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Chapter 29: Human Immunodeficiency Virus in Pregnancy

Laura Sienas; Carey Moreno-Hunt; Douglas Gillott

INTRODUCTION

KEY QUESTIONS

  • How does an OB/GYN hospitalist treat a patient with human immunodeficiency virus (HIV) with a detectable viral load (VL)? A nondetectable VL?

  • What is the workup for a patient with no HIV screening in pregnancy?

  • What considerations should be taken to decrease the rate of perinatal transmission?

  • What are key issues to discuss with the HIV patient in the postpartum period?

CASE 29-1

16 y.o. G1 P0 at 39 3/7 weeks gestation presents with spontaneous rupture of membranes. She was diagnosed with HIV in this pregnancy with a VL of 8000. She was immediately started on ART and had an undetectable VL throughout the remainder of her pregnancy.

CASE 29-2

32 y.o. G5P2022 at 37 4/7 weeks gestation presents in labor. She is homeless and has no prenatal care. She reports a history of drug dependence, with a toxicology screen positive for methamphetamine. Her rapid HIV is positive. Patient reports no history of prior HIV diagnosis.

Acquired immunodeficiency syndrome (AIDS) was first described in 1981, when several patients developed defective cellular immunity and Pneumocystis jiroveci (formally Pneumocystis carinii) pneumonia.1 Through attacking the body's own immune system, HIV places the patient at risk for opportunistic infections. HIV can be transmitted through blood and other bodily fluids, including amniotic fluid and saliva.

The incidence of AIDS in the United States is depicted in Figure 29-1. According to the Centers for Disease Control and Prevention (CDC), 1.2 million people in the United States were living with HIV in 2015.2 A total of 19% of infected individuals are women, and 1 in 8 patients do not know that they carry the disease.2 Each year, 8500 HIV infected women give birth, so it is important for OB/GYN hospitalists to know how to manage these patients.3

FIGURE 29-1.

Estimated number of perinatally acquired AIDS cases by year of diagnosis, 1985 to 2010, in the United States and dependent areas. (Data from Centers for Disease Control and Prevention (CDC), AIDS surveillance trends, slide set.)

A graph shows the years from 1985 to 2010 on the horizontal axis and number of diagnoses from 0 to 1000 on the vertical axis.
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Perinatal transmission, or passage of the virus from mother to infant, can happen anytime during the antepartum, intrapartum, or postpartum period. Risk of vertical transmission is related to the maternal viral load (VL) at the time of exposure (Figure 29-2).4

FIGURE 29-2.

Incidence of perinatal HIV infection plotted against plasma HIV-1 RNA levels in 1542 neonates born to mother in the Womens and Infants Transmission Study. (Data from Cooper ER, Charurat M, Mofenson L, et al., Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission, J Acquir Immune Defic Syndr. 2002 Apr 15;29(5):484-94.)

a graph shows the maternal plasma hiv-1 rna copies/ml from <400 to >100,000 on the horizontal axis and percentage of rate of neonatal infection from 0 to 40 on the vertical ... id=

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