Synopsis
Coordinate antiretroviral therapy, viral-load surveillance, delivery, neonatal prophylaxis and informed infant feeding to protect maternal health and minimise vertical HIV transmission.
- Offer and document antenatal HIV screening; confirm a reactive result urgently and involve specialist HIV, obstetric and paediatric teams without waiting for symptoms.
- Continue effective antiretroviral therapy in pregnancy; check adherence, interactions, tolerability, resistance history and HIV RNA because durable viral suppression is the central preventive intervention.
- BHIVA 2025 birth thresholds are explicit: support planned vaginal birth when HIV RNA is below 50 copies/mL; recommend planned caesarean at 50–399 after considering trajectory, treatment duration, adherence, obstetric factors and patient preference; recommend caesarean at 400 copies/mL or above.
Key red flags
Do not interpret a reactive screening assay as fully confirmed infection, but do not postpone specialist action while supplemental testing is arranged.
A rising or detectable viral load suggests adherence, absorption, interaction or resistance problems and requires urgent expert review rather than simply adding a drug.
Preterm labour or membrane rupture can invalidate a plan based on later viral-load testing; obtain current advice while providing indicated obstetric treatment.
Maternal seroconversion during pregnancy or breastfeeding carries high transmission risk and needs immediate ART, infant-risk assessment and partner care.
Formula feeding removes postnatal breast-milk HIV exposure; supported breast or chestfeeding requires sustained viral suppression, adherence and enhanced maternal and infant virological follow-up because residual transmission risk is not zero.
An infant who is unwell, has missed prophylaxis or lacks scheduled virological testing needs prompt paediatric HIV review.
A repeatedly reactive screening pathway requires confirmatory laboratory testing and urgent linkage, including baseline HIV RNA, CD4 count, resistance and hepatitis assessment.
Detectable HIV RNA near birth may reflect recent treatment, missed doses, interaction, vomiting, malabsorption or resistance and changes delivery and neonatal planning.
Fever, rash, lymphadenopathy or a new high-risk exposure with a negative or indeterminate assay can represent acute HIV and requires HIV RNA assessment.
Mastitis, cracked bleeding nipples, infant oral lesions or maternal viraemia during breast or chestfeeding prompts immediate specialist advice and temporary feeding decisions.
Investigation priorities
Distinguish a reactive screen from confirmed HIV and identify HIV type where relevant.
Management branches
An antenatal HIV screen is reactive or acute infection is suspected during pregnancy.
- Explain the result carefully, send confirmatory testing and baseline HIV RNA, CD4, resistance and coinfection samples, and contact the specialist team the same day.
- Start or optimise pregnancy-appropriate ART promptly with interaction, renal, hepatic, resistance and adherence review; do not wait for symptoms.