Table 47.7.

Measures for prevention of mother-to-child HIV transmission

Newly diagnosed or previously untreated

Women with HIV RNA ≥ 1000 copies/ml
- •
  Resistance testing prior to initiation of treatment
- •
  Zidovudine-containing HAART – if possible delay until after first trimester
Women with HIV RNA <1000 copies/ml
- •
  Zidovudine-containing HAART – if possible delay until after first trimester
- •
  Consider discontinuing HAART postnatally; if NNRTI was used, stop NNRTI prior to NRTI to prevent emergence of NNRTI resistance

Previously known HIV infection

On HAART, mother chooses to continue
- •
  Zidovudine-containing HAART regimen
- •
  Fetal ultrasound second trimester for malformations if fetal exposure to efavirenz in the first trimester
- •
  Resistance testing if persistently detectable HIV RNA
On HAART, mother chooses to stop
- •
  Intrapartum/postpartum zidovudine
- •
  Fetal ultrasound second trimester for malformations if fetal exposure to efavirenz in the first trimester

ALL HIV-infected pregnant women

•
Monitor CD4 cell count at initial visit and every 3 months
•
Measure HIV RNA at initial visit, 2–6 weeks after starting or changing HAART, monthly until undetectable, then every 2 months, and at 34–36 weeks gestation
•
Avoid efavirenz in first trimester
•
Avoid nevirapine in women with CD4 >250 cells/mm³
•
Monitor for hepatic dysfunction. Check transaminases and electrolytes monthly in the last trimester.
•
Monitor women on protease inhibitors for glucose intolerance
•
Fetal ultrasound first trimester to confirm gestational age
•
Intravenous zidovudine should be given during labor even to women with evidence of resistance by genotyping
•
Scheduled cesarean delivery if HIV RNA >1000 copies/ml near delivery
•
Avoid artificial rupture of membranes, invasive monitoring, and forceps or vacuum extractor during delivery
•
Avoid methergine (ergot) in women receiving protease inhibitors or efavirenz
•
6 week zidovudine prophylaxis of infants dosed by gestational age; consider additional agents if high maternal viral load or resistance. Should be started within 6–12 hours after birth
•
Woman does not breastfeed