HIV in Pregnancy
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults, Updated for the 2023 Edition
Consult the most recent National Department of Health Guideline for Vertical Transmission Prevention of Communicable Infections
O98.7 + (Z21/B24)
All pregnant women should receive routine counselling and voluntary HIV testing at their very first antenatal visit.
All women who test negative or who decline testing, should be offered repeat HIV testing at every routine visit throughout pregnancy (8 visits in all), at labour/delivery, at the 6-week EPI visit, and three monthly throughout breastfeeding.
WLHIV should be clinically staged and have a blood sample taken for CD4 cell count and serum creatinine on the same day as diagnosis. The results must be obtained within a week.
Initiate lifelong ART in all pregnant or breastfeeding women on the same day of diagnosis regardless of CD4 count or infant feeding practice.
Provide adequate support and counselling, particularly addressing ART adherence.
Discuss postpartum contraceptive use in the antenatal period.
Educate all women during the antenatal period about the benefits of exclusive breastfeeding for the first 6 months and breastfeeding with complimentary feeding from 6 months until at least 2 years after delivery. (Only in circumstance where the mother has confirmed 2nd or 3rd line ART regimen failure (VL >1000 copies/mL), advise not to breastfeed and prescribe replacement feeds).
Perform a TB symptom screen for all pregnant women at each visit. If any of the answers to the screening questions are positive, do further TB investigations. A TB-NAAT test must be done for all pregnant women with a new diagnosis of HIV disease, or known HIV positive women with a new pregnancy.
Screen and treat all patients for syphilis and other STIs, in line with basic antenatal care.
Test partner for HIV and perform routine cervical cancer screening.
Assist women with unwanted pregnancies <20 weeks’ gestation with access to TOP services.
MEDICINE TREATMENT
- Patients should receive ART at the first antenatal visit, whether newly diagnosed or known to be living with HIV but not on ART.
- Tenofovir should not be used in pregnant women with a serum creatinine ≥85 micromol/L (a more sensitive measure of renal impairment in pregnancy than calculated creatinine clearance).
- Pregnant women may be initiated on/switched to a dolutegravir-containing regimen.
- Initiate antenatal supplementation (see: Antenatal supplements), noting that calcium and DTG should not be taken together on an empty stomach, but can be taken together with food.
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| 1st ANC visit | |
| Pregnant women not on ART, with normal renal function, without TB. |
- TDF, oral, 300 mg daily. |
|
Pregnant women not on ART, with normal renal function, with TB (DTG requires boosting with TB treatment) |
- TDF, oral, 300 mg daily. AND - 3TC, oral, 300 mg daily. AND - DTG, oral, 50 mg daily. Provided as a fixed dose combination (FDC). WITH - DTG, oral 50 mg 12 hours later. |
| Pregnant woman on TDF + FTC + EFV | Switch to TDF+3TC+DTG |
| Pregnant woman already on ART with a VL between 50-1000 copies/ml | See Antiretroviral Therapy |
| 2nd ANC visit (1 week later) | |
| Creatinine ≤85 micromol/L | Continue ART as a FDC |
| Creatinine >85 micromol/L (TDF is contraindicated) |
Replace TDF with ABC as part of a FDC: - ABC, oral, 600 mg daily AND - 3TC, oral, 300 mg daily. AND - DTG, oral, 50 mg daily. |
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Caesarean Delivery (CD):
Provide antibiotic prophylaxis to all pregnant women, including HIV-infected pregnant women prior to surgery (See Surgical antibiotic prophylaxis).
Women with the following risk factors may be at higher risk of infection post Caesarean delivery:
- Advanced immunosuppression.
- Prolonged rupture of membranes (>18 hours).
- Multiple vaginal examinations during labour (>5 PVs).
- Second stage CD.
Monitor carefully and treat infection appropriately.
HIV-infected pregnant women not on ART undergoing elective Caesarean delivery/or in labour:
- NVP, oral, 200 mg as a single dose.
WITH
- TDF, oral, 300 mg as a single dose.
AND
- 3TC, oral, 300 mg as a single dose.
AND
- DTG, oral, 50 mg as a single dose (as a FDC 4 hours before Caesarean delivery).
Followed by lifelong:
- TDF+3TC+DTG (provided as a FDC).
For management of the HIV-exposed infant, see The HIV-exposed infant.
For more information on HIV management, see Antiretroviral Therapy.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2025-9 Review_Version 2.0_26 March 2026
Chapter 6 Obstetrics_6.6 HIV in Pregnancy