Optimal Delivery Choices for Pregnant Patients Living with HIV: A Comprehensive Decision-Making Guide

Case History

A 27-year-old pregnant woman, who is HIV positive but otherwise healthy, is seen in the clinic. She is currently 34 weeks pregnant and up to date on her antenatal care and has not experienced any pregnancy-related complications. Medications include antiretroviral therapy (ART) with Abacavir/Lamivudine/Dolutegravir. Her recent blood work shows hemoglobin of 12.7 g/dL, MCV is 87.0, and CD4 count is 425/mm³, and her HIV viral load (VL) is 725 copies/mL. Her previous HIV VLs were undetectable. She had no baseline HIV resistance mutations. She is keen on having a vaginal delivery and asks your advice regarding this. How would you counsel the patient?

Navigating Pregnancy and Delivery in HIV-Positive Patients

Pregnant individuals living with HIV encounter distinctive challenges and medical complexities throughout their pregnancy. Maternal HIV VL is directly linked to the risk of perinatal transmission. ¹ Effective management and care of HIV throughout the prenatal and intrapartum periods are imperative to protect against the transmission of the virus to the fetus.

ART is pivotal in suppressing the VL in the pregnant women thus diminishing the likelihood of virus transmission to the fetus during childbirth. Initiating ART regimens that are well tolerated, safe, and effective in suppressing viral replication as early as possible is strongly recommended for HIV patients not already on ART. In patients that are well controlled on ART before their pregnancy, current regimen should be continued if it is deemed safe in pregnancy.

Several ART regimens are considered safe in pregnancy. The recommended treatment regimen consists of combination of a dual nucleoside reverse transcriptase inhibitor backbone with the addition of either an integrase inhibitor or a protease inhibitor as the third drug. Prior studies on Efavirenz ² and Dolutegravir ³ had raised concerns of their association with neural tube defects; however, recent data demonstrate that there is no significant associated risk of neural tube defects with these medications and are considered safe to be used in pregnant patients. ^4,5 Medications such as cobicistat-containing regimens, when used during pregnancy may lead to lower plasma levels due to physiologic changes associated with pregnancy, potentially increasing the risk of virologic failure.

Evaluating the benefit of scheduled cesarean section delivery (C-section) for individuals who are virally suppressed on ART with undetectable VLs, is not routinely recommended, due to the low risk of perinatal HIV transmission in these patients. Vaginal delivery is typically recommended for these women. Perinatal transmission rates in women on ART with HIV RNA <1000 copies/mL who had a planned C-section were not significantly different from those who had a vaginal delivery in multiple studies. ^6,7 However, data from the French Perinatal Cohort found that transmission rates were slightly higher among planned vaginal deliveries compared to C-section in women with preterm deliveries with HIV RNA <1000 copies/mL. But the number of women with VLs <400 copies/mL was low in the study, and the differences across VL levels were not statistically significant. ⁷ Complication rates such as surgical trauma, rates of infection, prolonged hospitalizations, and hospital deaths for C-section deliveries were higher in women with HIV compared to women without HIV. ⁸

Department of Health and Human Services (HHS) Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission (a Working Group of the Office of AIDS Research Advisory Council) recommends scheduled C-section at 38 weeks of gestation in patients with HIV RNA >1000 copies/mL or unknown HIV VL near the time of delivery, to minimize perinatal HIV transmission.

Intrapartum intravenous Zidovudine is administered during labor or 3 hours before scheduled C-section if HIV RNA is unknown or >1000 copies/mL. ⁹ The newborn should receive ART after birth as a preventive measure against HIV transmission. The newborn should receive Zidovudine for 2 to 6 weeks based on mother's diagnosis status of acute/primary HIV infection, compliance with ART, and virological suppression status. ⁹ If the mother is virologically not suppressed, infants need to be placed on combination ART with zidovudine, lamivudine with either nevirapine or raltegravir for 6 weeks. ⁹

Increased maternal VL and decreased CD4 cell counts during breastfeeding were associated with increased risk of infant HIV infection. ¹⁰ The latest recommendation from HHS HIV clinical practice guideline Panel on breastfeeding is a shared decision-making for women with undetectable VL and those with detectable VL living in high resource settings are not suggested to breastfeed.

Answer: A.

As the patient is 34 weeks pregnant and has HIV VL less than 1000 copies/mL, vaginal delivery may be possible if her HIV VL remains less than 1000 copies/mL at 38 weeks' gestation. She needs to be encouraged to be compliant with ART to lower the HIV VL to undetectable levels as her previous HIV VL were undetected with no baseline resistance mutations.

B and E are incorrect as vaginal delivery can be recommended to select patients.

C is incorrect as the patient is on abacavir, lamivudine, and dolutegravir which is a safe regimen in pregnancy and can be continued.

D is incorrect as women with HIV can become pregnant and have safe pregnancies and with effective prenatal and intrapartum care, transmission to the fetus can be eliminated. These patients need caring support, empathy, and understanding of their condition.