HIV (congenital)

Approximately 1.2 million (range 950,000 to 1.4 million) women with HIV worldwide were pregnant in 2023, of whom an estimated 84% received antiretroviral therapy (ART) (1)

Around 1.4 million women diagnosed with HIV become pregnant every year

• HIV infection in pregnancy has become the most common complication of pregnancy in some developing countries (2)
• globally, there were approximately 39.9 million (range 36.1 to 44.6 million) people living with HIV in 2023, and 53% of all people with HIV were women and girls.
• approximately 12% of all pregnancy-related deaths are attributable to HIV in countries where more than 2% of the pregnant/postnatal population are living with HIV​ (3)
• the prevalence of UK-born women living with HIV has increased from approximately 17,000 in 2006 to 30,000 in 2019. Approximately 1200 of these women fall pregnant each year. (4)
• without intervention, between 15-45% of babies born to HIV-infected mothers in the most severely affected countries are also infected. (5)

It is thought that only 2% of mother to child transmission occurs trans-placentally during pregnancy - the rest occurs due to maternofoetal transmission of blood during parturition or postnatal breastfeeding. (6)

High maternal viral load (in plasma and in breast milk), breast milk immunological factors, maternal breast pathology (such as mastitis, cracked or bleeding nipples, abscesses), and low maternal CD4 count are associated with increased risk of transmission through breastfeeding. In mothers who are not virally suppressed, breast milk contains high levels of the HIV virus, and transmission can occur at any point during lactation. (7)

Interventions to reduce transmission of HIV during the antenatal period include antiretroviral therapy (ART), pre-labour caesarean section delivery and avoidance of breastfeeding after delivery. (8) These can reduce the risk of mother-to-child HIV transmission from 25-30% to less than 1%.

All pregnant women with HIV should receive antiretroviral therapy (ART) to prevent perinatal transmission. ART reduces perinatal transmission by decreasing maternal viral load in the blood and genital secretions. ART should be initiated as early as possible in the pregnancy, regardless of CD4 count or viral load, and should be administered during the antepartum, intrapartum, and postnatal periods, as well as neonatal prophylaxis for the infant.

The World Health Organization supports the use of dolutegravir plus tenofovir disoproxil plus emtricitabine or lamivudine as a preferred first-line option for all adults, including pregnant women and women of childbearing age. Lamivudine plus tenofovir disoproxil plus efavirenz (low dose) is an alternative first-line option. (9)

A scheduled caesarean delivery at 38 weeks' gestation (compared with 39 weeks for most other indications) is recommended for pregnant women with HIV who have HIV RNA levels >1000 copies/mL or unknown viral load near the time of delivery, in order to reduce the risk of perinatal transmission (10)

• advice from the UK National Screening Committee on antenatal screening for HIV..click here

References

1. World Health Organization. The Global Health Observatory. Data on the HIV/AIDS response [internet publication].
2. Siemieniuk RAC et al. Antiretroviral therapy in pregnant women living with HIV: a clinical practice guideline. BMJ. 2017;358:j3961
3. 3. World Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division​. Feb 2023 [internet publication].
4. Mother-to-child HIV transmission at all-time low in the UK but around two-thirds of reported cases involve women diagnosed after delivery; Aidsmap, May 2018
5. Elimination of mother-to-child transmission; UNICEF, 2022
6. Soilleux EJ, Coleman N; Transplacental transmission of HIV: a potential role for HIV binding lectins. Int J Biochem Cell Biol. 2003 Mar;35(3):283-7.
7. Mofenson LM. Pregnancy and perinatal transmission of HIV infection. In: Holmes KK, Sparling PF, Stamm WE, et al, eds. Sexually transmitted diseases. 4th ed. New York, NY: McGraw-Hill; 2008:1659-93.
8. BHIVA guidelines on antiretroviral treatment for adults living with HIV-1 2022; British HIV Association (2022)
9. World Health Organization. Update of recommendations on first- and second-line antiretroviral regimens. Jul 2019 [internet publication].
10. Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Jan 2024 [internet publication].