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Snapshot 
  • A 23-year-old woman presents to clinic with a positive pregnancy test. Two weeks ago, after having a fever and rash, she tested positive for HIV at the local health department. She is hoping to become a parent and wishes to maintain the pregnancy. In addition to typical prenatal counseling and testing, she has labs drawn for CD4 cell counts and plasma HIV RNA. She is initiated on antiretroviral therapy. 
Introduction
  • Overview
    • proper treatment of HIV during pregnancy, labor, and delivery can 
      • reduce maternal complications
      • reduce risk of perinatal transmission 
  • Epidemiology
    • incidence
      • < 5,000 estimated cases of HIV in pregnancy annually in the U.S.
    • risk factors for HIV
      • sex with an infected person
      • multiple sex partners
      • unprotected sex
      • first sexual intercourse at a young age
      • history of sexually transmitted infections (STI)
      • injection substance use 
    • risk factors for perinatal transmission
      • vaginal delivery in patients with high viral load 
  • Pathogenesis 
    • perinatal transmission
      • exposure to blood and vaginal secretions during delivery
      • transplacental circulation during uterine contractions
  • Prognosis
    • with proper treatment and low or undetectable viral loads (≤ 1,000 copies/mL)
      • perinatal transmission <1%
Presentation
  • History
    • +/- opportunistic infections, tuberculosis, and other STIs
  • Symptoms
    • new HIV infection
      • fever
      • dyspnea
      • weight loss
      • may be asymptomatic
    • advanced HIV infection
      • thrush
      • cachexia 
    • co-occuring STIs
      • genital ulcers
      • vaginal discharge
Imaging
  • Ultrasound
    • indications
      • at initial visit for gestational age
        • important as early delivery may reduce transmission
Studies
  • Serum labs
    • CD4 cell counts
      • at initial visit and every 3 months
      • every 6 months for patients with long-term viral suppression
    • plasma HIV RNA
      • initial visit
      • at antiretroviral initiation
      • 2-4 weeks after antiretroviral initiation/changes
      • monthly until viral load suppressed
      • every 3 months after viral load suppressed 
      • at 34-36 weeks to determine delivery timing/mode
    • CBC, BUN, and Cr
      • assess toxicities associated with antiretroviral therapy
      • prior to antiretroviral initiation
      • 3-6 months after initiation
Treatment
  • Lifestyle
    • some behavior modifications are associated with reduced risk of perinatal transmission
      • cigarette smoking cessation
      • cessation of recreational substances 
      • barrier protection during intercourse with multiple partners
  • Medical
    • antiretroviral therapy (ART) regimen 
    • intrapartum IV zidovudine
      • indications
        • HIV RNA > 1,000 copies/mL
  • Surgical
    • cesarean delivery at 38 weeks
      • indications
        • viral load >1,000 copies/mL near term
  • Delivery
    • standard vaginal
      • indications
        • viral load ≤ 1000 copies/mL and on ART
Complications
  • perinatal transmission
    • incidence
      • 1-2% with appropriate treatment
      • ~25% without treatment
    • risk factors
      • lack of prenatal care
      • lack of ART treatment
      • breastfeeding 
      • smoking
      • substance use
      • mode of delivery
    • treatment
      • ART for infant

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