The American College of Obstetricians and Gynecologists has published updated recommendations for human immunodeficiency virus (HIV) testing in pregnancy. In addition to decreasing perinatal transmission, there are additional benefits to identifying and treating HIV-infected pregnant women. Growing evidence suggests that early antiretroviral therapy is beneficial for HIV-infected persons. In addition, treatment of HIV-infected persons decreases the risk of transmission to HIV-uninfected sexual partners.¹

All pregnant women should be screened for HIV infection in each pregnancy. For women at high risk for HIV, testing should be repeated in the third trimester. Women who present to labor and delivery with undocumented HIV status should be offered expedited screening. If rapid test results are positive, antiretroviral prophylaxis should be started immediately while waiting for supplemental test results.

A French multicenter cohort study prospectively followed 8,075 nonbreastfeeding HIV-infected pregnant women and their infants; all women received combination antiretroviral therapy. Overall, the HIV perinatal transmission rate was 0.7% (56/8,075). Most notably, among 2,651 women who were receiving combination antiretroviral therapy before pregnancy, continued therapy in pregnancy, and had a low viral load at delivery (less than 50 copies/mL), there were no perinatal HIV transmissions. The perinatal transmission rates for women who started combination antiretroviral therapy in the first, second, or third trimester were 0.4% (3/709), 0.9% (24/2,810), and 2.2% (23/1,051), respectively.

Twenty-seven cases of perinatal HIV infection are described in Atlanta, Georgia, from 2005 to 2012. Among the 27 HIV-infected mothers, seven were not aware of their HIV status before pregnancy. Among the 20 mothers who knew they were HIV-infected, half did not receive prenatal care and half did not receive not receive antiretroviral therapy during pregnancy, delivery, or both. One woman who was not diagnosed with HIV until after delivery breastfed her infant for 3 months. This report highlights the importance of HIV testing in pregnancy, receipt of prenatal care, and linkage to comprehensive HIV care, including receipt of antenatal, intrapartum, and postnatal antiretroviral therapy, a plan for appropriate mode of delivery, and counseling regarding avoidance of breastfeeding.

This prospective observational study evaluates birth outcomes among a large group (N=3,314) of HIV-infected pregnant women. Because this study was conducted in Tanzania before the implementation of universal provision of combination antiretroviral therapy in pregnancy, it offers a rare opportunity to evaluate the effect of antiretroviral therapy in pregnancy with an appropriate control group for comparison. Compared with zidovudine monotherapy, starting antiretroviral therapy before pregnancy was associated with an increased risk of preterm delivery (adjusted relative risk [RR] 1.24; 95% confidence interval [CI] 1.05–1.47) and very preterm delivery (adjusted RR 1.42; 95% CI 1.02–1.99). Compared with zidovudine monotherapy, starting antiretroviral therapy during pregnancy was associated with an increased risk of severe small for gestational age (adjusted RR 1.47; 95% CI 1.09–1.98). The regression models were appropriately adjusted for CD4 cell count.

Although other studies have found conflicting results, the finding that combination antiretroviral therapy during pregnancy is associated with adverse birth outcomes is consistent with a growing body of evidence. As pointed out in an accompanying editorial,³ despite tremendous benefits for mothers and their infants, antiretroviral therapies used in pregnancy are not risk-free. These risks have not been well-documented, and additional studies are needed to maximize the health of HIV-infected women and their infants.