acidosis in some women, so it is important to monitor patients for this problem. deaths from lactic acidosis and liver failure have been primarily associated with two specific nrtis, stavudine and didanosine. therefore, combinations involving these drugs should be avoided in pregnancy. protease inhibitors (pis) have been studied extensively in pregnancy and are therefore the preferred third drug in the regimen. atazanavir-ritonavir and darunavir-ritonavir are two of the most common pis used during pregnancy. there is conflicting data regarding the association between protease inhibitors with preterm births. boosted lopinavir has the strongest correlation with this outcome, so women who are at a high risk for premature delivery are advised not to use this drug. some pis have been associated with high blood sugar (hyperglycemia) but is unclear whether or not they contribute to the development of gestational diabetes. some pis have been noted to cause hyperbilirubinemia and nausea, so these side effects should be monitored for closely. integrase inhibitors (iis) are generally the third drug in the regimen when a pi cannot be used. they rapidly reduce the viral load and for this reason, they are often used in women who are diagnosed with hiv late in their pregnancy. raltegravir (ral) is the most commonly used. non-nucleoside reverse transcriptase inhibitors (nnrtis) may be used during pregnancy, however, there are significant toxicities associated with their use. nnrtis are therefore them less desirable options for art. the most commonly administered nnrtis in pregnancy are efavirenz (efv) and nevirapine (nvp). pre-exposure prophylaxis (prep) pre-exposure prophylaxis (prep) should be offered in the form of oral combination tenofovir disoproxil fumarate/emtricitabine (tdf/ftc) to patients who are at risk of acquiring hiv and are trying to become pregnant, who are pregnant, who are postpartum/breastfeeding. people who are considered at risk for developing hiv are those who participate in condom-less sex with a partner who is hiv positive, patients who have been diagnosed with a recent sexually transmitted infection (sti), and patients who engage in injection drug use. prep is notably optional if a patient's hiv positive partner has been reliably on art and has an undetectable viral load. prep can reduce the risk of both mother and fetal acquisition of hiv. patients who take prep should be counseled on the importance of strict medication adherence and tested for hiv every three months and be aware of the symptoms of an acute hiv infection in case of viral contraction. nutritional supplements vitamin a plays a role in the immune system and has been suggested as a low-cost intervention that could help with preventing mother-to-child transmission of hiv. however, analysis of 5 large studies that utilized vitamin a supplementation to prevent hiv transmission showed that said supplementation likely has little or no effect on transmission of the virus in pregnant women. vitamin a supplementation has been largely superseded by antiretroviral therapy on a global basis. furthermore, high doses of natural vitamin a can be toxic to the fetus, which is important to consider in management of hiv in pregnant women. maternal follow-up the most important component of maternal follow-up for hiv positive mothers in the postnatal period is art. all mothers should continue their antiretroviral medications following hospital discharge, and any changes to their regimens should be made in consultation with the physicians who coordinate their hiv care. the nih also advises that providers should be wary of the unique challenges to medication compliance that mothers face in the postpartum period when designing a discharge art regimen for their patients. infant treatment and follow-up all newborns who were exposed to hiv in utero should receive postpartum antiretroviral drugs within 6 hours of delivery, and their dosing should be based on the newborn's gestational age. premature newborns should only receive zidovudine, lamivudine, and/or nevirapine based on toxicity testing. newborns who were exposed to hiv in utero and whose mothers were on art prior to and during pregnancy and achieved viral suppression by delivery should be administered zidovudine for 4 weeks to continue preventing hiv transmission following delivery. if a pregnant woman presents in labor with an unknown hiv status and a positive rapid hiv test result or an infant has a high risk of hiv transmission in utero (for example, the mother was not taking antiretroviral drugs in the pre-pregnancy period or during pregnancy, the mother had not achieved viral suppression, or the mother experienced an acute hiv infection during pregnancy or while breastfeeding), the infant should be started on a presumptive three drug art regimen for treatment of the infection until the infant's test results are available. if the infant has a documented hiv infection after birth, they should be started on 3-drug art at treatment doses that will be continued indefinitely. in infants younger than 18 months, hiv testing must consist of virologic assays that directly detect the hiv virus, not hiv antibody testing, as it is less reliable in the postpartum period. the results of these tests can be affected by antiretroviral drugs, so they should be repeated. all infants exposed to hiv in utero should be tested at three ages: 14–21 days, 1–2 months, and 4–6 months. any positive hiv testing should be repeated as soon as possible. hiv cannot be excluded as a diagnosis in an hiv-exposed, non-breastfed infant until the infant has had either two or more negative virologic tests at at least 1 month and 4 months of age, or two negative hiv antibody tests at at least 6 months of age. other important testing for newborns includes a complete blood count at birth to determine a baseline for the infant's blood cell numbers. the infant should then be followed with appropriate laboratory monitoring based on their gestational age and clinical condition, and both the fetal and maternal drug regimens. important hematologic anomalies being monitored include anemia and neutropenia. if either of these complications occur, the infant may need to discontinue their art regimen under physician supervision. infants exposed to hiv in utero should also be receive preventative drugs against pneumocystis jirovecii pneumonia between 4–6 weeks old after completing their 4-week course of antiretroviral medications, as this is a life-threatening complication of hiv. although the risk is very low, hiv can also be transmitted to a baby through food that was previously chewed by a mother or caretaker infected with hiv. to be safe, babies should not be fed pre-chewed food. breastfeeding while maternal compliance with art reduces the chance of hiv transmission to the infant, there is still a risk of viral transmission via the breastmilk. furthermore, there is concern that maternal antiretroviral drugs can enter the breastmilk and cause toxicity issues in the infant or future drug resistance. for these reasons, the nih, cdc, and the aap each discourage breastfeeding amongst hiv-positive women in the united states and other developed nations because there are safe, affordable feeding alternatives and clean drinking water. in fact, acog lists maternal hiv infection as one of very few contraindications to breastfeeding. despite these recommendations, some women in developed countries chose to breastfeed. in these situations, it is important that mothers adhere strictly to their art regimens and it is advised that infants are administered antiretroviral drugs for the prevention of possible viral transmission for at least 6 weeks. notably, when mothers do not comply with their art regimens, there is a 15-20% risk of infant hiv acquisition from breastfeeding over 2 years. both infants and mothers should be regularly tested every throughout breastfeeding to ensure appropriate viral suppression and lack of hiv transmission. maternal monitoring should be done with an assessment of hiv viral load, and infant testing should be done with virologic hiv testing. the who dictates that in developing nations, the decision about whether or not mothers breastfeed their infants must weigh the risk of preventing hiv acquisition in the infant against the increased risk of death from malnutrition, diarrhea, and serious non-hiv infection if the infant is not breastfed. in developing nations, clean water and formula are not as readily available, therefore, breastfeeding is often encouraged to provide children with adequate food and nutrients because the benefit of nourishment outweighs the risk of hiv transmission. the who's 2010 hiv and infant feeding recommendations intend to increase the rate of hiv-survival and reduce non-hiv related risk in infants and mothers, and they include the following: national health authorities in each country should recommend one, specific, universal infant feeding practice for mothers with hiv, as mothers will need persistent counselling while feeding their infants and this is better promoted when national authorities are unified in the guidance they administer. the choices for feeding include either breastfeeding while receiving antiretroviral medications or avoidance of all breastfeeding. when national health authorities chose the feeding practice they intend to promote and determine how to implement it, they should consider hiv prevalence, infant and child mortality rates due to non-hiv causes, current infant and young child feeding, the nutritional status of children, water quality, sanitation resources, and quality of health services. women who breastfeed while receiving art should exclusively breastfeed their infants for 6 months and then continue breastfeeding for until the infant is 12 months of age. they used to be advised to discontinue breastfeeding at 6 months, however, this recommendation has been changed to improve long-term nutritional outcomes. mixed feeding (when a baby is fed formula and breastmilk) should be avoided to reduce the risk of hiv transmission and avoid diarrhea and malnutrition. in developing nations, if the mother has a high hiv viral load (hiv rna more than 1000 copies/l), replacement feeding with formula is only initiated as per the unaids guidelines, termed the afass criteria, "where replacement feeding is acceptable, feasible, affordable, sustainable, and safe.":95-6 a mother should only give infant formula, as explained by the who, if the following conditions are met: "safe water and sanitation are assured at the household level and in the community; and the mother or other caregiver can reliably provide sufficient infant formula milk to support the normal growth and development of the infant; and the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhea and malnutrition; and the mother or caregiver can exclusively give infant formula milk in the first six months; and the family is supportive of this practice; and the mother or caregiver can access health care that offers comprehensive child health services." societal impacts discrimination despite advances made in preventing transmission, hiv-positive women still face discrimination regarding their reproductive choices. in asia, it was found that half the women living with hiv were advised not to have children and as many as 42% report being denied health services because of their hiv status. compulsory sterilisation in an attempt to limit mother-to-child transmission has been practiced in africa, asia, and latin american. women are forced to undergo sterilisation without their knowledge or informed consent, and misinformation and incentives are often used in order to coerce them into accepting the procedure. the forced sterilisation of hiv-positive women is internationally recognized as a violation of human rights. legal advocacy against this practice has occurred in some countries. in namibia, litigation was brought against the government by three hiv-positive women who claimed they were coerced during labour into signing consent forms that gave permission for the hospital to perform a sterilisation. the lm & others v government of namibia case is the first of its kind in sub-saharan african to deal with coerced sterilisation of hiv-positive women. the court ruled that these women were sterilised without their consent but failed to find that this was due to their hiv status. a 2010 case in chile have also aimed to seek government accountability for violation of sexual and reproductive rights of women living with hiv. health considerations pregnant women with hiv may still receive the trivalent inactivated influenza vaccine and the tetanus, diphtheria, and pertussis (tdap) vaccination during pregnancy. many patients who are hiv positive also have other health conditions known as comorbidities. hepatitis b, hepatitis c, tuberculosis and injection drug use are some of the most common comorbidities associated with hiv. women who screen positive for hiv should also be tested for these conditions so that they may be adequately treated or controlled during the pregnancy. the comorbidities may have serious adverse effects