NCLEX Review Guide: HIV & AIDS in Pregnancy

Pathophysiology of HIV During Pregnancy

• HIV (Human Immunodeficiency Virus) targets CD4+ T cells, progressively weakening the immune system and potentially leading to AIDS (Acquired Immunodeficiency Syndrome) if untreated. During pregnancy, physiologic immunosuppression may accelerate HIV progression, though antiretroviral therapy significantly mitigates this risk.
• Vertical transmission from mother to infant can occur during pregnancy (in utero), during labor and delivery, or through breastfeeding, with transmission rates of 15-45% without intervention but reduced to less than 1% with appropriate treatment.

Screening and Diagnosis

• Universal HIV screening is recommended for all pregnant women during the first prenatal visit, with repeat testing in the third trimester (28-32 weeks) for women at high risk or in high-prevalence areas. Initial screening typically involves an enzyme immunoassay (EIA) or rapid HIV test, with positive results confirmed by Western blot or immunofluorescence assay.
• HIV RNA viral load and CD4+ cell count are essential baseline tests for diagnosed women to determine disease status, guide treatment decisions, and assess transmission risk. Resistance testing should be performed before initiating therapy to select the most effective antiretroviral regimen.

Antiretroviral Therapy (ART)

• All HIV-positive pregnant women should receive combination antiretroviral therapy (cART) regardless of CD4+ count or viral load, ideally starting as early as possible in pregnancy. The primary goals of therapy are to reduce maternal viral load to undetectable levels and prevent vertical transmission to the fetus.
• Current recommended regimens typically include two nucleoside reverse transcriptase inhibitors (NRTIs) plus either an integrase strand transfer inhibitor (INSTI) or a protease inhibitor (PI). Drug selection must consider pregnancy safety data, potential teratogenicity, and maternal comorbidities.

Intrapartum Management

1. Administer intravenous zidovudine (ZDV) during labor for women with viral load >1,000 copies/mL or unknown viral load
2. Consider scheduled cesarean delivery at 38 weeks for women with viral load >1,000 copies/mL
3. Avoid invasive procedures like fetal scalp electrodes, fetal scalp sampling, and instrumental delivery when possible
4. Maintain intact membranes as long as possible; avoid artificial rupture of membranes
5. Continue oral antiretroviral medications during labor

Postpartum and Neonatal Care

• HIV-positive mothers in developed countries should avoid breastfeeding regardless of viral load or ART status, as breast milk transmission can occur despite undetectable plasma viral load. In resource-limited settings where formula is unavailable, exclusive breastfeeding with maternal and infant ART is recommended to reduce transmission risk.
• All infants born to HIV-positive mothers should receive 4-6 weeks of zidovudine prophylaxis starting within 6-12 hours of birth. High-risk infants (mothers with high viral load or inadequate ART) should receive additional antiretroviral medications. HIV testing for infants includes HIV DNA PCR testing at birth, 2-3 weeks, 1-2 months, and 4-6 months.

Maternal Complications

• HIV-positive pregnant women have increased risk of preterm birth, low birth weight, intrauterine growth restriction, and pregnancy-induced hypertension. These risks are higher with advanced HIV disease, low CD4+ counts, or inadequately treated infection.
• Opportunistic infections may occur in pregnant women with advanced HIV disease (CD4+ count <200 cells/mm³), with Pneumocystis jirovecii pneumonia (PCP), toxoplasmosis, and candidiasis being most common. Prophylaxis against PCP is recommended for women with CD4+ counts <200 cells/mm³.

Medication Side Effects and Monitoring

• Antiretroviral medications may cause adverse effects including anemia, hepatotoxicity, hyperglycemia, and lactic acidosis. Regular monitoring of complete blood count, liver function tests, and glucose levels is essential throughout pregnancy.
• Some antiretrovirals, particularly older NRTIs like didanosine and stavudine, have been associated with mitochondrial toxicity in pregnant women. Newer regimens have better safety profiles but still require vigilant monitoring for potential toxicities.

Psychosocial Considerations

• HIV diagnosis during pregnancy may cause significant psychological distress, including anxiety, depression, and fear of stigma. Comprehensive care should include mental health screening, counseling, and support services for affected women.
• Partner notification, testing, and treatment are essential components of care. Healthcare providers should facilitate disclosure to sexual partners while ensuring patient safety, particularly in situations where intimate partner violence is a concern.

• All pregnant women should be screened for HIV at first prenatal visit, with repeat testing in third trimester for high-risk women.
• Combination antiretroviral therapy (cART) is recommended for all HIV-positive pregnant women regardless of CD4+ count or viral load.
• Vertical transmission risk can be reduced from 15-45% to less than 1% with appropriate interventions (antiretroviral therapy, intrapartum management, and neonatal prophylaxis).
• Consider scheduled cesarean delivery at 38 weeks for women with viral load >1,000 copies/mL.
• Breastfeeding should be avoided in developed countries regardless of maternal viral load or treatment status.
• All infants born to HIV-positive mothers require antiretroviral prophylaxis and serial HIV testing.

Commonly Confused Points

Study Tips

• Focus on prevention of vertical transmission as the primary goal of management.
• Remember the three potential transmission times: antepartum (in utero), intrapartum (during delivery), and postpartum (breastfeeding).
• Know the viral load cutoff (1,000 copies/mL) that guides decisions about cesarean delivery and IV zidovudine.