Prenatal evaluation of women with HIV in resource-rich settings

INTRODUCTION — Comprehensive medical care of the pregnant individual with human immunodeficiency virus (HIV) is associated with favorable maternal health outcomes and low rates of vertical HIV transmission.

This topic will review elements of prenatal care and counseling for the female with HIV. In the United States, the Department of Health and Human Services has published guidelines on the evaluation and management of pregnant women with HIV [1]. Our recommendations below are largely consistent with these guidelines.

We recognize that not all pregnant, postpartum, and lactating individuals identify as women or mothers. However, using gender-inclusive language is not possible in all languages, all countries, and for all our readers. The topics discussed here are based on risks driven by biological sex and not gender identity. Therefore, throughout this topic, we use the term “woman” to signify a person of the female sex (regardless of gender identity) and the term “mother” to signify the female biological parent of a child (regardless of gender identity).

The use of antiretroviral medications during pregnancy, intrapartum care, and infant antiretroviral prophylaxis are discussed elsewhere. (See "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings" and "Intrapartum and postpartum management of pregnant women with HIV and infant prophylaxis in resource-rich settings".)

Recommendations on breastfeeding in resource-rich and resource-limited settings are discussed elsewhere. (See "Intrapartum and postpartum management of pregnant women with HIV and infant prophylaxis in resource-rich settings" and "Prevention of HIV transmission during breastfeeding in resource-limited settings".)

HISTORY AND PHYSICAL EXAMINATION — A thorough history and physical examination should be performed in the pregnant individual with HIV to see if there are health concerns in the mother, which may also affect the well-being of the fetus. Patients should be interviewed about any history of opportunistic infections, tuberculosis, sexually transmitted infections (STIs), medication use (including over the counter drugs), immunization status, or substance abuse issues. Immunosuppressed women who report fevers and weight loss may have an underlying opportunistic infection, which may compromise maternal and fetal health (eg, tuberculosis).

The physical examination should be focused on assessing any signs of advanced HIV infection (eg, thrush or evidence of wasting) or signs of concomitant STIs (eg, genital ulcers or vaginal discharge). Since many patients with HIV are also at risk for viral hepatitis, a careful examination for stigmata of advanced liver disease (eg, hepatomegaly, splenomegaly, spider angiomata) is also indicated.

GENERAL COUNSELING — Prenatal care providers should address potentially modifiable behaviors, which have been associated with an increased risk of vertical HIV transmission, such as cigarette smoking, illicit drug use (eg, cocaine, heroin), and unprotected intercourse with multiple partners [2-7]. Some of these risk factors are also associated with low birth weight. However, most of these studies were conducted prior to the era of potent antiretroviral therapy so the true magnitude of effect is unclear.

Pregnant individuals should be counseled regarding the harmful effects of substance use (including alcohol, cocaine, and opiates) on fetal development. Patients should also be counseled to discontinue cigarette smoking. (See "Substance use during pregnancy: Screening and prenatal care" and "Cigarette and tobacco products in pregnancy: Impact on pregnancy and the neonate".)

Patients should be advised to use condoms during sexual activity, as sexually transmitted infections (STIs) can lead to preterm delivery and teratogenicity (eg, congenital syphilis). Providers should evaluate for evidence of STIs as part of routine antenatal care. If a couple is monogamous, have tested negative for STIs, and the partner with HIV has achieved virologic suppression on antiretroviral therapy, we have taken a more liberal approach to condom use. (See "Screening for sexually transmitted infections" and "Spontaneous preterm birth: Overview of risk factors and prognosis" and "HIV infection: Risk factors and prevention strategies", section on 'Counseling on condom use'.)

DETERMINATION OF GESTATIONAL AGE — Ultrasound imaging can estimate gestational age and thereby calculate the expected date of delivery. Accurate determination of fetal gestational age is particularly important among pregnant individuals with HIV infection since early delivery may be necessary to decrease the risk of vertical HIV transmission. Delivery by prelabor cesarean section is recommended at 38 weeks gestation in the event of incomplete viral suppression (>1000 copies/mL). Because of the potential need for an early, scheduled cesarean delivery with the attendant risk of fetal pulmonary immaturity, a first trimester ultrasound should be performed, when possible, to ensure accurate pregnancy dating [1].

Several studies have demonstrated that ultrasound estimation during the first half of pregnancy is superior to estimating the delivery date based on the last menstrual period or physical examination [8-10]. (See "Prenatal assessment of gestational age, date of delivery, and fetal weight".)

PRENATAL LABORATORY TESTING

CD4 cell counts — CD4 cell count should be assessed at the initial visit and at least every three months during pregnancy. For patients who have been on combination antiretroviral therapy (ART) with consistent viral suppression and have CD4 counts above the threshold for opportunistic infections (>200 cells/microL and >14 percent), CD4 cell count monitoring may be done every six months [1,11].

Pregnancy itself is associated with a decline in absolute CD4 count number, which may be related to increased plasma blood volume; however, there is usually no effect on the CD4 cell percentage [12,13]. Therefore, some clinicians prefer to monitor the CD4 cell percentage during pregnancy; however, decisions regarding opportunistic infection prophylaxis and monitoring of ART response are based on absolute CD4 cell count numbers. The CD4 cell criteria for initiation of prophylaxis for pneumocystis, toxoplasmosis, or Mycobacterium avium complex are the same as in nonpregnant patients with HIV. (See "Overview of prevention of opportunistic infections in patients with HIV" and 'Chemoprophylaxis for opportunistic infections' below.)

Viral load measurement — Plasma HIV ribonucleic acid (RNA) is monitored frequently during pregnancy to confirm attainment and maintenance of viral suppression. As in nonpregnant adults, patients should exhibit at least a two log decline in plasma viremia by a month after initiation of therapy. Complete viral suppression should be achieved as soon as possible in pregnant patients. Persistent viremia detected more than eight weeks after initiation of therapy should warrant suspicion of poor adherence, HIV drug resistance, increased metabolism of drug(s) due to pregnancy resulting in low drug levels, or drug-drug interactions. (See "Patient monitoring during HIV antiretroviral therapy".)

Close monitoring is desired to confirm the effectiveness of the patient’s antiretroviral drug regimen since higher levels of HIV RNA are associated with increased risk of vertical transmission of HIV infection. HIV RNA levels are generally monitored at entry into care, at the time of ART initiation, two to four weeks after initiation (or changing) of therapy, monthly until complete viral suppression and then at least every three months for the remainder of the pregnancy. Patients who remain on ART regimens that lack data on use in pregnancy (eg, two-drug regimens, newer ART drugs with minimal or no pharmacokinetic data in pregnancy) should have their viral load checked more frequently (every one or two months) during pregnancy [1]. For patients who have viral suppression on a cobicistat-based regimen and do not want to change regimens during pregnancy, we check viral levels monthly throughout pregnancy. (See "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings", section on 'On ART with viral suppression'.)

Plasma viral load should also be assessed at 34 to 36 weeks gestation in order to aid in the decision regarding mode and timing of delivery [1]. If the viral load is detectable, resistance testing and assessment of adherence is advised. If the viral load is >1000 copies/mL near term gestation, the patient should be counseled regarding the benefits of scheduled pre-labor cesarean section at 38 weeks gestation for the prevention of vertical transmission. (See "Intrapartum and postpartum management of pregnant women with HIV and infant prophylaxis in resource-rich settings", section on 'Mode of delivery'.)

The relationship between HIV RNA levels and risk of vertical transmission is discussed in detail elsewhere. (See "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings", section on 'HIV viremia and risk of infant infection'.)

Drug resistance testing — HIV drug resistance testing should be performed prior to starting or modifying ART regimens in all pregnant individuals whose HIV RNA levels are above the threshold for resistance testing (ie, >500 to 1000 copies/mL) [1]. For treatment-naïve pregnant individuals with HIV, ART should be initiated without delay, prior to receiving the results of the resistance testing; the regimen can be modified if necessary based on the results of the resistance assay. This is particularly important if the mother presents late for care, as the risk of vertical HIV transmission is associated with the duration of antenatal ART and level of viral suppression at delivery. (See "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings", section on 'Detectable viremia late in pregnancy'.)

Monitoring for ART toxicity — Toxicities associated with ART should be assessed based on the particular drug regimen. As with all patients with HIV, complete blood count (CBC), blood urea nitrogen (BUN) and creatinine, and liver function tests are checked prior to ART initiation and every three to six months thereafter. Urinalysis is also checked after ART initiation and every six months while on a tenofovir-containing regimen. (See "Primary care of adults with HIV", section on 'Hematologic, renal, and hepatic toxicity'.)

Even in the absence of potential ART toxicity, HIV infection has also been associated with abnormalities of bone marrow, kidney, and liver function, either directly or because of comorbid conditions. Maternal anemia has been associated with an increased risk of both adverse pregnancy outcomes as well as vertical HIV infection [14]. Correction of potential underlying causes, such as iron deficiency, is important to prevent anemia-related complications of pregnancy.

Screening for gestational diabetes — Glucose challenge testing as screening for gestational diabetes is generally performed at the usual recommended gestational age of 24 to 28 weeks. However, it is reasonable to consider protease inhibitor use an indication for earlier glucose challenge screening, given the potential association between these agents and glucose intolerance in the general population with HIV. (See "Safety and dosing of antiretroviral medications in pregnancy", section on 'Gestational diabetes' and "Gestational diabetes mellitus: Screening, diagnosis, and prevention".)

Testing for viral hepatitis — Pregnant individuals with HIV should be screened for hepatitis A, hepatitis B, and hepatitis C virus (HCV) infections since coinfection is common in patients with HIV due to shared routes of transmission (eg, injection drug use). Testing for hepatitis B infection includes hepatitis B surface antigen and antibodies to core and surface antigens (ie, anti-HB core and anti-HBs). Testing for hepatitis C infection includes serologic testing; patients with advanced HIV infection (CD4 cell count <100 cells/microL) and risk factors for HCV (eg, injection drug use history) should also have HCV RNA testing since antibody testing can be falsely negative. (See "Epidemiology, clinical manifestations, and diagnosis of hepatitis B in patients living with HIV".)

Those without evidence of hepatitis B infection (ie, nonreactive anti-HB core and anti-HBs results) should begin a hepatitis B virus immunization series, since the recombinant vaccine is safe to give during pregnancy. Those with evidence of chronic hepatitis B infection will need consultation with a specialist knowledgeable in both liver and HIV disease. Certain antiretroviral medications have dual activity against HIV and hepatitis B viruses. (See "Treatment of chronic hepatitis B in patients with HIV" and "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings".)

Individuals without evidence of HCV infection should be counseled regarding avoidance of HCV acquisition (eg, abstinence from injection drug use; avoidance of unprotected intercourse with an HCV-seropositive partner). Acute infection with HCV during pregnancy is problematic because direct-acting antiviral agents have not been studied in pregnancy, ribavirin is contraindicated in pregnancy, and interferon is not recommended. Also, theoretically, there is an increased risk of HCV transmission to the infant due to the high levels of viremia that are observed during early infection.

Vertical transmission of HCV appears to be facilitated by HIV-coinfection, compared with patients without HIV. A meta-analysis of 10 studies demonstrated that maternal coinfection increases the odds of vertical HCV transmission by approximately 90 percent (odds ratio 1.9, 95% CI 1.4-2.7) compared with maternal HCV infection alone [15]. There are no differences in general management principles (eg, the timing or mode of delivery) based on HCV coinfection in the mother [1]. (See "Vertical transmission of hepatitis C virus".)

Patients should also be screened for antibodies to the hepatitis A virus, if this has not been done previously. Those testing negative should receive the hepatitis A virus vaccine series [16]. (See "Hepatitis A virus infection: Treatment and prevention".)

Testing for tuberculosis — Patients with HIV are at high risk of developing active disease after infection with Mycobacterium tuberculosis [17]. For this reason, all persons should be tested for latent tuberculosis infection after HIV is diagnosed [18]. (See "Tuberculosis infection (latent tuberculosis) in pregnancy" and "Tuberculosis disease (active tuberculosis) in pregnancy".)

Screening for STIs — Patients with HIV should be screened for evidence of certain sexually transmitted infections (STIs), which can be associated with stillbirth, preterm delivery, and low birth weight. Screening for maternal syphilis infection is not only important in preventing congenital syphilis; one study demonstrated that maternal infection was associated with an increased risk of vertical HIV transmission as well [19]. Screening for gonococcal, chlamydial, and trichomonal infection is recommended as well. (See "Syphilis in pregnancy" and "Screening for sexually transmitted infections", section on 'Patients with HIV infection'.)

Toxoplasma serologies — Congenital toxoplasmosis is a concern among pregnant individuals, but the seroprevalence varies based on geographic location. Toxoplasmosis titers are not routinely recommended for pregnant individuals in the United States because the prevalence is relatively low and the serology test must be performed in a reference laboratory. Thus, among those without HIV, evidence of acute infection is generally determined based on discovery of abnormal ultrasound findings [20]. Congenital toxoplasmosis causes intracranial calcifications and neurologic disability in the neonate. (See "Toxoplasmosis and pregnancy".)

However, in the setting of HIV infection, documentation of maternal Toxoplasma gondii serologic status should be obtained during pregnancy if not known previously. Suppressive therapy to prevent reactivation toxoplasmosis is indicated in patients with CD4 cell counts <100 cells/microL and a positive T. gondii IgG. (See 'TMP-SMX during pregnancy' below.)

Patients with evidence of potential primary Toxoplasma infection during pregnancy or evidence of fetal infection should be referred to a maternal fetal medicine specialist for evaluation. Diagnostic and therapeutic interventions are administered during pregnancy for affected fetuses.

Cytomegalovirus serologies — Cytomegalovirus (CMV) is the most common congenital infection, with a birth prevalence of approximately 0.5 to 1 percent in the United States. It is the most common infectious cause of congenital hearing loss. While the majority of infected infants are asymptomatic, approximately 10 percent suffer major handicap or death and up to 25 percent develop sequelae later in life [21]. (See "Cytomegalovirus infection in pregnancy".)

It is unknown whether the fetuses of individuals with HIV infection are at higher risk for congenital infection. The majority of pregnant individuals with HIV (>90 percent) have a history of CMV exposure [22,23]. Thus, routine antibody screening for evidence of primary CMV infection in pregnant individuals with HIV is not indicated. Assessment of re-infection or reactivation of disease is the same as for nonpregnant adults with HIV.

There is no fetal therapy currently recommended, therefore treatment should be considered only if it is necessary for active maternal CMV disease.

IMMUNIZATIONS — Certain immunizations are generally recommended during pregnancy while others are specifically targeted for those with HIV.

The vaccines recommended for routine use during pregnancy are primary or booster doses of adult-type tetanus and reduced diphtheria toxoids with or without pertussis (Td or TdaP), and inactivated influenza vaccines (seasonal and H1N1) [24]. Tetanus and influenza immunizations may be given during the first trimester because of special risks to the unimmunized pregnant individual, fetus, or newborn. TdaP is routinely administered in the third trimester of pregnancy for infant prophylaxis. As a general rule, live vaccines (eg, measles, mumps, rubella) are not used during pregnancy. (See "Immunizations during pregnancy".)

Coronavirus disease 2019 (COVID-19) vaccination is recommended for all adults, including those with HIV who are pregnant, and may be administered in any trimester. (See "COVID-19: Overview of pregnancy issues", section on 'Vaccination in people planning pregnancy and pregnant or recently pregnant people'.)

Additional routine immunizations that are administered to individuals with HIV include the following inactivated vaccines:

●Pneumococcal vaccine

●Hepatitis A and B vaccines for those who have not been infected in the past

Immunization of patients with HIV is discussed in detail elsewhere. (See "Immunizations in persons with HIV".)

ANTIRETROVIRAL THERAPY — Antiretroviral therapy (ART) during pregnancy involves two separate but related goals: reduction of perinatal transmission and treatment of maternal HIV disease [1]. It is recommended that all pregnant individuals with HIV receive ART, regardless of CD4 cell count or plasma HIV RNA copy number, to prevent vertical transmission and for the benefit to maternal health. (See "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings".)

CHEMOPROPHYLAXIS FOR OPPORTUNISTIC INFECTIONS

TMP-SMX during pregnancy — Trimethoprim-sulfamethoxazole (TMP-SMX) is the agent of choice for patients who warrant Pneumocystis jirovecii pneumonia (PCP) and reactivation toxoplasmosis chemoprophylaxis. Although there are concerns regarding possible teratogenicity associated with systemic TMP-SMX exposures during the first trimester, the benefit of using TMP-SMX for chemoprophylaxis is generally thought to outweigh that theoretical risk [25]; these issues should be discussed with the patient. We use TMP-SMX for prevention of PCP and reactivation toxoplasmosis when indicated in pregnancy, regardless of gestational age. If the patient declines to use TMP-SMX during the first trimester because of concerns with first-trimester drug exposure, oral atovaquone can be used as an alternative for prophylaxis during that period; in such cases, we recommend that TMP-SMX be used for chemoprophylaxis during the second and third trimester. Alternatives for those with allergies or intolerance to TMP-SMX include dapsone (for PCP) and dapsone with pyrimethamine and leucovorin (for toxoplasmosis).

Limited and indirect data support the overall safety of TMP-SMX during pregnancy. In a systematic review of 16 studies that evaluated the rate of congenital deformities in infants whose mothers used TMP-SMX during pregnancy for various reasons, the pooled rate was 3.5 percent, which is comparable to historically reported rates of congenital anomalies in the general population [26]. The pooled rate of anomalies was 4.8 percent among those studies that evaluated TMP-SMX exposure during the first trimester and 1.4 percent among those that evaluated exposure during the second and third trimesters only. However, in many of the included studies, TMP-SMX exposure was limited to short-term use, which may not accurately reflect the risk with daily, long-term use for chemoprophylaxis.

Indications for chemoprophylaxis of PCP and reactivation toxoplasmosis in pregnant individuals are the same as in non-pregnant adults with HIV and are discussed in detail elsewhere. (See "Treatment and prevention of Pneumocystis infection in patients with HIV", section on 'Preventing initial infection' and "Toxoplasmosis in patients with HIV", section on 'Prevention'.)

Treatment of these infections during pregnancy is also discussed elsewhere. (See "Treatment and prevention of Pneumocystis infection in patients with HIV", section on 'Pregnancy' and "Toxoplasmosis in patients with HIV", section on 'Special considerations during pregnancy'.)

Mycobacterium avium complex (MAC) — Patients with a CD4 cell count <50 cells/microL are at risk for disseminated infection with MAC. Recommendations for chemoprophylaxis is similar to that in non-pregnant adults (see "Overview of prevention of opportunistic infections in patients with HIV", section on 'Mycobacterium avium complex (MAC)'). In pregnant patients who warrant chemoprophylaxis, we recommend azithromycin 1200 mg once weekly. For those with gastrointestinal upset with this dose, 600 mg twice weekly may be better tolerated. We recommend against the use of clarithromycin for MAC prophylaxis during pregnancy because of an association with birth abnormalities in animal studies [25].

Candidal infections — Chemoprophylaxis against candidal infections is not generally warranted in patients with HIV. Candidal infections are common in such patients, particularly among those with CD4 cell counts below 200 cell/microL. Vaginal candidiasis and oropharyngeal candidiasis (thrush) are frequent nuisances for pregnant patients with HIV infection as well. Fluconazole, the recommended oral therapy outside of pregnancy for treatment and suppressive therapy of frequent outbreaks, is not recommended as the first-line treatment option in pregnancy given a potential risk of miscarriage [27,28]. In a Danish registry-based observational study, oral fluconazole use in pregnancy was associated with an increased risk of spontaneous abortion compared with no or only topical azole exposure [29]. Until more data on the association are available, oral fluconazole should be used with caution in pregnancy. Instead, for treatment of oropharyngeal candidiasis during pregnancy, we recommend using topical treatment with nystatin suspension, and for treatment of vaginal candidiasis during pregnancy, we recommend topical treatment with an azole for seven days. We use oral fluconazole, as a single dose of 150 mg, for treatment of vaginal candidiasis when other recommended treatments have failed. (See "Candida vulvovaginitis: Clinical manifestations and diagnosis", section on 'Definition' and "Candida vulvovaginitis in adults: Treatment of acute infection", section on 'Pregnancy'.)

PRENATAL FETAL MONITORING

Ultrasound — In addition to a first trimester ultrasound for gestational age determination, most experts recommend a detailed second trimester ultrasound evaluation of fetal anatomy in patients who were taking an antiretroviral regimen during the first trimester of pregnancy. While the available data suggest there is not an increase in overall congenital anomalies with first trimester exposure to most antiretroviral therapy (ART) agents, there are only limited data on newer antiretroviral agents in pregnancy and insufficient data to rule out congenital anomalies that have a low prevalence in the general population [30]. (See "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings", section on 'On ART with viral suppression' and "Safety and dosing of antiretroviral medications in pregnancy".)

Because of the possible association of low birth weight with ART use, careful monitoring of fundal height to assess fetal growth is warranted; third trimester ultrasound is appropriate if there are concerns regarding fetal growth. (See "Safety and dosing of antiretroviral medications in pregnancy", section on 'Fetal growth'.)

Invasive diagnostic procedures — In a patient with viral suppression on ART, amniocentesis does not appear to pose additional risk of HIV transmission in utero, although data are limited. Ideally, patients should be on an effective ART regimen with an undetectable plasma viral load before any invasive procedure is performed. If amniocentesis or other invasive procedure is necessary and plasma viral load is not below detectable, we have a risk-benefit discussion with the patient about whether the information gained by performing the invasive procedure would change pregnancy management; consultation with an expert is recommended. HIV infection alone is not an indication for amniocentesis. (See "Diagnostic amniocentesis", section on 'Indications'.)

The evidence of the general safety of such procedures in the setting of viral suppression comes from several studies that cumulatively reported on 159 pregnant women with HIV who took a combination ART regimen and underwent amniocentesis [31-35]. None of them transmitted HIV to their infant. This is in contrast to an apparent increased risk of transmission in older studies among women who were not receiving ART agents or were on nonsuppressive ART regimens and underwent amniocentesis. In the largest of these older studies, which analyzed data prospectively collected on a large cohort of pregnant women with HIV in France, there were non-significant trends towards increased transmission to the infant after amniocentesis in women who had not taken ART agents (3 of 12 [25 percent] versus 343 of 2113 [16 percent] without amniocentesis) and in those who took only a zidovudine or a dual nucleoside inhibitor regimen (3 of 49 [6.1 percent] versus 117 of 3556 [3.3 percent] without amniocentesis) [32].

SUPPORT SERVICES — Depending on the individual's circumstances, provision of support services, mental health services, substance use treatment services, intimate partner violence services, and public health assistance programs may be required. Such services are especially important in promoting adherence to daily medications.

COUNSELING

Breastfeeding — Prior to delivery, patients with HIV should be counseled on the risk of transmitting HIV to the infant via breastfeeding. The risk of HIV transmission from mother to child through breastfeeding depends on maternal viral load, ART adherence, infant ART prophylaxis, and whether the infant is exclusively breastfed or receives combination feeding of formula and breastmilk [1]. This is discussed in further detail elsewhere. (See "Intrapartum and postpartum management of pregnant women with HIV and infant prophylaxis in resource-rich settings", section on 'Breastfeeding'.)

In contrast with resource-rich settings, avoidance of breastfeeding in infants born to mothers with HIV in resource-limited settings is associated with increased infant morbidity and mortality. The prevention of vertical HIV transmission in breastfeeding individuals in resource-limited settings is discussed elsewhere. (See "Prevention of HIV transmission during breastfeeding in resource-limited settings".)

Family planning — All patients should be counseled on family planning and postpartum contraceptive options. Postpartum contraception and contraception issues related to HIV are discussed in detail elsewhere. (See "Contraception: Postpartum counseling and methods" and "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".)

SUMMARY AND RECOMMENDATIONS

●Introduction − Comprehensive medical care of pregnant individuals with HIV is associated with favorable maternal health outcomes and low rates of vertical HIV transmission. (See 'Introduction' above.)

●History and physical − A thorough history and physical examination should be performed in patients with HIV to see if there are health concerns in the mother, which may also affect the well-being of the fetus. (See 'History and physical examination' above.)

●General counseling

•Prenatal care providers should address potentially modifiable behaviors, which have been associated with an increased risk of vertical HIV transmission, such as cigarette smoking, illicit drug use (eg, cocaine, heroin), and unprotected intercourse with multiple partners. (See 'General counseling' above.)

•Patients with HIV should be counseled that breastfeeding is not recommended by the United States Public Health Service, due to concerns regarding risk of breast milk transmission of HIV. If the patient desires to breastfeed, the approach to infant prophylaxis depends on the maternal viral load and antiretroviral therapy (ART) adherence. (See 'Breastfeeding' above and "Intrapartum and postpartum management of pregnant women with HIV and infant prophylaxis in resource-rich settings", section on 'Breastfeeding'.)

●Determination of gestational age − Early accurate determination of fetal gestational age is particularly important among pregnant individuals with HIV infection, since scheduled cesarean delivery at 38 weeks gestation may be necessary to decrease the risk of perinatal HIV transmission if maternal viral load is >1000 copies/mL near term. (See 'Determination of gestational age' above and "Intrapartum and postpartum management of pregnant women with HIV and infant prophylaxis in resource-rich settings", section on 'Mode of delivery'.)

●Testing for viral hepatitis − Pregnant individuals with HIV should be screened for hepatitis A, hepatitis B, and hepatitis C virus (HCV) infections since coinfection is common in patients with HIV due to shared routes of transmission (eg, injection drug use). (See 'Testing for viral hepatitis' above.)

●Immunizations − Vaccines recommended for routine use during pregnancy include primary or booster doses of adult type tetanus and reduced diphtheria toxoids (Td or TdaP), and inactivated influenza vaccine. Coronavirus disease 2019 (COVID-19) vaccination is recommended for all patients, including pregnant individuals. Pneumococcal vaccine and hepatitis A and hepatitis B vaccines are also indicated in pregnant patients with HIV. (See 'Immunizations' above and "Immunizations during pregnancy" and "COVID-19: Overview of pregnancy issues", section on 'Vaccination in people planning pregnancy and pregnant or recently pregnant people'.)

●CD4 cell count measurement − Pregnancy itself is associated with a decline in absolute CD4 cell count, which may be related to increased plasma blood volume; however, there is usually no effect on the CD4 percentage. Therefore, some clinicians prefer to monitor the CD4 percentage during pregnancy, although decisions regarding opportunistic infection prophylaxis and monitoring of ART response are based absolute CD4 cell counts. (See 'CD4 cell counts' above.)

●Plasma viral load measurement − Plasma HIV RNA is monitored frequently during pregnancy to confirm attainment and maintenance of viral suppression. Close monitoring is desired to confirm the adherence to and effectiveness of the patient’s ART regimen since higher levels of HIV RNA are associated with increased risk of vertical HIV transmission. (See 'Viral load measurement' above.)