O98.7 + (Z21/B24)
Consult the most recent National Department of Health Guideline for the Prevention of Mother to Child Transmission of Communicable Infections
All pregnant women should receive routine counselling and voluntary HIV testing at their very first antenatal visit.
All women who test negative should be offered repeat HIV testing at every routine visit throughout pregnancy (8 visits in all), at labour/delivery, at the 6-week EPI visit and three monthly throughout breastfeeding.
HIV-infected pregnant women upon diagnosis, should be clinically staged, and have a blood sample taken for CD4 cell count and serum creatinine taken on the same day. The result must be obtained within a week.
Postpartum contraceptive use should be discussed in the antenatal period.
All women should be educated during the antenatal period about the benefits of exclusive breastfeeding for the first 6 months and breastfeeding with complimentary feeding from 6 months until at least 2 years after delivery (Only in circumstance where the mother has confirmed 2nd or 3rd line ART regimen failure (VL >1000 copies/mL), advise not to breastfeed and prescribe replacement feeds).
All pregnant women should have a TB symptom screen at each visit, with further TB investigations if any of the answers to the screening questions are positive. A TB geneXpert test must be done for all pregnant women with a new diagnosis of HIV disease, or known HIV positive women with a new pregnancy diagnosis.
Patients should be screened and treated for syphilis and other STIs, in line with basic antenatal care.
Initiate lifelong ART in all pregnant or breastfeeding women on the same day of diagnosis regardless of CD4 count or infant feeding practice.
Provide adequate support and counselling, particularly addressing ART adherence.
Assist women with unwanted pregnancies <20 weeks’ gestation with access to TOP services.
MEDICINE TREATMENT
- Patients should receive ART at the first antenatal visit, whether newly diagnosed or known to be living with HIV but not on ART.
- Perform a baseline ALT and serum creatinine at commencement of ART.
- Tenofovir should not be used in pregnant women with a calculated creatinine clearance <60 mL/minute or a serum creatinine ≥85 micromol/L (the latter is a more sensitive measure of renal impairment in pregnancy).
- Pregnant women may be initiated on/switched to dolutegravir-containing regimen after 6 weeks gestational age. Counsel appropriately on the risk of NTDs in subsequent pregnancies and effective postpartum contraception to enable patient to make an informed choice of ART-regimen. Switching between TEE and TLD regimens with a VL <50 copies/mL in the last 6 months. See section 10.1: Antiretroviral therapy.
- Initiate antenatal supplementation (see PHC STGs and EML,Antenatal supplements ), noting that calcium and DTG should not be taken together on an empty stomach, but can be taken together with food.
- Test partner for HIV and perform routine cervical cancer screening.
1st ANC visit
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Pregnant women >6 weeks gestation - not on ART, with normal renal function, without TB, with no desire for more children and who chooses to use DTG after understanding the risk and benefits. (DTG associated with NTDs, ≤6 weeks gestation) |
- TDF, oral, 300 mg daily. AND - 3TC, oral, 300 mg daily AND DTG, oral, 50 mg daily. Provided as a fixed dose combination (FDC). |
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Pregnant women >6 weeks gestation - not on ART, with normal renal function, with TB, with no desire for more children and who chooses to use DTG after understanding the risk and benefits. (DTG requires boosting with TB treatment) |
- TDF, oral, 300 mg daily. AND - 3TC, oral, 300 mg daily AND DTG, oral, 50 mg daily. Provided as a fixed dose combination (FDC). WITH DTG, oral 50 mg 12 hours later. |
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Pregnant women ≤6 weeks gestation - or planning a pregnancy after this one |
- TDF, oral, 300 mg daily. AND - FTC, oral, 200 mg daily AND EFV, oral, 600 mg at night. Provided as a fixed dose combination (FDC). |
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Pregnant woman already on TDF+3TC+DTG and understands the risk and benefits of DTG. (Document in the antiretroviral pregnancy register http://www.apregistry.com/) |
Chooses to remain on TDF+3TC+DTG: Enter in antiretroviral pregnancy register http://www.apregistry.com/ |
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Pregnant woman (>6 weeks gestation) already on TDF + FTC + EFV and understands the risk and benefits of DTG. Obtain consent for DTG use (Document in patient’s clinical notes, sign notes and provide patient with medicine information leaflet)[i] |
Chooses to switch to TDF+3TC+DTG: » Switch only if VL is <50 copies/mL in the last 6 months |
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Pregnant woman already on ART with a VL between 50-1000 copies/ml |
See section 10.1: Antiretroviral Therapy |
2nd ANC visit (1 week later)
| Creatinine ≤ 85 micromol/L | Continue ART as a FDC |
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Creatinine > 85 micromol/L (TDF is contraindicated) |
Stop FDC: TDF+FTC/3TC+EFV/DTG Replace TDF with ABC: - ABC, oral, 600 mg daily. |
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Active psychiatric illness (EFV may be contraindicated. Consult an HIV specialist and/or psychiatrist) |
Replace EFV with DTG If DTG not suitable: Replace EFV with LPV/r, oral, 400/100 mg 12 hourly |
Caesarean Delivery (CD):
Provide antibiotic prophylaxis to all pregnant women, including HIV-infected pregnant women prior to surgery (See Surgical antibiotic prophylaxis).
Women with the following risk factors are at higher risk of infection post Caesarean section:
- Advanced immunosuppression.
- Prolonged rupture of membranes (>18 hours).
- Multiple vaginal examinations (> 5 PVs).
- Second stage CD.
Monitor carefully and treat infection appropriately.
HIV infected pregnant women not on ART undergoing elective Caesarean delivery/or in labour:
- NVP, oral, 200 mg as a single dose.
WITH
- TDF, oral, 300 mg as a single dose.
AND
- 3TC, oral, 300 mg as a single dose.
AND
- DTG, oral 50 mg as a single dose (as a FDC 4 hours before Caesarean delivery) .
Followed by lifelong:
- TDF+3TC+DTG (provided as a FDC), provided the mother has been adequately counselled on the risk of NTDs in subsequent pregnancies and effective postpartum contraception.
If the mother chooses not to use effective contraception and is of child-bearing potential or has fertility intentions:
- TDF+ FTC+EFV (provided as a FDC).
For management of the HIV-exposed infant, see PHC STG and EML HIV-exposed infant.
For more information on HIV management, see Antiretroviral Therapy .