Policy

Clinical Guideline
HIV in Pregnancy

Policy developed by: SA Maternal & Neonatal Clinical Network

Approved SA Health Safety & Quality Strategic Governance Committee on:
24 June 2015
Next review due: 30 June 2018

Summary Clinical practice guideline on HIV in pregnancy.

Keywords HIV, human immunodeficiency virus, ELISA, HPV, Western blot,

viral load, resistance testing, ART, Antiretroviral treatment,
Zidovudine, AZT, HIV in Pregnancy clinical guideline

Policy history Is this a new policy? N

Does this policy amend or update an existing policy? Y v2.0
Does this policy replace an existing policy? Y

Applies to All Health Networks

CALHN, SALHN, NALHN, CHSALHN, WCHN, SAAS

Staff impact All Staff, Management, Admin, Students, Volunteers

All Clinical, Medical, Nursing, Allied Health, Emergency, Dental,
Mental Health, Pathology

PDS reference CG216

Version control and change history

Version Date from Date to Amendment

1.0 15 Apr 2004 26 Jul 2011 Original version
2.0 26 Jul 2011 24 Jun 2015 Reviewed
3.0 24 Jun 2015 Current

© Department for Health and Ageing, Government of South Australia. All rights reserved.
 South Australian Perinatal Practice Guidelines

HIV in pregnancy
© Department for Health & Ageing, Government of South Australia. All rights reserved.

Note

This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and facilitate
standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based on a review of
published evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not
sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and
professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the
patient’s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful
confidential discussion. This includes:
• The use of interpreter services where necessary,
• Advising consumers of their choice and ensuring informed consent is obtained,
• Providing care within scope of practice, meeting all legislative requirements and maintaining standards of
professional conduct, and
• Documenting all care in accordance with mandatory and local requirements

The ‘Management of Perinatal Infections’ guideline for Human Immunodeficiency Virus

by the Australasian Society for Infectious Diseases 2014 has been used to inform this
practice guideline.
Available at URL: http://www.asid.net.au/resources/clinical-guidelines

Explanation of the aboriginal artwork:

The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. The horse shoe shape
design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant women. The smaller horse shoe shape in this
instance represents the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in
unison.

Australian Aboriginal Culture is the oldest living culture in the world yet we
experience the worst health outcomes in comparison. Our Aboriginal women are
2-5 times more likely to die in childbirth and our babies are 2-3 times more likely to
be low birth weight. Despite these unacceptable statistics the birth of an Aboriginal
baby is an important Cultural event and diverse protocols during the birthing
journey may apply.

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
[email protected] Page 1 of 17
 South Australian Perinatal Practice Guidelines

HIV in pregnancy

Management of HIV in pregnancy

Offer HIV pregnancy screening to all women at the first antenatal visit
in every pregnancy

Pre-existing HIV Newly diagnosed HIV

Multidisciplinary team management

in a tertiary hospital
 Referral to Maternal Fetal
Medicine/High risk management
obstetrician, infectious diseases
consultant

Investigations Strategies to reduce Mother to Child

 Routine booking bloods (if not already transmission (MTCT) of HIV
done)  Formula feeding only NO breastfeeding
 Baseline bloods – LFTs , electrolytes,  Anti-Retroviral Therapy (ART): If not
urea, creatinine, amylase, lactate, HLA already taking, commence as soon as
B5701 possible (see further details in guideline
 FBC, CD4 cell count and lymphocyte below)
subsets Mode of birth:
 HIV viral load  Viral load <50 copies/mL and ≥36 weeks
 HIV resistance testing (unless already done and no other obstetric complications, for
 Consider low vaginal swab for genital and vaginal birth
other STDs (e.g. gonorrhoea, chlamydia,  Viral load 50-399 ≥36 weeks: Consider
bacterial vaginosis) and first void urine for caesarean section, give intrapartum
chlamydia, gonorrhoea zidovudine
 Cervical smear: (high risk of intra-  Viral load >400 copies/mL ≥36 weeks:
epithelial neoplasia secondary to HPV) Plan caesarean section, give intrapartum
zidovudine

Postpartum care
 Actively discourage breastfeeding
 Consider lactation suppression with
cabergoline (Dostinex®)
 ART should be prescribed in
consultation with an infectious
diseases consultant
 Contraception advice before
discharge

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
[email protected] Page 2 of 17
 South Australian Perinatal Practice Guidelines

HIV in pregnancy
Care of the newborn (maternal HIV)

At birth
 Standard precautions (protective gown, gloves and eyewear)
 Notify paediatrician of impending birth
 Routine cord bloods

Immediate care after birth Prevention of mother to child

 Baby to remain in birthing room transmission (MTCT)
with mother until transfer to ward Undetectable maternal viral load AND
(unless transfer to nursery is optimal HIV suppression strategies in
required) place AND bottle fed baby
 Wash all visible maternal blood  Commence zidovudine prophylaxis as soon
from hair or skin of baby as possible after birth (within 6-12 hours)
 Actively discourage and continue for 4 weeks
breastfeeding  Pneumocystis jiroveci pneumonia (PJP)
 Ensure skin at injection site is prophylaxis not needed
clean (soap and water or use an Unknown or detectable viral load OR no
alcohol swab) before optimal suppression strategies in place
administering any injection OR breastfed baby OR mother found to be
including Vitamin K, hepatitis B HIV positive after delivery
vaccine, hepatitis B
immunoglobulin  Commence lamivudine and nevirapine as
well as zidovudine prophylaxis as soon as
possible after birth (within 6-12 hours). Use
a tapering regimen to cover the long half-life
of nevirapine and continue lamivudine and
zidovudine for 4 weeks (see dosage in text)
 PJP prophylaxis required

TEST

Time of PCR – Proviral HIV

testing DNA or HIV RNA
antibody

Week 1 Yes No
Week 6 Yes No
3 Months Yes No
6 months No No
12 months No (Clinical visit only) NO
18 months Yes

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
[email protected] Page 3 of 17
 South Australian Perinatal Practice Guidelines

HIV in pregnancy
Introduction
 The care of the pregnant HIV infected women is complex and requires a multidisciplinary
approach by health care providers who have current knowledge and expertise in this area
 Specialist advice should always be sought for each woman with HIV, especially when
recommendations may be inconsistent and / or evidence is lacking

Pre-existing HIV before pregnancy

 All women with known HIV should be referred to an HIV physician, sexual health physician
and an obstetric consultant with specialist knowledge of the pregnant HIV infected woman
to discuss the following:
 Preconception counselling

 Fertility management

 Sexual health assessment

 Social assessment

 The need for optimal suppression of the woman’s viral load before pregnancy

 Education about the side effects of anti-retroviral therapy, including

hyperglycaemia, anaemia and hepatic toxicity
 Pre-pregnancy screening should include:
 Sexual health - screen for and treat any infectious or sexually transmitted
diseases (e.g. rubella, hepatitis B, hepatitis C, syphilis, varicella,
toxoplasmosis, cytomegalovirus, herpes simplex virus)
 Cervical cytology (unless a recorded negative result within the last 12 months).
HIV is associated with increased risk of Human Papilloma Virus (HPV) related
cervical squamous intraepithelial lesions. These are precursor lesions for
cervix cancer

 Social assessment - screen for maternal psychological issues and substance

abuse and refer as appropriate

Pregnancy HIV screening and notification

 HIV screening is offered to all women at their first antenatal visit with the option to decline.
Screening must be:
 Voluntary and confidential
 Accompanied by adequate pre-test discussion, including how the result will be
communicated. A positive screen with ELISA is confirmed with Western blot (WB)
 HIV is a notifiable disease
 The medical officer should telephone CDCB on 1300 232 272, Monday to Friday (8.30 am
to 5.00 pm). The notification form is sent out to the medical officer upon receipt of a
positive laboratory result. The responsible medical officer then completes the medical
notification form. Fax to (08) 8226 7187 or post to the Communicable Disease Control
Branch (CDCB) PO Box 6 Rundle Mall, 5000
 This form is not to be sent by email for reasons of confidentiality

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
[email protected] Page 4 of 17
 South Australian Perinatal Practice Guidelines

HIV in pregnancy
Post-test counselling
HIV positive
 The responsible medical officer should contact the woman to arrange face to face
notification of the positive HIV test result
 The implications of the positive HIV test result for the woman, her pregnancy,
and her partner should be discussed in detail, as well as the need for
implementation of transmission precautions for both her baby, partner and
health care workers
 The notifying medical officer should explicitly state their obligation to protect patient
confidentiality at all times
 Referral to high risk management in a tertiary centre with a multidisciplinary team for further
counselling including:
 HIV physician, specialist obstetrician (Maternal Fetal Medicine or High Risk),
infectious disease consultant, infection control coordinator, neonatologist /
paediatrician, anaesthetist, midwife and allied health services as appropriate
(e.g. social worker, perinatal substance use team, perinatal mental health
team, pharmacist)
 Ensure the woman is informed of the medical officer’s obligation to notify the Communicable
Disease Control Branch of the diagnosis as Partner Notification officers will interview the
woman

HIV negative
 Low risk: no further testing
 High risk of recent exposure or re-exposure likely: Repeat HIV testing in 4 weeks

Indeterminate Western blot

 Further testing needed
 Discuss with HIV reference laboratory
 Discuss with a clinical pathologist / virologist

Investigations
Bloods
 Routine antenatal bloods (see in ‘Normal pregnancy’ guideline in the A to Z index at
www.sahealth.sa.gov.au/perinatal)
 Additional serology for cytomegalovirus, varicella, herpes simplex virus and
toxoplasmosis at the time of routine antenatal bloods (see Appendix I: HIV
management summary chart)
 Full blood count, CD4 cell count and lymphocyte subsets
 HIV viral load
 HIV resistance testing (unless already performed)
 Baseline bloods including:
 Liver function tests, electrolytes, urea, creatinine, amylase, lactate, HLA B5701

Swabs and urine screening

 Consider a low vaginal swab for genital and other sexually transmitted infections
(gonorrhoea / chlamydia / bacterial vaginosis) and first void urine for chlamydia:
 In early pregnancy

 At 28 weeks

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
[email protected] Page 5 of 17
 South Australian Perinatal Practice Guidelines

HIV in pregnancy
 If detected, Chlamydia trachomatis should be treated with a single 1 g oral dose of
Azithromycin
 If detected, treat bacterial vaginosis with:
 Clindamycin 300 mg orally, every 12 hours for 7 days or Metronidazole 400
mg orally, every 12 hours for 5 days (Bacterial vaginosis has been associated
6
with preterm birth and a higher rate of mother to child HIV transfer)
 Cervical cytology (high risk of intra-epithelial neoplasia secondary to Human Papilloma
Virus [HPV] infection)
 Routine low vaginal swab for GBS screening at 36 weeks of gestation

Management
 Arrange multidisciplinary team meeting soon after diagnosis or pregnancy presentation with
known HIV
 Ensure optimal suppression of HIV viral load during pregnancy
 Confirm mode of delivery (see below) and management plan for both mother and baby and
document in case notes
 Educate mother about the need to continue and / or commence ART throughout her
pregnancy and in labour (as required) and advise woman to present to hospital as soon as
contractions begin or if rupture of the membranes occurs
 Notify pharmacy to ensure adequate supply of ART for both mother and baby

Education
 Advise against breastfeeding
 Discuss the known evidence on the benefits and risks associated with vaginal birth versus
elective caesarean section in relation to the woman’s individual circumstances
 Document discussion and agreement by the woman regarding planned mode
of delivery
 Discuss management of the baby at birth including antiretroviral prophylaxis

Intrapartum
Women who present in early labour or with ruptured membranes at term
 If spontaneous rupture of the membranes (SROM) occurs before or early in labour,
interventions to decrease the interval to delivery (e.g. administration of oxytocin) can be
considered in HIV-infected women with viral suppression and no indications for caesarean
section (AIDSinfo online 2015)
 There are too few data to advise if caesarean section will reduce the risk of
perinatal transmission of HIV after the onset of labour or spontaneous rupture
of the membranes (SROM). Most studies have shown a similar risk of
transmission between caesarean section performed for obstetric indications
after labour and SROM and for vaginal delivery (AIDSinfo online 2015)
 In cases where women scheduled for elective caesarean section present with rupture of the
membranes OR early labour, it is not clear how soon after the onset of labour OR rupture of
the membranes the benefit of elective caesarean section is lost
 The decision about whether to deliver by expeditious caesarean section must
be individualized, taking into account duration of rupture of the membranes or
labour upon presentation, projected length of labour remaining, the most
recent RNA level, and current ART drug regimen status. The ART drug
regimen should be continued and IV zidovudine initiated (AIDSinfo 2015)

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
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 South Australian Perinatal Practice Guidelines

HIV in pregnancy

 Data regarding the potential risk of perinatal transmission of HIV associated with operative
vaginal delivery using forceps or vacuum extraction and / or use of episiotomy are limited to
studies in the pre-ART era. These procedures may be performed for a clear obstetric
indication (AIDSinfo 2015)
 Medical expert opinion recommends the use of Forceps rather than Vacuum
extraction in women HIV on the premise that forceps are less likely to damage
the integrity of the skin
Preterm prelabour rupture of the membranes (PPROM)
 Recommend immediate delivery when PPROM occurs between 34 to 37 weeks gestation
with either caesarean section or vaginal delivery, according to obstetric indications and
individual circumstances
 See ‘Preterm prelabour rupture of the membranes’ in the A to Z index at URL
www.sahealth.sa.gov.au/perinatal for further information regarding antibiotic
prophylaxis and indications for corticosteroid cover
 Virological control should be optimised
 In cases < 34 weeks gestation there should be multidisciplinary discussion about the timing
and mode of delivery (AIDSinfo 2015)

Strategies to minimise mother to child transmission of HIV

 All mothers with HIV should be advised to formula feed their baby (no breastfeeding)
 ART should be prescribed in consultation with an infectious diseases specialist to
ensure that it is appropriate for the woman’s situation and commensurate with the latest
evidence
 The woman should be fully informed about the known potential benefits versus risks of
5
antiviral treatment. Obtain written consent before commencing treatment
 NB: If required intrapartum, ensure intravenous zidovudine is available in the
hospital at the point of care
 Highly active anti-retroviral therapy (HAART) regimens must be prescribed in accordance
with pregnancy guideline recommendations by the infectious diseases or STD consultants

1. Conceiving on effective HAART

Viral load less than 50 copies/mL (undetectable) at or after 36 weeks gestation
 Continue current treatment

 No need for intrapartum zidovudine

 Vaginal delivery if no obstetric contraindications

2. Naïve to HAART, needing therapy for own health

 Commence HAART as soon as possible
 Choice of regimens
 Nucleoside backbone: zidovudine + lamivudine OR tenofovir + emtricitabine
OR abacavir + lamivudine
 Third agent: Boosted Protease inhibitor (PI), (preferred PI regimens include
atazanovir / ritonavir, lopinavir / ritonavir), efavirenz (if after 8 weeks gestation)
or nevirapine (if CD4 cell count < 250 cells/uL)
Viral load less than 50 copies/mL (undetectable) at or after 36 weeks gestation
 Continue current treatment

 No need for intrapartum zidovudine

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
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 South Australian Perinatal Practice Guidelines

HIV in pregnancy
 Vaginal delivery if no obstetric contraindications

Viral load 50-399 copies/mL at or after 36 weeks gestation

 Give intrapartum zidovudine (see table below)

 Consider elective caesarean section between 38 and 39 weeks gestation

Viral load more than 400 copies/mL at or after 36 weeks gestation

 Give intrapartum zidovudine (see table below)

 Plan elective caesarean section between 38 and 39 weeks gestation

3. Naïve to HAART, not needing therapy for own health

 Commence anti-retroviral therapy (ART), preferably in the second trimester but at least by
week 24 of pregnancy in consultation with STD or infectious disease consultant
 Nucleoside backbone: zidovudine + lamivudine OR tenofovir + emtricitabine OR abacavir +
lamivudine
 Third agent: boosted PI
 Manage according to viral load (as above)

4. Late presenter, not on HAART

Not in labour
 Presentation after 28 weeks
 Commence HAART as soon as possible after HIV assessment

 Intrapartum zidovudine and planned caesarean section if viral load detectable

(> 50 copies/mL)
 Viral load unknown or >100,000 copies/mL
 Commence HAART as soon as possible, after HIV assessment

 Add raltegravir to regimen

 Intrapartum zidovudine and

 Plan caesarean section delivery

In labour at term
 Stat dose of nevirapine

 Start oral fixed dose combination zidovudine/lamivudine

 Add raltegravir to regimen

 Intrapartum zidovudine (see table below)

 Plan caesarean section delivery

In labour preterm
 Stat dose of nevirapine

 Start HAART

 Use double dose tenofovir

 Add raltegravir to regimen

 Intrapartum zidovudine (see table below)

 Consider caesarean section depending on obstetric factors

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
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 South Australian Perinatal Practice Guidelines

HIV in pregnancy
Intrapartum zidovudine 9-12
 NB: Ensure zidovudine is available in the hospital at the point of care of intended
delivery

Rates of transmission are increased in case of:

 Advanced maternal illness

 High maternal viral load (due to advanced infection or viral activity)

 Poor maternal immune status e.g. low CD4 count (also known as T cell count)

 Rupture of membranes > 4 hours before birth

 Preterm birth

 Breastfeeding

 Procedures that may jeopardise the integrity of natural barriers (e.g. fetal scalp
electrodes, vigorous suctioning, injections through unwashed skin)

Vaginal birth
 If indicated, commence zidovudine infusion once labour has started (see regimen below)
 Notify the consultant obstetrician in charge of labour ward and the infection control
coordinator when the woman is admitted in labour
 Notify the Neonatologist and Infectious Diseases physician at time of birth
 Deliver the baby gently, with minimal aerial dispersion of vaginal secretions
 Clean the eyes of the baby with saline at delivery of the head
 Clamp cord as soon as possible
 Avoid procedures that may inoculate the baby, for example:
 Fetal scalp monitoring

 Fetal blood sampling

 Vigorous aspiration or oral suction of baby

 If there is an obstetric indication to expedite delivery in second stage, an instrumental
delivery may be the safest mode; however, there is a small risk of traumatising the fetal skin
and inoculating the baby

Elective caesarean section

 If indicated, commence zidovudine infusion 4 hours before planned birth (see regimen
below)
 Notify theatre staff of woman’s imminent admission for surgery
 The team should be limited to essential members
 The consultant obstetrician and midwife in charge of the woman must ensure there is strict
adherence to ALL standard precautions and operating room infection control management
guidelines
 NB: No pre-operative shaving of the woman (clipping is acceptable if deemed necessary)

At birth
 Protective eyewear (goggles, mask or face shield), gown / apron, gloves and boots /
overshoes should be worn by ALL persons having direct contact with the woman and baby
before, during and in the early postpartum period (first hours before transfer to ward). For
more information see “infection control precautions” below

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
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 South Australian Perinatal Practice Guidelines

HIV in pregnancy

Zidovudine infusion regimen

 Zidovudine IV 10 mg / mL - available in vial 200 mg / 20 mL
 NB: Zidovudine is obtained via the Special Access Scheme (SAS). Supply needs to be
arranged in advance. If outside normal working hours, notify on-call pharmacist for the
location of SAS drug to expedite treatment
 Give intravenously via infusion pump
 Dilute zidovudine with 0.9 % sodium chloride to a concentration of 1 mg / mL and administer
by slow intravenous infusion over a one hour period

Set up
 Withdraw 100 mL sodium chloride 0.9 % from a 1,000 mL sodium chloride 0.9 % bag
Add 1,000 mg (100 mL zidovudine 10 mg / mL vials) to the bag to give a total dose of 1,000
mg in 1,000 mL (i.e. 1 mg / mL)

Vaginal birth Caesarean section

 Commence zidovudine 2 mg / kg IV over  Commence zidovudine 2 mg / kg IV over 60
60 minutes, at the onset of labour, minutes, starting four hours before the
followed by a maintenance dose of 1 mg / anticipated caesarean section, followed by a
kg per hour IV until the umbilical cord is maintenance dose of 1 mg / kg per hour IV
clamped until the umbilical cord is clamped

Maternal dose calculation guide

Maternal weight (kg) Loading dose (over Maintenance dose

60 minutes)
50 100 mL / hr 50 mL / hr

55 110 mL / hr 55 mL / hr

60 120 mL / hr 60 mL / hr

65 130 mL / hr 65 mL / hr

70 140 mL / hr 70 mL / hr

75 150 mL / hr 75 mL / hr

80 160 mL / hr 80 mL / hr

85 170 mL / hr 85 mL/ hr

90 180 mL / hr 90 mL / hr

95 190 mL / hr 95 mL / hr

100 200 mL / hr 100 mL / hr

ISBN number: 978-1-74243-097-3

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Last Revised: 24/06/15
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 South Australian Perinatal Practice Guidelines

HIV in pregnancy
Infection control precautions
 Standard precautions
 Staff with known broken skin or dermatitis should not assist

Prevention of injuries
 Maintenance of standard precautions is essential when handling needles, scalpels and
other sharp instruments. The USER is responsible for their safe disposal into a designated
“sharps” container

Operating room techniques

 The principle of “confine and contain” should always be applied
 Avoid passing needles, blades, or other sharp instruments from hand to hand. A dish for
disposal must be placed nearby
 Closed wound drainage systems should be used
 Wound dressings should be of the type that will contain exudate inside an impervious outer
covering
 Suction apparatus used should be disposable

Reprocessing of equipment
 Staff must wear adequate protective clothing when cleaning instruments and equipment
 Instruments should be rinsed in cold water to remove blood, followed by thorough cleaning
with detergent before being sterilised
 Pasteurisation or chemical disinfection may be necessary for some items of equipment. Non
disposable equipment, operating trolley, barouche and the floor should be cleaned
thoroughly with detergent and wiped over with a hospital approved cleaning product
containing sodium hypochlorite (may be a combined detergent / disinfectant)

Waste disposal
 All “medical” infectious waste must be put into yellow biological plastic bags and securely
tied before disposal into a designated bin

Care of the newborn

 A neonatologist / paediatrician must be notified of impending birth
 Protective gown, gloves and eyewear should be worn
 Collect routine cord bloods after the cord is carefully wiped clean to avoid contamination
with maternal blood
 The baby should remain in the birthing room until transfer to the ward unless transfer to the
nursery is indicated
 After birth, wash all maternal blood from the baby
 Consider washing any visible blood from hair or skin before contact with
extended family
 The skin at the injection site should be cleaned with soap and water (if not already done)
OR with an alcohol swab before administering any injection including hepatitis B vaccine,
®
immunoglobulin (if required) or Konakion (vitamin K)
 Breast feeding should be actively discouraged

Prevention of mother to child transmission (pMTCT)

 Treatment needs to be coordinated between neonatologist (paediatrician) and infectious
diseases specialist
Undetectable maternal viral load (<50 copies/mL) and optimal HIV suppression
strategies in place during pregnancy in a bottle fed baby

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
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 South Australian Perinatal Practice Guidelines

HIV in pregnancy
 In the setting of undetectable maternal viral load at or later than 36 weeks gestation with no
other risk factors contributing to MTCT, the estimated transmission risk is less than 2%
 Zidovudine monotherapy is recommended if MTCT risk is low (<2%), even if the mother has
a previous history of zidovudine resistance but has an ‘undetectable’ viral load. Prophylaxis
should start as soon as possible after birth (within 6-12 hours of delivery) for 4 weeks

 Zidovudine (AZT) oral concentration 10 mg/mL

Frequency and
Gestational age (weeks) Dose (mg/kg)
Duration

<30 2 12 hourly for 4 weeks

12 hourly for 2 weeks

30 to 34 weeks 2 followed by 8 hourly for 2
weeks

≥ 35 weeks 4 12 hourly for 4 weeks

 If neonates are unable to take oral zidovudine; give intravenously

 Zidovudine IV formulation 10 mg/mL
Gestational age Dose (mg/kg) Frequency

Term neonate 1.5 6 hourly

Preterm 1.5 12 hourly

 Please note this formulation is not marketed in Australia and is only available via the Special
Access Scheme (SAS). SAS paperwork and informed parental consent should be organised
before to starting treatment. For further information see ‘Zidovudine’ in the A to Z index at
www.sahealth.sa.gov.au/neonatal
 Maternal zidovudine resistant strain: Monotherapy with zidovudine (postnatal) is still the
recommended antiretroviral therapy of choice if MTCT risk is low (<2%) i.e. where maternal
viral load is undetectable at or later than 36 weeks gestation with no other risk factors
contributing to MTCT
Unknown or detectable viral load and/or no optimal suppression strategies in place
 Antiretrovirals in addition to zidovudine are indicated: MTCT is considered significant
(> 2%) if maternal viral load is detectable at ≥ 36 weeks, or late maternal presentation and
viral load is unknown, or mother found to be HIV positive just after delivery. Lamivudine and
nevirapine are added to zidovudine, with a tapering regimen to cover the long half-life of
nevirapine. Commence together with zidovudine as soon as possible after birth within 6-12
hours of delivery
In addition to zidovudine, use
 Lamivudine (3TC), 3TC oral solution: concentration 10 mg/mL
 Give 2 mg/kg/dose orally, 12 hourly for 4 weeks
 For further information see ‘lamivudine’ in the A to Z index at
www.sahealth.sa.gov.au/neonatal
PLUS
 Nevirapine (NVP) oral suspension: concentration 10 mg/mL
 If mother has never taken nevirapine or was taking nevirapine for < 3 days:
 2 mg/kg/dose orally, daily for 1 week

 Then 4 mg/kg/dose orally, daily for 1 week in the second week, then stop
 If mother was taking nevirapine for the last 3 days or more:
 4 mg/kg/dose, daily for 2 weeks, then stop
 For further information see ‘nevirapine’ in the A to Z index at
ISBN number: 978-1-74243-097-3
Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
[email protected] Page 12 of 17
 South Australian Perinatal Practice Guidelines

HIV in pregnancy
www.sahealth.sa.gov.au/neonatal
 Further follow-up in consultation with the infectious diseases consultant is required

Pneumocystis jiroveci pneumonia (PJP) prophylaxis:

 PJP prophylaxis with trimethoprim with sulfamethoxazole “co-trimoxazole” is recommended
if MTCT risk is high (>2%). Commence PJP prophylaxis when ART post exposure
prophylaxis is discontinued at the end of 4 weeks. Continue PJP prophylaxis until HIV
infection is excluded. If HIV infected, PJP prophylaxis should be continued and managed
as per following:
Age 1 month to 12 months
 Use trimethoprim with sulfamethoxazole “co-trimoxazole” (1 mL of oral liquid contains 8 mg
trimethoprim and 40 mg of sulfamethoxazole)
 NOTE: Dosing is based on trimethoprim component
 2.5 to 5 mg / kg twice a day, on 2 or 3 days of the week (may be given on consecutive or
alternate days) OR
 5 to 10 mg / kg as a single daily dose on every day of the week

Suggested testing regimen for infant

TEST

Time of testing PCR – Proviral HIV antibody

DNA or HIV RNA

Week 1 Yes No

Week 6 Yes No

3 Months Yes No

6 months No No

12 months No (Clinical visit only) NO

18 months Yes (to document

clearance of maternal HIV
antibodies and confirm
infant’s HIV negative
status)

 Testing should occur at least 2 weeks and 2 months after antiretroviral prophylaxis is
ceased, hence testing at 6 weeks and 3 months
 Whilst testing at 6 and 12 months is no longer recommended, clinical visits here provide the
opportunities for clinical assessment, routine childhood immunisations and maintenance of
contact with family

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
[email protected] Page 13 of 17
 South Australian Perinatal Practice Guidelines

HIV in pregnancy
Postpartum care
 Breast feeding (and expressed breast milk feeding) should be actively discouraged
12
 Consider lactation suppression with cabergoline (Dostinex®) 1 mg oral stat dose
 ART should be prescribed in consultation with an infectious diseases consultant
 Contraception advice before discharge

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
[email protected] Page 14 of 17
 South Australian Perinatal Practice Guidelines

HIV in pregnancy
References
1. Palasanthiran P, Starr M, Jones C, Giles M, editors. Management of perinatal
infections. Sydney: Australasian Society for Infectious Diseases (ASID) 2014.
Available from: URL: http://www.asid.net.au/resources/clinical-guidelines
2. National Health and Medical Research Council (NHMRC). Australian guidelines for
the prevention and control of infection in healthcare. Commonwealth of Australia;
2010. Available from URL:
http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/CD33_InfectionC
ontrolGuidelines2010.pdf
3. AIDSinfo. Panel on treatment of HIV-infected pregnant women and prevention of
perinatal transmission. Recommendations for Use of Antiretroviral drugs in Pregnant
HIV-1-infected women for maternal health and interventions to reduce perinatal HIV
transmission in the United States. March 2014 [cited 2015 Jan 11]; p. D7-D10.
Available at URL: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf

Useful web sites:

You’ve got what? SA Health in A to Z index: Human Immunodeficiency Virus

(HIV)Australasian Society for HIV Medicine at URL:

http://www.ashm.org.au/default.asp?active_page_id=1

AIDS info site at URL: http://www.aidsinfo.nih.gov/

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
[email protected] Page 15 of 17
 South Australian Perinatal Practice Guidelines

HIV in pregnancy
Appendix I: HIV Management summary chart

Address Phone h___________________________

wk ___________________________
mob___________________________

ID or SH specialist _______________Tel____________________ Informed date ________________

Obstetrician____________________Tel____________________ Informed date ________________
Paediatrician___________________Tel____________________ Informed date ________________
Neonatologist__________________ Tel ____________________ Informed date ________________
Inf control _____________________Tel ___________________ Informed date ________________
Pharmacist_____________________Tel ___________________ Informed date ________________

Date Date
HIV diagnosis ART to commence
LMP Multidisciplinary meeting
EDC Vaginal  Caesarean  HSV prophylaxis

Test Date Result Medications Start date

Hep BsAb
Hep BcAb
Hep BsAg
Hep B Viral load
Hep C 1.
(28 weeks) 2.
Hep C viral load
Syphilis 1.
(28 weeks)2.
EBV HIV resistance mutations
CMV NNRTI
Toxo NRTI
HSV I PI
HSV II
Chlamydia 1.
Allergies
(28 weeks) 2.
Gonorrhoea 1.
(28 weeks) 2. HLA B57 negative  positive 
TB CXR
Immunisations Date Date Date
Rubella Hepatitis B
Varicella Influenza
Pap Smear

ID: Infectious Disease specialist

SH: Sexual Health specialist

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
[email protected] Page 16 of 17
 South Australian Perinatal Practice Guidelines

HIV in pregnancy
Abbreviations
AIDS Acquired immune deficiency syndrome
ART Antiretroviral treatment
ASHM Australasian Society for HIV Medicine
AZT Zidovudine, Azidothymidine
CD4 A type of lymphocyte
CMV Cytomegalovirus
EBV Epstein Barr virus
EDC Estimated date of confinement
e.g. For example
et al. And others
GBS Group B streptococcus
HCV Hepatitis C virus
HIV Human Immunodeficiency Virus
HLA Human Leukocyte Antigen
HPV Human Papilloma Virus
HSV Herpes simplex Virus
ID Infectious disease
LMP Last menstrual period
mg Milligram(s)
mL Millilitre(s)
NNRTI Non-Nucleoside Reverse Transcriptase Inhibitors
PACTG 076 Paediatric AIDS Clinical Trial Group
PCP Pneumocystis jeroveci (previously carinii) pneumonia
% Percent
PI Protease Inhibitor
PHSTF Public Health Service Task Force
RNA Ribonucleic acid
TB Tuberculosis
> More than

Version control and change history

PDS reference: OCE use only

Version Date from Date to Amendment

1.0 15 Apr 2004 26 Jul 2011 Original version
2.0 26 Jul 2011 24 Jun 2015 Reviewed
3.0 24 Jun 2015 Current

ISBN number: 978-1-74243-097-3

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 24/06/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
[email protected] Page 17 of 17