GA at delivery (weeks)	Clinical chorioamnionitis	Delivery
Aagaard‐Tillery et. al	2006	Retrospective cohort	7	4 PSU 3 Trichomonas, 1 chlamydia, 2 TB, 1 HCV	4 Yes 3 No	4 Yes 3 No	4 Yes 3 None	1404 range = 50–3710 n = 4 a	N/A	112 range = 24–240 n = 6 b	29 N = 6 b R = 25–32	3 Yes 4 No	4 SVD 3 C/S
Alvarez et. al	2007	Retrospective cohort	18	3 HCV, 1 chlamydia	18 Yes	10 Yes 8 No	18 Yes	17 290 range = 81–100 000 n = 17 c	436 range = 117–935 n = 18	63.2 range = 4–288 n = 18	31 N = 18 R = 28–34	7 Yes 9 No	18 C/S
Cotter et. al	2012	Prospective cohort	12	N/A	12 Yes	N/A	12 Yes	5 patients < 1000 7 patients > 1000	N/A	N/A	N/A	N/A	N/A
Onwughara et. al	2020	Retrospective cohort	23	N/A	N/A	18 Yes 1 No 4 N/A	N/A	N/A	N/A	N/A	33 (SD = 1.3) R = 30–37 = < 34 = 13, > 34 = 10	N/A	10 C/S 13 SVD

Abbreviations: ART, antiretroviral therapy; C/S, cesarean section; GA, gestational age; h, hours; HCV, Hepatitis C Virus; HIV, Human Immunodeficiency Virus; IUFD, intrauterine fetal demise; MTCT, maternal to child transmission; N/A, not applicable; PPROM, preterm premature rupture of membranes; PSU, post‐gonococcal urethritis; SD, standard deviation; SVD, spontaneous vaginal delivery; TB, tuberculosis.

^a Missing data for two patients with MTCT and one with IUFD.

^b Missing data for patient with IUFD.

^c Reported as < 400 for one patient, not included in calculation.

3.3. Primary Outcome

Among the 60 women who were HIV‐positive with PPROM, one patient was lost to follow up and another experienced a fetal demise without clear indication of neonatal HIV status, leaving a cohort of 58 patients. Within this group, four neonates had confirmed MTCT of HIV, yielding a pooled rate of 6.9%. Among these four cases, there was no reported use of anti‐retroviral therapy at time of PPROM, although all four received antibiotics in the latency period and three out of the four reported use of nevirapine and/or zidovudine at time of delivery. See Table 2 for characteristics of patients with MTCT.

TABLE 2.

Characteristics of individual patients with HIV and PPROM that experienced MTCT.

Patients	Co‐infections	Latency antibiotics	ART at time of PPROM	ART intrapartum	VL at delivery (copies/mL)	CD4 at delivery (abs/mm3)	Length of PPROM (h)	Mean GA at delivery (weeks)	Clinical chorioamnionitis
Aagard‐Tillery et al. #1 (Patient 6)	None	Yes	None	None	N/A	N/A	72	31 + 3	Yes
Aagard‐Tillery et al. #2 (Patient 7)	Trichomonas HCV, PSU	Yes	None	Yes (zidovudine)	N/A	N/A	168	24 + 4	None
Alvarez et al. #1 (Patient 17)	None	Yes	None	Yes (nevirapine and zidovudine)	8595	935	288	31	None
Alvarez et al. #2 (Patient 18)	HCV	Yes	None	Yes (nevirapine and zidovudine)	100 000	306	48	33	Yes

Abbreviations: ART, antiretroviral therapy; HCV, Hepatitis C Virus; PPROM, preterm premature rupture of membranes; PSU, post‐gonococcal urethritis.

3.4. Secondary Outcomes

3.4.1. Latency Period, Gestational Age, and Delivery

Two studies reported on latency period (i.e., interval to delivery) in HIV‐positive women following PPROM (n = 24) [1, 2]. Gestational age at time of PPROM was only available for seven patients from Aagard–Tillery et al. and ranged from 17 weeks and 2 days to 31 weeks and 4 days. The mean interval among all 24 patients was 160 h, or 6.1 days (range: 4–2208 h). Among this cohort, 12 patients were not on ART prior to PPROM, however all but one patient were prescribed ART after PPROM. There were no explanations available for this one case, however, this was one of the four positive cases of MTCT, who experienced a latency period of 3 days. The mean latency period for all four patients with MTCT was 6 days, ranging from 2 to 12 days (mean interval to delivery in patients without MTCT: 3 days, range 0–10 days, n = 22).

In the population under study by Cotter et al. all HIV‐positive pregnancies with PPROM equal to or greater than 34 weeks gestational age underwent immediate induction.

Gestational age at time of delivery was reported by two studies [1, 2], with a mean of 30 completed weeks of gestation (n = 25, range: 24–34 weeks).

The mean gestational age of delivery for all four positive MTCT patients was 29.8 completed weeks of pregnancy, ranging from 24 weeks to 33 weeks (mean gestational age of delivery in patients without MTCT: 31 weeks, range 25–34 weeks, n = 22). Onwughara et al. found no significant difference in gestational age at delivery between HIV‐positive and HIV‐negative mothers that experienced PPROM (p = 0.08, OR 3.1, CI 0.9–10.7). Regarding the delivery modality of the four patients with MTCT, two deliveries were spontaneous vaginal deliveries (SVD) whereas the other two were by cesarean section (CS). The two patients with MTCT that underwent SVD are from Aagard–Tillery et al. and did not have a VL available at the time of delivery; the other patients that did not have MTCT underwent delivery modality according to VL with < 1000 copies/mL as an indication for CS.

3.4.2. Viral Load and CD4 Count

Both Aagard–Tillery et al. and Alvarez et al. reported on VL, although only the latter reported on CD4 counts, including data on cases of MTCT (two out of four cases). The mean VL at time of delivery for these two cases of MTCT was 54 298 copies/mL (range: 8595–100 000 copies/mL), in comparison to a mean VL in patients without MTCT of 10 050 copies/mL (range: 50–89 198, median = 3050, n = 20). CD4+ count at time of delivery was also available for only these two cases of MTCT and averaged 621 abs/mm³ (range: 306–935 abs/mm³) in comparison to a mean CD4+ count in patients without MTCT of 389 abs/mm³ (range: 117–851, median = 342 abs/mm³, n = 16).

3.4.3. Neonatal Birthweight

Two articles Aagaard‐Tillery et al. and Onwughara et al. reported on birthweight in HIV‐positive women with PPROM [1, 5]. The weighted mean birthweight among these 30 patients was 1729 g. There was one reported IUFD with a birthweight of 710 g at 30 + 2 weeks gestational age, or below the 1st percentile. Aagaard‐Tillery et al. found a median birthweight of 1360 g among seven neonates (mean = 1277 g, range: 1290 g, SD: 471.6) whereas Onwughara et al. found a mean birthweight of 2180 g (SD: 499 g) among 23 neonates. Of note, in the latter study, there was no statistical difference in birthweights between HIV‐positive and HIV‐negative mothers that experienced PPROM (p = 1.00, OR = 1, CI: 0.3–3.4).

3.4.4. Neonatal Birth Complications and NICU Admission

Reporting of neonatal complications at birth was inconsistent and sparse. Among the seven pregnancies in the Aagaard‐Tillery et al. study, the following complications were observed: grade 1 intraventricular hemorrhage (n = 1), RDS (n = 4), IUFD (n = 1). Alvarez et al. reported nine cases of RDS, either mild or severe, among the 18 neonates born to HIV‐positive women with PPROM. There were no incidences of periventricular leukomalacia, necrotizing enterocolitis (NEC), or IUFD in this cohort. Lastly, Onwughara et al. was the only article to report on IUFD rates in their cohort, of which there were none, as well as APGAR scores, with 20 out of 22 neonates scoring an APGAR of 8–10 at 5 min (p = 1.0, OR = 0.9, CI: 0.1–7.4).

Two articles (Aagaard‐Tillery et al. and Alvarez et al.) reported on NICU admission and had a 100% admission rate following delivery (n = 24). Their respective lengths of admission were 54 and 27 days. The weighted average among both studies was 41 days (median = 29, range = 7–148 days). Neonatal disposition following NICU admission was not reported; whether discharge, transfer, or neonatal demise occurred could not be verified. See Tables 3 and 4 for obstetrical and neonatal outcomes.

TABLE 3.

Obstetrical outcomes of all patients with HIV and PPROM.

Author	Total patients	Patients with MTCT data	Delivery modality	Mean NICU LOS (days)	Mean birthweight (grams)	Neonatal complications	MTCT	Mechanism of confirming MTCT
Aagaard‐Tillery et al.	7	6	4 SVD 3 C/S	54	1277	4 RDS 1 IVH 1 IUFD	2	Neonates tested twice with DNA PCR or AIDS‐defining illness or death up to 18 months of age.
Alvarez et al	18	18	18 C/S	27	N/A	9 RDS	2	Neonatal testing with DNA PCR up to 6 months after delivery
Cotter et al.	12	12	N/A	N/A	N/A	N/A	0	Neonates tested with 2 consecutive DNA PCR tests performed up to 6 months after delivery.
Onwughara et al.	23	22	10 C/S 13 SVD	N/A	2180	N/A	0 (1 unknown)	Neonates tested only in the immediate postpartum period with DNA PCR.

Abbreviations: AIDS, acquired immunodeficiency syndrome; C/S, cesarean section; HIV, Human Immunodeficiency Virus; IUFD, intrauterine fetal demise; IVH, intraventricular hemorrhage; LOS, length of stay; MTCT, maternal‐to‐child transmission; NICU, neonatal intensive care unit; PCR, polymerase chain reaction; RDS, respiratory distress syndrome; SVD, spontaneous vaginal delivery.

TABLE 4.

Outcomes of individual patients with maternal‐to‐child transmission of HIV.

Patients	Delivery modality	Mean NICU LOS (days)	Mean birthweight (grams)	Neonatal complications
Aagard‐Tillery et al. #1 (Patient 6)	SVD	29	1605	RDS, neutropenia
Aagard‐Tillery et al. #2 (Patient 7)	SVD	60	827	RDS, IVH Grade 1, anemia
Alvarez et al. #1 (Patient 17)	C/S	N/A	N/A	N/A
Alvarez et al. #2 (Patient 18)	C/S	N/A	N/A	N/A

Abbreviations: C/S, cesarean section; IVH, intraventricular hemorrhage; NICU, neonatal intensive care unit; RDS, respiratory distress syndrome; SVD, spontaneous vaginal delivery.

3.5. Risk of Bias and Heterogeneity

All four included studies were retrospective cohort studies by design, three of which were evaluated as fair and one as good in terms of quality assessment. Selection bias was low in all four papers given the population studied was unique and uniformly identified. However, the comparability and outcome biases were high in three papers and low in only one paper. Despite excellent homogeneity within the primary outcome of vertical transmission, significant bias was introduced due to a multitude of uncontrolled variables and missing data regarding parameters such as delivery modality, VL, ART use, and neonatal outcomes and complications. Only two studies (Aagaard‐Tillery et al. [1] and Alvarez et al. [2], n = 24) provided individualized patient data alongside individual characteristics which allowed for data synthesis.

3.6. Logistic Regression—Synthesis of Results

Unadjusted logistic regression of two studies (Aagaard‐Tillery et al. [1] and Alvarez et al. [2], n = 24) revealed no association between MTCT of HIV and ART use at time of delivery, CD4 count at time of delivery, gestational age at time of delivery, and length of PPROM (latency period). However, there was a trend toward an association between elevated VL and higher rate of MTCT of HIV (p = 0.09) and a borderline significant association between delivery modality of spontaneous vaginal delivery and higher rate of MTCT of HIV when compared to cesarean delivery (p = 0.06).

4. Discussion

4.1. Main Findings and Comparison With Existing Literature

This review showed an approximate rate of 6.9% MTCT in HIV‐positive patients with PPROM, over a mean latency period of 6.1 days. These findings can be contrasted with current MTCT rates which are generally < 2% in developed countries (without controlling for gestational age)—a dramatic improvement from rates of 25%–40% in the early 1990's prior to effective ART [6].

There are numerous factors that must be taken into consideration when deciding on management for PPROM for HIV‐infected parturients due to concern of MTCT. However, neither the American College of Obstetricians and Gynecologists (ACOG) nor the Society of Obstetrics and Gynecology in Canada (SOGC) [4, 7] organization comments specifically on management of PPROM in HIV‐positive patients given the paucity of evidence‐based data to inform decision making. The British HIV Association (BHIVA) guidelines [8] recommend that if HIV‐positive PPROM patients are greater than or equal to 34 weeks gestational age, they should be managed in a similar manner to HIV‐positive patients at term, with an aim to deliver within 24 h; however, if less than 34 weeks, focus should be on optimizing HIV VL alongside multidisciplinary discussion regarding timing and mode of delivery. All HIV‐positive patients in the study by Alvarez et al. [2], Cotter et al. [3], and Aagard‐Tillery et al. [1], underwent expectant management following PPROM as they were all less than 34 weeks gestation. However, it is unclear whether active or expectant management was conducted with the patients in the study by Onwughara et al. [5].

Our analysis of Aagard‐Tillery did suggest a trend toward an association between elevated VL in rate of MTCT (p = 0.09). Both ACOG [9] and SOGC [10] conception counseling for HIV‐positive patients emphasize utilizing ART preconception and, if not initialized prior to conception, initiating treatment immediately upon knowledge of conception, given that a maternal VL less than 1000 copies/mL can reduce MTCT of HIV to 1%–2% regardless of the route of delivery or duration of ROM. Multiple studies have identified that compliance to ART resulted in undetectable levels of VL at time of delivery and that MTCT can be minimized when the VL is below 1000 copies/mL [10, 11, 12, 13]. Cotter et al. [3] found that a VL of 10 000 copies/mL (p < 0.001) was the single most important risk factor for MTCT of HIV at the time of delivery. Regarding the four patients with MTCT, three of them were on ART at the time of delivery (one on monotherapy and two on dual therapy) with very elevated mean VL of 54 298 copies/mL (range 8595–100 000 copies/mL), and one did not receive any ART for unclear reasons. The VL and latency period of those with MTCT is almost five times and two times that of those without MTCT respectively. Furthermore, it is important to note that compliance to ART was not indicated and given that detection of MTCT was diagnosed up to 6 months postdelivery, breastfeeding status was also not indicated, an important limitation given that breastfeeding has consistently been associated with increased MTCT of HIV [10]. This highlights the importance of optimization of preconception and perinatal ART to obtain an undetectable VL to decrease MTCT of HIV in all clinical scenarios including PPROM and expectant management.

Our sub‐analysis found a statistically insignificant trend toward increased risk of MTCT of HIV with SVD when compared to CS for MTCT (OR: 15.1, p = 0.06) without consideration of VL as this information was not available; however, it is important to note that only 3 of our 24 patients included underwent an SVD, while the remaining 21 patients were delivered by CS. Furthermore, the difference between mean VL at delivery for patients with MTCT and without MTCT was over five‐fold greater (54 298 vs. 10 050 copies/mL). Numerous studies indicate that prior to the adoption of ART, CS was the optimal choice due to significant correlation between the mode of delivery and MTCT of HIV, likely due to uncontrolled viral levels and the greater risk of blood‐borne exposure to the neonate [14, 15, 16]. Nonetheless, data is conflicting during this time period as the previously mentioned meta‐analysis of approximately 4000 parturients conducted by the International Perinatal HIV Group [17] did not find any association with delivery modality and MTCT. Today, several organizations and studies recommend using VL as the guiding factor on the appropriate delivery modality with recommendations that if VL is under 1000 copies/mL, SVD or CS are both acceptable options [18]. Our data reaffirms this as two of the four MTCT cases are from patients that underwent SVD without a known VL.

The significance of duration of ROM and MTCT remains heavily debated; the data is largely conflicting, likely due to the multitude of other relevant factors such as use of ART and VL. No significance was found in this review, in keeping with other studies which found a duration of ROM greater than 4 h did not have an increased risk of HIV MTCT as long as the VL was less than 1000 copies/mL, [2, 3, 19, 20]. However, a large meta‐analysis including studies from 1980–1990 of approximately 4000 parturients conducted by the International Perinatal HIV Group [17] identified length of ROM as a risk factor for MTCT, although patients were on monotherapy ART and VL was not taken into consideration regarding transmission. Several studies from the 1990's have also suggested a duration of under 4 h favorable to lower transmission rate [14, 17, 21]. These findings speak to the complex interplay of VL, ART, duration of ROM, and delivery modality on MTCT, all of which must be balanced in individualized clinical decision making.

4.2. Strengths and Limitations

The findings of this review must be interpreted in the context of the study design and available literature. There was significant heterogeneity between and within studies regarding important characteristics (i.e., VL, CD4 count, use of ART, gestational age), as well as omissions of relevant delivery characteristics (i.e., instrumental delivery, use of scalp electrodes etc.). Incomplete data (e.g., HIV status of the one case of IUFD, indications for delivery, birthweights) limited the analyses that could be performed. Additionally, a more informative comparison would have been patients with HIV and PPROM managed conservatively versus those managed by immediate delivery, perhaps with matching for gestational age, however no such data exists in the literature at this time. Lastly, the management of HIV in pregnancy has evolved over the last few decades, and more recent studies would have been more generalizable to the current clinical reality. Despite these limitations, there are several strengths to this current study including the broad and inclusive search strategy employed and the thorough extraction and reporting of relevant data. Individual patient data from two of the four included studies facilitated data synthesis and analysis, and although neonatal data was incomplete, there was reasonable reporting of immediate neonatal outcomes to be commented on.

4.3. Conclusion and Implications

PPROM and the choice of management in the setting of HIV‐positive parturients remains a clinical challenge—this review showed a MTCT rate of HIV in patients with PPROM of 6.9%. Findings from more contemporary management of HIV‐positive patients are needed to inform evidence‐based counseling and decision making.

Author Contributions

S.I., A.D.C., A.Z., and K.W. contributed to the study conception and design, S.I., A.D.C., and B.J. prepared the material, collected and analyzed the data, S.I., A.D.C., A.Z. and K.W. interpreted the findings and prepared the manuscript. S.I., A.D.C., and B.J. contributed to the methodology and statistical plan. All authors have contributed to the final manuscript preparation and have approved it in its current form.

Disclosure

An abstract of this article was presented at the Society of Obstetricians and Gynecologists of Canada Annual Clinical Scientific conference, which was held in Edmonton, Canada on June 13, 2024. An abstract of this article was presented at the Society of Maternal Fetal Medicine conference, which was held in Rome, Italy from September 25–28, 2024. An oral presentation of this article was presented at the McGill University Women's Health Symposium, which was held in Montreal, Canada on September 4, 2024.

Ethics Statement

The authors have nothing to report.

Consent

No written consent was require d as this manuscript is a systematic review and does not include any patient‐identifiable data.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix SI: Search strategy.

Appendix SII: PRISMA checklist.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.