Primary prevention
Education and counseling about HIV in pregnancy is recommended early in the course of HIV care to enable women to make informed decisions about contraception and pregnancy planning.
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Discussions about contraception and pregnancy should be repeated at intervals throughout care, especially with changes in personal circumstances (e.g., a new sexual partner).
Prepregnancy (preconception) counseling and care[7]
Reproductive intentions should be reviewed at each health care encounter. For couples where one or both partners are living with HIV and they want to conceive, expert consultation is recommended so that the approach can be tailored to the couple’s specific needs.
Both people should be screened and treated for genital tract infections before attempting to conceive. Rescreening may be considered based on individual potential exposure and the length of the preconception period.
For serodiscordant couples who want to conceive, initiation of antiretroviral therapy (ART) and sustained viral suppression of the partner with HIV is recommended before attempting conception. [
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Initiation of ART (or regimen modifications) should be made with sufficient time to achieve viral suppression before attempting to conceive, whenever possible. Use of contraception is not required to initiate (or continue) ART, even if there are limited data in pregnancy.If the partner with HIV is on ART and has achieved sustained viral suppression, there is negligible risk of sexual transmission of HIV from sexual intercourse without a condom while attempting conception. If the partner with HIV has not been able to achieve viral suppression (or their status is unknown or there are concerns about adherence to ART), pre-exposure prophylaxis (PrEP) in the partner without HIV may be recommended to reduce the risk of transmission. The partner without HIV can choose to take PrEP even if the partner with HIV has achieved viral suppression. Timing condomless sex to coincide with ovulation (peak fertility) can optimize the probability of conception.
For couples where both partners are living with HIV, both partners should be on ART with maximal viral suppression before attempting conception, with unprotected intercourse during the periovulatory period being a reasonable option.
For women with HIV who have an HIV-negative male partner, assisted insemination with the partner's semen during the periovulatory period either at home or in a provider's office eliminates the risk of transmission.
For men with HIV who have an uninfected female partner, the use of a sperm donor from a man who is uninfected eliminates the risk of HIV transmission. Sperm preparation techniques coupled with either intrauterine insemination or in vitro fertilization with intracytoplasmic sperm injection may be considered, particularly in cases of male infertility. Semen analysis is recommended before conception is attempted to check for sperm abnormalities.
Recognize that transgender and gender diverse people who were assigned female sex at birth may have special needs. Consider that people of all gender identities may seek various options to build families and should be supported to do so with minimal risks of HIV transmission within the partnership or to a child.
The impact of HIV on the course and outcome of pregnancy and the impact of pregnancy on HIV progression should be discussed. Coexisting drug or alcohol use and existing medical conditions, such as hypertension and diabetes, and, where applicable, advanced maternal age should also be discussed. Preconception nutritional counseling (e.g., folic acid) should be offered, and the importance of early and regular prenatal care stressed. The issues of safe conception (if the partner is HIV negative), use of antiretrovirals and other medications in pregnancy, and perinatal HIV transmission should also be discussed.[7]
Reducing risk of HIV infection
Women may be more susceptible to HIV infection during pregnancy and postpartum.[59] Modifying behaviors that increase the risk of exposure to HIV can prevent infection. It is recommended that people with high potential for exposure to HIV are referred to HIV risk reduction services, such as PrEP services, drug rehabilitation clinics, and STI treatment centers. Prevention counseling need not be linked explicitly to HIV testing, but it is recommended that counseling is offered or made available through referral in all healthcare facilities.[60] By obtaining regular sexual and illicit drug use histories from their patients, healthcare providers can address HIV prevention.
Discuss the use of PrEP with all sexually active people without HIV, including those who are trying to conceive, or who are pregnant, postpartum, or breast-feeding. Offer PrEP to those who desire PrEP or have specific indications for its use. Indications include:[7]
History of bacterial STI including gonorrhea, chlamydia, or syphilis
Infrequent condom use with one or more partners of unknown HIV status (especially within a high-prevalence sexual network with high HIV prevalence)
Taking nonoccupational postexposure prophylaxis (nPEP) and anticipate ongoing indications for prevention, or have used multiple courses of nPEP
Engaging in transactional sex
Substance misuse disorder and/or substance use associated with sex
Partner with HIV with unknown or inconsistent virologic suppression
History of intimate partner violence
Partner with any of the factors listed above.
Oral daily tenofovir disoproxil/emtricitabine is currently the preferred option in people who have receptive vaginal sex during pregnancy and breast-feeding.[7]
One open-label, randomized, noninferiority trial in South Africa found that tenofovir disoproxil/emtricitabine as PrEP in pregnant women was not associated with preterm birth or small for gestational age infants.[61]
Tenofovir alafenamide/emtricitabine has not demonstrated efficacy in people with receptive vaginal exposure, although adherence to daily oral tenofovir alafenamide/emtricitabine was low, and as a result it is not currently recommended for PrEP.[62]
Additional prevention strategies (e.g., condoms) are recommended for the first 20 days after initiating PrEP and for 28 days after the last potential vaginal exposure. Women who become pregnant while using oral PrEP can continue oral PrEP throughout their pregnancy.[7]
Ongoing use for 7-28 days after last HIV exposure is recommended for people planning to discontinue oral daily PrEP.
Episodic or nondaily PrEP is not recommended for protection against vaginal exposure due to a lack of data.
Non-oral formulations include a long-acting injection and a vaginal ring. Additional non-oral formulations are in development.
Dapivirine: the dapivirine vaginal ring (a non-nucleoside reverse transcriptase inhibitor) and long-acting injectable cabotegravir (an integrase strand transfer inhibitor) have been shown to reduce the risk of HIV acquisition; however, safety data are limited during conception, pregnancy, and breast-feeding. The World Health Organization recommends the dapivirine vaginal ring as a safe and effective additional prevention choice for women who are at substantial risk of HIV infection as part of combination prevention approaches.[63] The dapivirine ring is not available in the US or Europe.
Cabotegravir: pharmacokinetic and safety data on long-acting injectable cabotegravir for HIV prevention in pregnancy from the open-label extension of the HIV Prevention Trial Network (HPTN) 084 study have been presented as oral abstracts and offer reassurance on both the pharmacokinetic exposure and safety of cabotegravir use in pregnancy.[64][65] However, peer reviewed publications are pending. If a woman becomes pregnant while receiving cabotegravir, the available safety and pharmacokinetic data should be discussed.[7]
Lenacapavir: the long-acting injectable lenacapavir has been found to be highly effective in preventing HIV acquisition in cisgender women when used as PrEP. Safety data in pregnancy appear reassuring.[62] However, lenacapavir is not yet approved for HIV prevention.
Topical microbicides: topical microbicide formulations (e.g., tenofovir) applied vaginally or rectally are an experimental strategy for HIV prevention, but are not commercially available as yet.[66][67][68]
People who become pregnant while using PrEP are encouraged to register with an antiretroviral pregnancy registry as early in pregnancy as possible. This is particularly important if the person is on drugs that are not approved for PrEP (e.g., tenofovir alafenamide, cabotegravir).
When used consistently and correctly, male condoms are highly effective in preventing the sexual transmission of HIV infection.[69] A limited number of studies found that, if used consistently and correctly, the female condom substantially reduced the risk of contracting an STI.[70]
Male circumcision has been shown to reduce the efficiency of HIV transmission.[66]
Postexposure prophylaxis (PEP) is discussed in detail in a separate topic. See Postexposure HIV prophylaxis.
Secondary prevention
Secondary prevention strategies focus on the prevention of perinatal transmission. There are various factors involved in reducing the risk of perinatal transmission including:
Universal HIV screening in the prenatal setting
Early diagnosis and treatment of maternal HIV infection
Antepartum, intrapartum, and postpartum antiretroviral therapy
Scheduled cesarean delivery in patients with HIV RNA levels >1000 copies/mL or unknown viral load.
Integration of HIV and prenatal care may improve the use of antiretroviral therapy during pregnancy, thereby reducing the risk of perinatal transmission.[104]
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