HIV in Pregnancy
Description General measures Medicine treatment Referral O98.7 DESCRIPTION HIV is currently the commonest cause of maternal deaths in South Africa. Transmission of HIV from mother to infant may occur during pregnancy, delivery and/or breastfeeding. Without intervention, 25–40% of infants born to HIV-infected women may become infected. With appropriate interventions, maternal mortality as well as
Description
General measures
Medicine treatment
Referral
O98.7
DESCRIPTION
HIV is currently the commonest cause of maternal deaths in South Africa. Transmission of HIV from mother to infant may occur during pregnancy, delivery and/or breastfeeding. Without intervention, 25–40% of infants born to HIV-infected women may become infected. With appropriate interventions, maternal mortality as well as perinatal transmission of HIV can be substantially reduced. 4% of women who were initially HIV-negative become positive later during pregnancy. Repeat HIV testing is essential.
For comprehensive information on the care of HIV-infected pregnant women refer to the current National Consolidated Guidelines for the Prevention of Mother-to-Child Transmission of HIV (PMTCT) and the management of HIV in Children, Adolescents and Adults as well as the current Guidelines for Maternity Care in South Africa. See Chapter: HIV and AIDS.
GENERAL MEASURES
HCT in all pregnant and breastfeeding women
- Provide routine counselling and voluntary HIV testing to all pregnant women (if HIV status is negative or unknown) at their very first antenatal visit, and treat other STIs if necessary.
- All women who test negative must be offered repeat HIV testing at every routine visit throughout pregnancy, at labour/delivery, at the 6-week EPI visit and 3 monthly throughout breastfeeding.
- Perform a TB symptom screen at each visit
Women who choose not to be tested
- Provide with individual 'post-refusal' counselling and offer HIV testing at every subsequent visit.
- Perform a TB symptom screen at each visit.
- Counsel on risks of MTCT to unborn baby, HIV risk reduction behaviour and offer HIV prevention services.
Pregnant women who test HIV positive
- Confirm result with a 2nd rapid HIV test of another type in compliance with current HCT policy.
- If results are discordant, repeat both first and confirmatory rapid HIV tests and if still discordant, send blood for a laboratory HIV ELISA.
- All confirmed HIV-infected women must be fast-tracked for ART regardless of CD4 count.
- Perform clinical staging and TB symptom screen, and take a blood sample for CD4 cell count and creatinine, on the day of testing. Obtain results within a week.
- If CD4 < 100 cells/mm3, do a serum cryptococcal antigen (CrAg) test.
- Start ART on the day of diagnosis (unless there are symptoms of TB).
- Investigate all those with TB symptoms before ART initiation. If TB treatment is started, defer ART for 2 weeks.
- HIV-infected women (WLHIV) must return 1 week after their initial ANC visit to get their creatinine, and CD4 cell count results and be managed accordingly.
- Refer women with unwanted pregnancies < 20 weeks' gestation for termination of pregnancy (TOP) services.
- Perform a TB symptom screen at each visit
Pregnant women already known to be HIV-infected
- If not on ART, do clinical staging; take blood for CD4 count (to determine eligibility for cotrimoxazole prophylaxis) and creatinine. If CD4< 100 cells/mm3, do a serum cryptococcal antigen (CrAg) test.
- Start ART the same day if no contraindication.
- If already on ART for > 3 months, take blood for viral load measurement irrespective of when it was last done.
- Perform a TB symptom screen at each visit
Antenatal support
- Counsel about the importance of adherence and virological suppression for PMTCT.
- Counsel on infant feeding, safer sex, family planning, postnatal contraception, partner testing, routine cervical cancer screening.
- Provide appropriate nutritional care and support including iron, folate and calcium supplementation and Hb testing.
Postpartum support
- Provide adequate support and counselling, particularly addressing ART adherence during breastfeeding.
- Educate mothers about the benefits of breastfeeding. Only in circumstance where the mother has confirmed 2nd or 3rd line ART regimen failure, advise not to breastfeed and prescribe replacement feeds.
- Refer mother to appropriate services to continue lifelong ART as part of the general adult ART population.
MEDICINE TREATMENT
Opportunistic infection treatment and prophylaxis for HIV-infected pregnant women:
Pregnant women diagnosed with pulmonary TB:
- First line TB treatment is safe and effective in pregnant women.
- See Pulmonary tuberculosis (TB) in adults.
Pregnant women on ART with no symptoms of TB:
Women with CD4 ≤ 200 cells/mm3 or WHO clinical stage 3 or 4:
- Cotrimoxazole, oral, 160/800 mg daily, until CD4 > 200 cells/mm3.
If CrAg-positive, consult an infectious disease expert, and refer.
See Cryptococcosis.
Note:
All CrAg positive women need a LP, unless contra-indicated, regardless of symptoms.
CAUTION
- Although fluconazole should be avoided in the 1st trimester, pregnant women should be counselled that the benefits of fluconazole outweigh the risks in the management of cryptococcosis.
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- All pregnant women <20 weeks gestation exposed to fluconazole should have an ultrasound scan to detect congenital abnormalities.
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- Fluconazole is present at concentrations similar to maternal plasma concentrations in breast milk.
| FIRST-LINE ART REGIMENS | ||
| 1ST ANC VISIT | ||
| Pregnant women |
- Tenofovir, oral 300 mg daily |
- Contraindication to TDF: renal insufficiency with creatinine >85 μmol/L. |
| If TDF contraindicated |
Start alternative regimen (Doctor - Abacavir, oral, 600 mg, daily |
|
| Pregnant women currently on ART | - Continue current ART regimen. | - Do a VL as soon as pregnancy is confirmed. |
| Pregnant women not currently on ART but ART exposed (previous PMTCT or ART loss to follow-up) |
- Tenofovir, oral, 300 mg daily |
LoE:IIIb47 Resistance testing for WLHIV failing a DTG- based regimen and who meet the definition of confirmed virological failure may be authorized by an expert on a case- by-case basis.
|
| 2ND ANC VISIT (1 WEEK LATER) | ||
| Creatinine ≤ 85 mmol/L | - Continue FDC: TDF+3TC+DTG | |
|
Creatinine > 85 mmol/L (TDF is contra - indicated) |
- Stop tenofovir |
- High-risk pregnancy: change to alternate triple therapy within 2 weeks (doctor consult) and refer for renal dysfunction investigation. |
| VL < 50 c/mL (Pregnant women currently on ART) | If still on EFV-based ART, offer switch to: - Tenofovir, oral, 300 mg daily AND - Lamivudine, oral, 300 mg daily AND - Dolutegravir, oral, 50 mg daily |
|
| VL ≥ 50 c/mL (Pregnant women currently on ART) | Continue current regimen whilst investigating and managing cause of elevated VL. Determine if the client should switch to 2nd line. | - Doctor/ expert consult or refer for expert advice. - Pregnant women with confirmed 2nd or 3rd line ART regimen failures should not breastfeed their infants, if they can safely formula feed. |
| WOMEN DIAGNOSED HIV POSITIVE IN LABOUR | ||
| All unbooked women who test positive during labour should be given prophylactic ART during labour and initiated on lifelong ART before being discharged. | - Nevirapine, oral, 200 mg single dose as early as possible in labour. AND - Tenofovir, oral, 300 mg daily AND - Lamivudine, oral, 300 mg daily AND - Dolutegravir, oral, 50 mg daily Note: Provide TDF + 3TC + DTG as a FDC |
Before discharge: Start lifelong ART the day after delivery, if there are no contraindications, regardless of CD4: - TDF+3TC+DTG as a FDC |
| POST-DELIVERY | ||
| The mother should start ART within 24 hours of delivery to protect the baby during breastfeeding. | Start lifelong ART regardless of CD4: TDF+3TC+DTG as a FDC | |
| BABY | ||
| See: The HIV-exposed infant to decide whether infant is low risk or high risk and what HIV prophylactic management is needed. | ||
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Note:
- eGFR and creatinine clearance are not reliable for diagnosing renal impairment in pregnancy.
- Monitor response to ART within 3 months of ART initiation with a plasma VL. If VL is not suppressed, refer or consult for expert advice.
Viral load monitoring for 1st line regimen in pregnant and breastfeeding women:
Newly diagnosed and initiated ART for the first time:
- Do 1st VL at 3 months on ART.
- If VL < 50 c/mL, repeat VL at delivery.
Known HIV-positive women already on ART:
- Measure VL at first/booking visit in ANC,
- If VL < 50 c/mL, repeat VL at delivery.
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Known HIV-positive women, who are not currently on ART, but are ART exposed (e.g. previous PMTCT, or ART loss to follow-up) and who are initiating a DTG-containing regimen:
- Do 1st VL at 3 months on ART.
- If VL < 50 c/mL, repeat VL at delivery.
REFERRAL
- Refer mothers suspected of non-adherence early.
Urgent
- Creatinine > 85 mmol/L.
- ALT > 100 IU/L.
- Pregnant women who are CrAg+, and
- LP cannot be performed, or
- symptomatic (headache, confusion), or
- asymptomatic, but in the 1st trimester.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2025-9_Version 1.0_26 March 2026
Chapter 6: Obstetrics and Gynaecology_6.8 HIV in Pregnancy