Version July 2025
INTRODUCTION —
The management of the pregnant woman with human immunodeficiency virus (HIV) infection has evolved significantly over the past three decades in light of advancements in drug development and a greater understanding of the prevention of vertical HIV transmission. In the United States and Europe, the risk of HIV transmission from mother to infant has declined to historically low levels with the use of antiretroviral medications [1-3]. Contributions to this successful prevention effort include universal testing of pregnant women for HIV infection, antiretroviral therapy (ART) for all pregnant women with HIV, and the use of cesarean delivery in certain circumstances. (See "Prenatal evaluation of women with HIV in resource-abundant settings".)
We recognize that not all pregnant, postpartum, and lactating individuals identify as women or mothers. The topics discussed here are based on risks driven by pregnancy and transmission of infection to the fetus/infant and apply regardless of the pregnant person's gender identity. For simplicity, we use the term "woman" to signify the pregnant person or someone who may become pregnant and the term "mother" to signify the birthing parent of a child (regardless of gender identity and/or parental rights).
This topic will address the intrapartum and postpartum management of pregnant women with HIV, including breastfeeding, in resource-abundant settings. In the United States, the Department of Health and Human Services (DHHS) publishes guidelines on the evaluation and management of pregnant women with HIV, which are updated on an ongoing basis [4]. Our recommendations below are largely consistent with these guidelines.
Other guidelines that are relevant to resource-abundant settings include those from the American College of Obstetricians and Gynecologists (ACOG), the British HIV Association, and the European AIDS Clinical Society [5-7]. Links to these and other expert guidelines can be found in the society guideline links section below. (See 'Society guideline links' below.)
Antepartum evaluation and management are discussed separately in the following topics:
●Resource-abundant settings:
•(See "Prenatal evaluation of women with HIV in resource-abundant settings".)
●Resource-limited settings:
•(See "Prevention of vertical HIV transmission in resource-limited settings".)
•(See "Prevention of HIV transmission during breastfeeding in resource-limited settings".)
Management of infants born to mothers with HIV is discussed separately in the following topics:
●(See "Pediatric HIV infection: Epidemiology, clinical manifestations, and outcome".)
●(See "Pediatric HIV infection: Diagnostic testing in children younger than 18 months".)
Information regarding the pharmacokinetics and safety of individual antiretroviral agents during pregnancy is found elsewhere. (See "Safety and dosing of antiretroviral medications in pregnancy" and "Prenatal evaluation of women with HIV in resource-abundant settings" and "Antiretroviral selection and management in pregnant individuals with HIV in resource-abundant settings".)
INTRAPARTUM MANAGEMENT
Mode of delivery — The approach to delivery mode depends on the viral load obtained within four weeks of delivery.
●Women with plasma viral load ≤1000 copies/mL − In women with plasma HIV ribonucleic acid (RNA) ≤1000 copies/mL on antiretroviral therapy (ART), the overall incidence of transmission of HIV is low regardless of the mode of delivery (cesarean delivery versus standard vaginal delivery) or duration of membrane rupture, and whether there would be a further decrease in transmission risk with cesarean delivery in such women is unclear [2,8-13]. In a meta-analysis that included observational studies conducted after the introduction of combination ART, pre-labor cesarean delivery at 38 weeks was not associated with decreased risk of HIV transmission compared with vaginal delivery among mothers who were on suppressive ART at the time of delivery [13]. Thus, we do not advise cesarean deliveries for these women, unless indicated for obstetric reasons (table 1).
●Women with plasma viral load >1000 copies/mL − In women whose viral loads remain >1000 copies/mL beyond 34 weeks gestation (eg, women not taking ART, women presenting late in pregnancy, or women not responding or not adherent to their current ART regimen), we recommend performing cesarean delivery at 38 weeks, prior to labor onset and rupture of membranes [4]. For these women, prelabor cesarean delivery decreases the risk of transmission to the child. This was illustrated by a meta-analysis of 15 prospective cohort studies performed prior to the widespread use of antiretroviral agents during pregnancy, in which the incidence of HIV transmission to the infant was 8.4 percent (72 of 857 births) with cesarean delivery versus 16.7 percent (1280 of 7676 births) with vaginal delivery [14]. The reduction in risk was similar when adjusted for use of zidovudine (versus nothing) and advanced HIV disease in the mother. A subsequent trial from the same time period that randomly assigned 436 women with HIV to cesarean or vaginal delivery produced similar results [15].
If such women present in labor or with ruptured membranes prior to scheduled cesarean delivery, management must be individualized and consider the duration of rupture of membranes/labor, current ART regimen, and HIV RNA level. If a woman is already in advanced labor or has prolonged rupture of membranes (≥4 hours), the benefit of cesarean may be lost, and consideration should be given to vaginal delivery.
Prior to the widespread use of ART during pregnancy, duration of membrane rupture was associated with risk of transmission [16]. However, in a prospective study of deliveries between 1996 and 2008, there were no cases of HIV transmission among 493 pregnant women on ART with HIV RNA <1000 copies/mL near delivery, 144 of whom had rupture of membranes for more than four hours [10]. Among the 146 women on ART who had HIV RNA >1000 copies/mL (55 of whom had cesarean while the others had vaginal delivery), vertical transmission was 3.8 percent if duration of membrane rupture was less than four hours compared with 4.9 percent if four or more hours, and this difference was not statistically significant. Only viral load above 10,000 copies/mL was an independent risk factor for vertical transmission.
Intrapartum antiretrovirals — Women should continue taking their ART regimen as much as possible during labor and delivery or scheduled cesarean delivery. Additional administration of intrapartum intravenous zidovudine depends on the maternal HIV viral load within four weeks of anticipated delivery (table 1). If indicated, intravenous zidovudine (2 mg/kg loading dose followed by a continuous infusion of 1 mg/kg/hour until delivery) should be given regardless of the presence of drug resistance to zidovudine.
●For women on ART with HIV RNA ≤50 copies/mL consistently in late pregnancy and near the time of delivery (ie, four weeks before delivery) and no concerns regarding adherence or resistance to the ART regimen, intravenous zidovudine is not specifically recommended as it does not appear to further reduce the risk of vertical transmission in this setting [4,17,18]. Patients with acute or primary (first six months of infection) HIV during pregnancy should be treated similarly to women with HIV RNA ≥1000 copies/mL within four weeks before delivery.
●For women on ART with HIV RNA between 50 and 1000 copies/mL (ie, four weeks before delivery) or those who have had challenges consistently taking ART, the decision to use intrapartum intravenous zidovudine should be individualized; we suggest using it in women with these HIV RNA levels, and starting the intravenous infusion at the time the woman presents in labor or prior to a scheduled cesarean delivery. While observational data do not suggest a prevention benefit with intravenous zidovudine for this viral level range, the data are relatively limited. The transmission risk remains slightly higher with low-level viremia compared with undetectable levels; thus, some clinicians and patients may reasonably decide to use zidovudine in this setting. (See "Antiretroviral selection and management in pregnant individuals with HIV in resource-abundant settings", section on 'HIV viremia and risk of infant infection'.)
●For women with HIV RNA ≥1000 copies/mL within four weeks before delivery, possible poor adherence, or unknown HIV RNA levels, we recommend intravenous zidovudine. We also suggest intravenous zidovudine for women with acute or primary (first six months of infection) HIV during pregnancy. For women scheduled for cesarean delivery, intravenous zidovudine should be started at least three hours prior to scheduled cesarean delivery. Women with HIV who present in labor should be given intravenous zidovudine immediately to decrease the risk of vertical transmission.
●Zidovudine crosses the placenta rapidly and can provide pre-exposure prophylaxis to the fetus. In the PACTG 076 trial, combined antepartum zidovudine, intravenous zidovudine during labor, and six weeks of infant zidovudine prophylaxis reduced vertical transmission by 66 percent [19]. There are no randomized clinical trials evaluating the benefit of intravenous zidovudine during labor among women using current combination antiretroviral regimens. However, among 7917 women (most of whom were receiving combination ART antenatally) from the French Perinatal Cohort who had HIV RNA <400 copies/mL at delivery, receipt of intravenous zidovudine intrapartum was not associated with a decreased risk of vertical HIV transmission (transmission rates of 0.6 percent [42 of 7576] and 0 percent [0 of 341] with and without intrapartum zidovudine, respectively) [17]. In contrast, zidovudine receipt was associated with lower transmission rates among women who had HIV RNA ≥1000 copies/mL (2.9 percent [45 of 1561] versus 7.5 percent [8 of 107] without intrapartum zidovudine).
Specific circumstances
Preterm premature rupture of membranes — When membrane rupture occurs before 37 weeks gestation, decisions about timing of delivery should be based on best obstetric practices, considering risks of prematurity for the infant. The presence of HIV infection of the mother should not change management. There are no data to guide expectant management of preterm prelabor rupture of membranes (PPROM). However, in patients with viral load <1000 copies/mL at delivery, the duration of membrane rupture does not appear to affect the risk of HIV transmission to the infant. As an example, in a study of 707 pregnant women with HIV receiving ART, there was no significant difference in perinatal transmission in women with membrane rupture less than four hours compared with greater than four hours (1.0 versus 1.9 percent) [10]. Of 493 participants with delivery viral load <1000 copies/mL, there were no cases of perinatal transmission despite ruptured membranes of up to 25 hours. Administration of antenatal corticosteroids to accelerate fetal lung maturity should be given if appropriate, as no data exist to suggest that these recommendations need be altered for women with HIV. When the decision is made to deliver, route of delivery should be according to obstetric indications.
Other intrapartum interventions — Obstetric management should minimize the duration of fetal exposure to maternal fluids and blood and avoid fetal scalp electrode monitoring when possible. The possible risks of other interventions during management of labor should be weighed against the obstetric indications and benefits. Artificial rupture of membranes and operative vaginal delivery (eg, with forceps or vacuum extractor) should generally be avoided, when possible, in women with a viral level ≥50 copies/mL. Delayed cord clamping after birth in vigorous term and preterm infants is recommended by the American College of Obstetricians and Gynecologists (ACOG) to improve iron stores and hemoglobin levels in the infant. This practice does not appear to affect the risk of HIV transmission. As an example, in a study of 64 mother-infant pairs, of whom all the mothers were receiving ART, the 32 infants with delayed cord clamping (120 seconds post birth) had higher hemoglobin levels at 24 hours and 1 month of age, and no increased risk of jaundice or polycythemia, compared with the infants who had early cord clamping (<30 seconds after birth) [20]. There was no perinatal transmission in either group.
BREASTFEEDING —
The risk of HIV transmission from mother to child through breastfeeding depends on maternal viral load, antiretroviral therapy (ART) adherence, infant antiretroviral (ARV) prophylaxis, and whether the infant is exclusively breastfed or receives combination feeding of formula and breastmilk in the first six months of life [4]. (See "Prevention of HIV transmission during breastfeeding in resource-limited settings", section on 'Epidemiology of HIV transmission through breastfeeding'.)
Mothers without viral suppression — For women without viral suppression or who are not on ART during the third trimester of pregnancy and at delivery, we recommend not to breastfeed because of concern for an increased risk of HIV transmission from mother to infant through breastmilk [4].
For individuals who choose to breastfeed despite these recommendations, clinicians should provide counseling on harm-reduction measures, including adherence to ART and infant ARV prophylaxis [4,21]. (See 'Continuation of ART' below and "Pediatric HIV infection: Management of infants born to mothers with HIV in resource-abundant settings", section on 'Initial ARV prophylaxis for all HIV-exposed infants'.)
Mothers with viral suppression — For women who have been on ART with an undetectable viral load at delivery and at least through all of the third trimester of pregnancy, the risk of HIV transmission through breastmilk appears to be less than 1 percent, although not zero [4,22]. For women who desire to breastfeed, we provide specific guidance on how to minimize risk of transmission by following these practices:
●Monitor maternal plasma HIV viral load every one to two months while the mother is breastfeeding.
●Provide guidance on good breast care, including how to prevent and resolve overproduction of breastmilk, milk stasis, and breast engorgement.
●Promptly identify and treat cracked, sore, and/or bleeding nipples, yeast infection, mastitis, and breast abscess.
●Counsel mother to exclusively breastfeed up to six months of age, acknowledging there may be scenarios where formula supplementation is needed. In pre-ART era studies, mixed feeding with breastmilk and non-breastmilk replacements (formula or solid foods/liquids) prior to six months of age increased the risk of HIV transmission; whether this remains a risk factor when viral suppression is sustained in the breastfeeding parent on ART has not been studied.
●When the mother is ready to wean, advise to wean breastfeeding slowly over a two- to four-week period. Rapid weaning has been associated with an increased risk of HIV shedding into breast milk [23-25] and development of milk stasis and breast engorgement during the weaning process. (See 'Mother with nipple damage, mastitis, or breast abscess' below.)
The data available on HIV transmission through breastfeeding mostly comes from resource-limited settings and mothers who initiated ART during the second trimester of pregnancy or later. In one retrospective study of 72 breastfeeding mothers on ART residing in the United States or Canada, 68 (94 percent) of the infants remained HIV negative at six weeks postpartum; the remaining four infants were lost to follow up [26]. All infants received some sort of ARV prophylaxis.
The data from resource-limited settings show that in mothers who are on ART and have viral suppression, the risk of transmitting HIV through breastfeeding is low but not zero. As an example, in a study of over 2400 breastfeeding mothers with HIV randomized following delivery to either 18 months of maternal ART or infant prophylaxis for prevention of HIV transmission through breastfeeding, two transmissions occurred in mothers on ART who had viral loads <40 copies/mL [22]. In another study of 500 breastfeeding mothers with HIV, there were two transmissions in mothers on ART who had viral loads <50 copies/mL [27]. It remains unknown whether the risk of transmission through breastfeeding is lower in patients who are already virally suppressed at conception and continue to take ART throughout their pregnancy or in those taking newer ART regimens.
Special circumstances — There are certain circumstances in which the mother may need to stop breastfeeding, such as if there is damage to the nipple (eg, cracked, sore, and/or bleeding nipples), mastitis, or breast abscess, or if the mother develops viremia.
Mother with nipple damage, mastitis, or breast abscess — If the mother develops cracked, sore, and/or bleeding nipples, mastitis, or a breast abscess, we advise either to pump and flash heat the breastmilk to eradicate HIV prior to giving it to the baby or pump and discard the milk from the affected breast and continue to feed the baby from the unaffected breast. Flash heating the breastmilk entails placing a glass container containing the breastmilk in a small pot of water, heating the water to a boil, and then immediately removing the breastmilk from the water and letting it cool to room temperature prior to administering to the infant. Temporary supplementation with formula or pasteurized donor human milk is also an option; while mixed feeding prior to age six months was associated with a slightly increased risk of HIV transmission in studies of women with HIV who were not receiving ART, there are no data regarding women receiving ART. Breastfeeding from the affected breast can resume without flash heating the milk when the breast recovers and no skin breakdown is noticeable. Some mothers may also choose to stop breastfeeding completely and transition to formula.
Newly detectable viral load while breastfeeding — If the mother is noted to have a newly detectable viral load, we counsel the mother to stop breastfeeding immediately and consider one of the following options until the viral load is repeated:
●Give previously stored breastmilk that was expressed at a date when mother was virally suppressed. Pump and discard the breastmilk while viremia is present.
●Pump and flash heat the breastmilk before feeding it to the baby.
●Provide replacement feeding with formula, or if available, pasteurized donor human milk.
●Consider stopping breastfeeding altogether and transition to formula.
The viral load should be repeated as soon as possible. If the repeat viral load is undetectable, clinicians should engage in shared decision making with the parents regarding whether to resume breastfeeding. The likelihood of HIV transmission through breastmilk from women who have transient viremia followed by viral suppression is likely low, although there are no data available to guide practice. If the repeat viral load has detectable virus, the clinician should advise the mother to stop breastfeeding and discuss the increased risk of HIV transmission to the infant if the mother decides to continue breastfeeding [4].
Infants with exposure to breastmilk from a person with a newly detectable viral load should be treated as high-risk breastfed infants for the remainder of the breastfeeding period. The infant should undergo an HIV nucleic acid diagnostic test as soon as possible to determine HIV infection status. Presumptive HIV therapy is recommended while diagnostic testing is pending and for the next six weeks if the infant tests negative for HIV. If breastfeeding is continued, the infant should receive daily single-drug antiretroviral prophylaxis (nevirapine or lamivudine) throughout breastfeeding and for one to four weeks after weaning to minimize the risk of vertical transmission. (See "Pediatric HIV infection: Management of infants born to mothers with HIV in resource-abundant settings", section on 'Detectable viral load within four weeks prior to delivery' and "Pediatric HIV infection: Management of infants born to mothers with HIV in resource-abundant settings", section on 'Continuation of ARV prophylaxis for breastfed infants'.)
POSTPARTUM MANAGEMENT
Continuation of ART — All women should continue antiretroviral therapy (ART) following pregnancy. This is consistent with recommendations in the United States and elsewhere to initiate and continue ART in all individuals with HIV, regardless of CD4 cell count or clinical state, to reduce the risk of disease progression and to prevent HIV sexual transmission, given findings from randomized clinical trials [28-30]. (See "When to initiate antiretroviral therapy in persons with HIV".)
In the postpartum period, adherence to an antiretroviral regimen may be particularly difficult. In a meta-analysis of studies of antiretroviral use during and after pregnancy, the pooled rate of adequate adherence (>80 percent of doses) in the postpartum setting was only 53 percent [31]. This finding highlights the importance of careful adherence counseling and social support during the postpartum period to mitigate the risk of poor compliance among those who continue an antiretroviral regimen.
Modification of the ART regimen may be appropriate if pregnancy-related factors (eg, pharmacokinetic issues or toxicity concerns) led to selection of an ART regimen that contains agents that are not preferred agents in nonpregnant individuals. (See "Switching antiretroviral therapy for adults with HIV-1 and a suppressed viral load".)
Family planning — Family planning issues should be discussed with all women, and postpartum contraception should be offered. (See "HIV and women", section on 'Choice of contraception'.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: HIV treatment in pregnant patients" and "Society guideline links: HIV infection in infants and children".)
SUMMARY AND RECOMMENDATIONS
●Introduction − In the United States and Europe, the risk of vertical HIV transmission has declined to historically low levels with the use of antiretroviral medications. The combined use of maternal antepartum, maternal intrapartum, and infant antiretroviral prophylaxis maximizes infant pre-exposure and postexposure prophylaxis to decrease the risk of HIV acquisition. (See 'Introduction' above and "Antiretroviral selection and management in pregnant individuals with HIV in resource-abundant settings".)"Antiretroviral selection and management in pregnant individuals with HIV in resource-abundant settings"
●Mode of delivery
•For women who have a viral load >1000 copies/mL beyond 34 weeks gestation (eg, women not taking antiretroviral therapy [ART], women presenting late in pregnancy, or women not responding to their current ART regimen), we recommend prelabor cesarean delivery at 38 weeks to reduce the risk of HIV transmission to the infant (table 1) (Grade 1A). (See 'Mode of delivery' above.)
•The mode of delivery for women on ART with a viral load <1000 copies/mL at ≤4 weeks prior to delivery depends on obstetric indications alone. (See 'Mode of delivery' above.)
●Intrapartum ART use − Women should continue taking their ART regimen during labor and delivery or scheduled cesarean delivery. (See 'Intrapartum antiretrovirals' above.)
•For women who have a viral load ≥1000 copies/mL or unknown viral levels in late pregnancy and around the time of delivery, we recommend intrapartum intravenous zidovudine to further reduce the risk of vertical transmission (table 1) (Grade 1B). Additionally, for women who were diagnosed with acute or primary HIV infection during pregnancy, we suggest intrapartum intravenous zidovudine, irrespective of viral load (Grade 2C), in order to further reduce the risk of vertical transmission.
•We also suggest intrapartum intravenous zidovudine for women with HIV RNA between 50 and 1000 copies/mL and those who had inconsistent ART adherence (Grade 2C).
•For women who have had viral load ≤50 copies/mL consistently in late pregnancy and around the time of delivery and have no concerns related to adherence or resistance to the regimen, intrapartum intravenous zidovudine is not associated with further reduction of HIV transmission.
●Breastfeeding
•For women without viral suppression or who are not on ART during the third trimester of pregnancy and at delivery, we recommend not to breastfeed because of concern for an increased risk of HIV transmission from mother to infant through breastmilk (Grade 1A).
•For women who have been on ART with an undetectable viral load (<50 copies/mL) at least through the third trimester of pregnancy and at delivery, breastfeeding is an option that should be discussed with the patient. Although the risk of HIV transmission through breastmilk appears to be low in this patient population, it is not zero. Certain breastfeeding practices may minimize the risk of HIV transmission. (See 'Breastfeeding' above.)
●Postpartum maternal ART use − Maternal ART should be continued postpartum in all patients with HIV, regardless of immune, clinical, or viral status. Adherence to ART during the postpartum period may be particularly problematic, and it is important to provide careful adherence counseling and social support during the postpartum period to mitigate the risk of poor compliance. (See 'Postpartum management' above and "When to initiate antiretroviral therapy in persons with HIV".)
