# HIV in Pregnancy and PMTCT

> HIV PMTCT for FMGE Obstetrics: NACO PPTCT pathway, lifelong TDF 3TC EFV, mode of delivery, infant nevirapine and DNA PCR diagnosis.

- Canonical URL: https://prepelephant.com/topics/fmge/obstetrics-and-gynaecology/hiv-pmtct
- Exam / course: FMGE · Subject: Obstetrics and Gynaecology
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-02
- Last updated: 2026-10-02
- How to cite: "HIV in Pregnancy and PMTCT", PrepElephant, https://prepelephant.com/topics/fmge/obstetrics-and-gynaecology/hiv-pmtct

## Direct answer

Under India's PPTCT (prevention of parent-to-child transmission) programme run by NACO, every pregnant woman is offered HIV testing at registration — opt-out, with consent and counselling — and every woman found positive starts lifelong triple antiretroviral therapy regardless of CD4 count or stage (the Option B+ strategy), typically tenofovir plus lamivudine (or emtricitabine) plus efavirenz, with dolutegravir-based regimens incorporated in recent updates. With sustained viral suppression, transmission falls from 20-45 per cent without intervention to under 2 per cent: vaginal delivery is acceptable when the viral load near delivery is low (commonly quoted below 1000 copies/mL), whereas a higher load, unknown status in labour or obstetric indication favours caesarean; amniotomy duration is kept short. The breastfed HIV-exposed infant receives nevirapine prophylaxis from birth for at least six weeks (longer when maternal suppression is uncertain), exclusive breastfeeding is supported on ART, and early infant diagnosis uses HIV DNA PCR at six weeks with repeat testing through breastfeeding and a final antibody test at 18 months.

## What you must remember

- **Test every pregnancy:** provider-initiated counselling and testing at the first antenatal visit under NACO's PPTCT programme; retest in the third trimester in high-prevalence settings, and in labour if status is unknown.
- **Maternal ART (Option B+ / Test and Treat):** lifelong triple therapy from diagnosis in pregnancy — TDF + 3TC (or FTC) + EFV as the classical preferred pregnancy regimen; dolutegravir-containing regimens have been added in recent national updates; efavirenz is safe in the first trimester, which older teaching doubted.
- **Viral load decides delivery:** suppressed load (commonly below 1000 copies/mL near term) permits vaginal birth; higher or unknown load favours elective caesarean; avoid prolonged rupture of membranes, invasive procedures (fetal scalp electrodes, forceps) and unnecessary episiotomy with high viral loads.
- **Mode of feeding:** exclusive breastfeeding for six months with maternal ART is recommended in India — mixed feeding (breast plus other foods) carries the highest transmission risk and is discouraged; formula is acceptable only where safe water and affordability are assured.
- **Infant prophylaxis:** nevirapine syrup daily from birth — six weeks minimum when the mother is on effective ART (high-risk infants, including those born to untreated or viraemic mothers, receive extended dual or longer prophylaxis per national protocol); co-trimoxazole prophylaxis from six weeks until infection is excluded.
- **Early infant diagnosis:** HIV DNA PCR (dried blood spot) at six weeks, again around six months, six weeks after breastfeeding stops, with a rapid antibody test at 18 months as the definitive test; a positive PCR is confirmed and treatment started without waiting.
- **In labour emergencies:** an unbooked woman — test with a rapid kit, and if positive start ART and treat as high viral load (caesarean if feasible, infant extended prophylaxis).
- **Partner testing and adherence counselling** — missed doses in pregnancy are the commonest real-world failure of PPTCT.

## A PPTCT pathway from test to infant follow-up

Walk a 24-year-old through the system. At her booking visit she is counselled and tested; the rapid test is reactive, confirmed by two further assays per the national three-test algorithm. Same visit: CD4 count, viral load, screening for tuberculosis, hepatitis and syphilis, cotrimoxazole if indicated — and her first TDF-3TC-EFV tablets, started the same day. The counselling frames the pregnancy in numbers: on effective ART, her baby's risk of HIV is under 2 per cent; without it, up to 45 per cent including breastfeeding. Her husband is tested; iron and folate continue like any pregnancy.

Third trimester: a viral load check near 34-36 weeks returns under 50 copies per mL — plan vaginal delivery, avoid prolonged rupture, minimise interventions. Delivery: the baby starts nevirapine syrup within hours of birth, continues six weeks, and receives BCG, OPV-zero and hepatitis B vaccines; exclusive breastfeeding runs to six months on ART. Follow-up: DNA PCR at six weeks (negative), repeat at six months and six weeks after weaning, and the final antibody test at 18 months. Had the viral load returned 50,000 near term, the forks shift: caesarean at 38 weeks, extended infant prophylaxis, and adherence support rather than shame.

## The usual distractors

Three old teachings still circulate in options: "no breastfeeding, give formula" — wrong under current NACO and WHO guidance for a mother on ART; "single-dose nevirapine in labour" — obsolete, replaced by lifelong ART plus infant prophylaxis; and "delivery only by caesarean" — reserved for unsuppressed loads. The EID schedule (six weeks, six months, six weeks post-weaning, 18-month antibody) is asked verbatim.

## Frequently asked questions

### What ART regimen is started in a pregnant HIV-positive woman under India's PPTCT programme?

Lifelong triple ART regardless of CD4 count — classically TDF plus 3TC (or FTC) plus efavirenz, with dolutegravir-based options in recent national updates.

### When is caesarean section indicated for HIV in pregnancy?

When the viral load near delivery is unsuppressed (commonly above 1000 copies/mL) or unknown, or for obstetric indications; suppressed women deliver vaginally.

### What prophylaxis does the HIV-exposed infant receive?

Nevirapine syrup from birth for at least six weeks when maternal ART is effective, extended for high-risk infants, plus co-trimoxazole from six weeks until infection is excluded.

### How is HIV infection diagnosed in the breastfed infant?

HIV DNA PCR at six weeks, repeated around six months and six weeks after breastfeeding cessation, with a rapid antibody test at 18 months as the definitive test.

### Is breastfeeding advised for HIV-positive mothers in India?

Yes — exclusive breastfeeding for six months with maternal lifelong ART, since suppression makes transmission rare and mixed feeding carries the highest risk.