Synopsis
Maintain maternal viral suppression through pregnancy and birth, select delivery and neonatal prophylaxis from viral load and acquisition timing, and prevent postnatal transmission through informed feeding care.
- Offer HIV testing early in every pregnancy and repeat in later pregnancy when ongoing exposure or clinical risk warrants it.
- Continue effective suppressive ART in someone already treated; avoid switching a stable regimen without a maternal, fetal or interaction reason.
- Start a potent complete ART regimen promptly after a new diagnosis, using resistance, hepatitis B, gestation and comorbidity to select drugs.
- Measure viral load throughout pregnancy and at about 36 weeks because the late-pregnancy result determines delivery planning.
- Planned vaginal birth is appropriate when viral load is below 50 copies/mL and no obstetric contraindication exists.
- Recommend planned caesarean birth at 50–399 copies/mL after individual assessment, and caesarean birth at 400 copies/mL or higher. If caesarean prevents transmission with viral load above 50, consider birth from 38 weeks.
- Give neonatal prophylaxis as soon as possible, ideally within four hours of birth, with drug number and duration based on transmission risk.
- Formula feeding eliminates breast-milk HIV transmission; supported breastfeeding requires sustained suppression, exclusive feeding and intensive monthly maternal and infant monitoring.
Key red flags
Acute HIV acquisition during pregnancy or breastfeeding produces high viraemia and a major transmission risk.
Viral load at or above 400 copies/mL near delivery calls for caesarean birth and specialist intrapartum planning; consider delivery from 38 weeks when preventing vertical transmission.
A rising or newly detectable viral load requires same-day adherence, interaction, resistance and delivery-plan review.
Preterm labour or ruptured membranes before the agreed plan needs immediate HIV maternity contact.
An infant whose prophylaxis is delayed, incomplete or based on missing maternal results requires urgent paediatric HIV review.
Breastfeeding with detectable maternal viral load, mastitis, breast abscess or infant oral inflammation requires immediate interruption and specialist assessment.
A reactive screen requires urgent confirmation, baseline viral load and rapid specialist ART while emotional and safeguarding support begins.
Fever, rash, pharyngitis and lymphadenopathy after pregnancy exposure may precede antibody positivity and requires HIV RNA.
Detectable viral load may reflect missed doses, vomiting, cation interaction or resistance and changes mode and timing of birth.
Labour or ruptured membranes before viral suppression and neonatal plans are documented requires immediate intrapartum risk management.
Investigation priorities
Confirm a reactive antenatal screen and detect acute infection during a serological window.
Management branches
HIV is newly confirmed or acute infection is suspected during pregnancy.
- Contact the specialist HIV maternity team the same day and obtain viral load, CD4, resistance, hepatitis, renal and liver specimens.
- Start a complete potent ART regimen promptly after interaction and gestation review rather than waiting for every result.
- Assess opportunistic infection, mental health, partner safety, conception context and support needs privately.
- Repeat viral load early to demonstrate decline and modify the regimen if genotype, toxicity or absorption makes it unreliable.