Update on HIV prevention and management in pregnancy Number 10 – 2025

Key points Pregnancy is the period of greatest risk of infection by the human immunodeficiency virus (HIV) for women, and acute infection during pregnancy has a high potential for transmission of the virus to the baby. Combined HIV prevention should be offered to women at risk, including use in pregnant and lactating women, in which Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP) have proven safe.Pre-Exposure Prophylaxis should be started at least seven days before sexual exposure and can only be discontinued seven days after the last sexual intercourse.Adherence to PrEP (6 to 7 tablets per week) is essential to ensure efficacy in HIV prevention. An HIV diagnosis allows access to antiretroviral therapy (ART) that can prevent sexual and perinatal transmission.The partner's prenatal care includes offering diagnostic tests to the partner and plays a fundamental role in preventing the woman from becoming infected. The ART should be started as soon as possible during prenatal care to control viremia and minimize fetal and neonatal exposure to the virus.For women living with HIV (WLHIV), pregnancy represents a period of greater vulnerability to other infections, and the vaccination record should be reviewed and completed during prenatal care, including vaccinations against pneumococcus, influenza, COVID-19, and Tdap. The mode of delivery should be defined according to maternal viremia levels in the third trimester.Most women with good adherence to ART will have a viral load (VL) lower than 1,000 copies/mL and may deliver vaginally. Breastfeeding always represents a risk of postnatal transmission, and this must be communicated during prenatal care.The distribution of formula together with inhibition of lactation has been recommended by the Brazilian Ministry of Health and this option offers greater safety.Some countries have recently updated their guidelines in this area, including recommendations for counseling, information about risks and support when women wish to breastfeed, provided they have a history of undetectable VL, good adherence to ART and undergo frequent and careful follow-up. Safe contraceptive methods, including LARCS (long-acting reversible contraceptives), should be offered to WLHIV for effective reproductive planning. Recommendations HIV testing should be requested at the first prenatal appointment and repeated in the third trimester and at the time of delivery, as well as in any situation of risk exposure.Rapid tests (RT) are the preferred diagnostic method, as they can expedite the initiation of treatment. Pregnant and lactating women who are HIV-negative but have an increased risk of sexual transmission (irregular use of condoms with partners with unknown serology, partners with unsuppressed HIV or unknown VL, sex workers, drug addiction) should be informed about forms of combined prevention, including the use of PrEP.The oral PrEP (tenofovir + emtricitabine) requires the use of additional prevention methods for at least the first seven days of use and quarterly serology testing.PrEP is safe during pregnancy and breastfeeding and prevents transmission, as long as there is good adherence (use of 6 or more pills per week). Serodiscordant couples in which the partner is on regular, consistent ART, maintaining undetectable VL, do not present a risk of transmitting the virus.In this situation, there is no need for the HIV-negative preg- FEBRASGO POSITION STATEMENTUpdate on HIV prevention and management in pregnancy