HIV pregnancy antiretroviral

WHO HIV pregnancy antiretroviral therapy mother infant guidelines 2026

https://clinicalinfo.hiv.gov/en/guidelines/perinatal/recomme…

HIV pregnancy antiretroviral

site:clinicalinfo.hiv.gov perinatal HIV guidelines pregnancy infant antiretroviral 2026

https://clinicalinfo.hiv.gov/en/guidelines/perinatal/recomme…

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diagram HIV mother to child transmission pregnancy labour breastfeeding prevention antiretroviral therapy

PMID: 39760703

PMID: 39407417

mkdir -p "/tmp/workspace/hiv-pregnancy-pdf/src" "/tmp/workspace/hiv-pregnancy-pdf/output" && python - <<'PY' from pathlib import Path p=Path('/tmp/workspace/hiv-pregnancy-pdf/src/create_hiv_pregnancy_pdf.py') p.write_text(r'''from reportlab.lib import colors from reportlab.lib.pagesizes import A4 from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.enums import TA_CENTER, TA_LEFT from reportlab.lib.units import cm from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, PageBreak, Table, TableStyle, KeepTogether, HRFlowable, ListFlowable, ListItem from reportlab.pdfbase.ttfonts import TTFont from reportlab.pdfbase import pdfmetrics from reportlab.lib.colors import HexColor from reportlab.pdfbase.pdfmetrics import stringWidth from reportlab.platypus.tableofcontents import TableOfContents from reportlab.lib import utils OUT='/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_Detailed_Study_Guide.pdf' NAVY=HexColor('#123B5D'); TEAL=HexColor('#007C83'); SKY=HexColor('#EAF5F5'); PALE=HexColor('#F4F7FA'); RED=HexColor('#9E2A2B'); GOLD=HexColor('#D9A441'); INK=HexColor('#17212B'); GREY=HexColor('#54606B') styles=getSampleStyleSheet() styles.add(ParagraphStyle(name='TitleCustom', parent=styles['Title'], fontName='Helvetica-Bold', fontSize=27, leading=33, textColor=NAVY, alignment=TA_CENTER, spaceAfter=12)) styles.add(ParagraphStyle(name='Subtitle', parent=styles['Normal'], fontName='Helvetica', fontSize=12, leading=17, textColor=GREY, alignment=TA_CENTER, spaceAfter=12)) styles.add(ParagraphStyle(name='H1x', parent=styles['Heading1'], fontName='Helvetica-Bold', fontSize=18, leading=23, textColor=NAVY, spaceBefore=12, spaceAfter=8, keepWithNext=True)) styles.add(ParagraphStyle(name='H2x', parent=styles['Heading2'], fontName='Helvetica-Bold', fontSize=13, leading=17, textColor=TEAL, spaceBefore=10, spaceAfter=5, keepWithNext=True)) styles.add(ParagraphStyle(name='Bodyx', parent=styles['BodyText'], fontName='Helvetica', fontSize=9.4, leading=13.4, textColor=INK, spaceAfter=6)) styles.add(ParagraphStyle(name='Small', parent=styles['BodyText'], fontName='Helvetica', fontSize=7.7, leading=10.5, textColor=GREY, spaceAfter=4)) styles.add(ParagraphStyle(name='Box', parent=styles['BodyText'], fontName='Helvetica', fontSize=9.2, leading=13, textColor=INK, leftIndent=7, rightIndent=7, spaceBefore=5, spaceAfter=5)) styles.add(ParagraphStyle(name='TOC', parent=styles['BodyText'], fontSize=10, leading=15, leftIndent=10, textColor=INK)) class Doc(SimpleDocTemplate): def afterFlowable(self, flowable): if isinstance(flowable, Paragraph) and flowable.style.name=='H1x': text=flowable.getPlainText(); self.notify('TOCEntry',(0,text,self.page)) def footer(canvas, doc): canvas.saveState() w,h=A4 canvas.setStrokeColor(HexColor('#D8E1E8')); canvas.line(1.6*cm,1.25*cm,w-1.6*cm,1.25*cm) canvas.setFont('Helvetica',7.5); canvas.setFillColor(GREY) canvas.drawString(1.6*cm,.85*cm,'HIV in Pregnancy | Study guide | Updated 7 October 2026') canvas.drawRightString(w-1.6*cm,.85*cm,f'Page {doc.page}') canvas.restoreState() def P(text, style='Bodyx'): return Paragraph(text, styles[style]) def bullets(items): return ListFlowable([ListItem(P(x), leftIndent=12) for x in items], bulletType='bullet', start='circle', leftIndent=17, bulletFontSize=6, spaceAfter=6) def box(title, text, color=SKY): return Table([[P(f'<b>{title}</b><br/>{text}','Box')]], colWidths=[17.7*cm], style=TableStyle([('BACKGROUND',(0,0),(-1,-1),color),('BOX',(0,0),(-1,-1),HexColor('#BCD2D7'),.6),('LEFTPADDING',(0,0),(-1,-1),6),('RIGHTPADDING',(0,0),(-1,-1),6),('TOPPADDING',(0,0),(-1,-1),4),('BOTTOMPADDING',(0,0),(-1,-1),4)])) def table(headers, rows, widths): data=[[P(f'<b>{x}</b>','Small') for x in headers]]+[[P(x,'Small') for x in r] for r in rows] return Table(data,colWidths=widths,repeatRows=1,style=TableStyle([ ('BACKGROUND',(0,0),(-1,0),NAVY),('TEXTCOLOR',(0,0),(-1,0),colors.white),('VALIGN',(0,0),(-1,-1),'TOP'), ('GRID',(0,0),(-1,-1),.35,HexColor('#C5D0D8')),('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,PALE]), ('LEFTPADDING',(0,0),(-1,-1),5),('RIGHTPADDING',(0,0),(-1,-1),5),('TOPPADDING',(0,0),(-1,-1),4),('BOTTOMPADDING',(0,0),(-1,-1),4) ])) doc=Doc(OUT,pagesize=A4,rightMargin=1.6*cm,leftMargin=1.6*cm,topMargin=1.5*cm,bottomMargin=1.65*cm,title='HIV in Pregnancy: Detailed Study Guide',author='Orris') story=[] # Cover story += [Spacer(1,2.0*cm), P('HIV IN PREGNANCY','TitleCustom'), P('Detailed OBGY study guide: antiretroviral therapy, maternal care, delivery, neonatal prophylaxis and follow-up','Subtitle'), Spacer(1,.4*cm), HRFlowable(width='75%', thickness=2,color=TEAL,spaceAfter=18), box('Scope','An exam-oriented but clinically current guide. It supplements core OBGY principles with current NIH Perinatal HIV Clinical Guidelines. Drug choices, doses, and infant schedules must always be checked against the local/national protocol and a perinatal HIV specialist.'), Spacer(1,.4*cm), P('<b>Learning objectives</b>','H2x'), bullets(['Explain the routes, timing, and determinants of mother-to-child transmission (MTCT).','Plan antenatal, intrapartum, postpartum, and neonatal care for a woman living with HIV.','Describe ART principles in pregnancy and risk-stratified neonatal ARV management.','Write a structured 10-mark answer and recognise urgent referral situations.']), Spacer(1,.6*cm), P('Primary OBGY text source: <i>Creasy & Resnik’s Maternal-Fetal Medicine: Principles and Practice</i>, HIV Mother-to-Child Transmission and Management of HIV During Pregnancy, pp. 1171-1174. Current guidance source: NIH Perinatal HIV Clinical Guidelines, 2026.','Small'), PageBreak()] # TOC story += [P('Contents','H1x')] toc=TableOfContents(); toc.levelStyles=[ParagraphStyle(name='toc0',fontName='Helvetica',fontSize=10,leading=15,leftIndent=8,firstLineIndent=-8,textColor=INK)] story += [toc, PageBreak()] story += [P('1. Overview and burden','H1x'), P('<b>HIV can be transmitted to the fetus or infant during pregnancy, labour and delivery, or breastfeeding.</b> The prevention strategy is therefore continuous: diagnose HIV early, suppress maternal viraemia with effective ART, minimise exposure during birth, provide infant ARVs, test the infant virologically, and plan safe feeding.'), box('Key result','In the textbook, MTCT without maternal treatment is approximately 25% without breastfeeding and can reach about 40% with breastfeeding through 12 months. Combination ART throughout pregnancy has reduced transmission to <1% in high-resource settings when breastfeeding is not occurring.','EAF5F5'), P('Timing of transmission','H2x'), table(['Period','Mechanism / clinical implication'],[['In utero','Transplacental infection or ascending infection. Infection may be associated with prolonged rupture of membranes and maternal viraemia.'],['Intrapartum','Exposure to infected blood and genital secretions. This is the largest component of perinatal transmission in untreated disease.'],['Postnatal','HIV may be transmitted in breast milk. Maternal ART markedly lowers risk but does not make it zero.']], [3.2*cm,14.5*cm]), Spacer(1,8), P('Determinants of transmission','H2x'), bullets(['<b>Maternal viral load:</b> the strongest modifiable determinant. Sustained suppression is the central goal.','<b>Maternal disease:</b> low CD4 count, acute seroconversion in pregnancy/breastfeeding, untreated HIV, resistance, and poor adherence increase risk.','<b>Obstetric factors:</b> prolonged membrane rupture, chorioamnionitis, invasive fetal procedures and delivery mode may influence exposure.','<b>Co-infection and social factors:</b> STIs, tuberculosis/hepatitis treatment interactions, substance use, stigma and barriers to care require active management.']), P('A modern principle','H2x'), P('ART is treatment for the mother and prevention for the infant. It should not be withheld because of pregnancy; the benefits of viral suppression overwhelmingly outweigh theoretical drug risks. Regimens and comorbidities should be reviewed with HIV and maternal-fetal medicine teams.')] story += [P('2. Antenatal care of the mother','H1x'), P('Screening and diagnosis','H2x'), bullets(['Offer HIV testing to all pregnant women as early as possible using an antigen-antibody assay, following consent procedures and local policy.','Repeat in the third trimester for women at increased risk, and test promptly for symptoms compatible with acute HIV infection or a new STI.','If status is unknown in labour, perform expedited testing and begin prevention measures without avoidable delay when the test is positive.','Test partners where appropriate and provide prevention counselling. For an HIV-negative woman with ongoing substantial risk, consider PrEP.']), P('Initial assessment after a positive test','H2x'), table(['Domain','Actions'],[['Confirm / stage HIV','Confirm diagnosis per testing algorithm. Obtain plasma HIV RNA (viral load), CD4 count and HIV resistance genotype. Do not delay ART while waiting for genotype.'],['Baseline safety','Full blood count, renal and hepatic function; screen for hepatitis B/C, syphilis, TB and other STIs. Assess vaccinations and cervical screening.'],['Pregnancy assessment','Dating, routine obstetric evaluation, anatomy scan and fetal growth surveillance as clinically indicated.'],['Medication review','Check prior ART and resistance, interactions with TB drugs or anticonvulsants, renal/hepatic disease, and teratogenicity data.'],['Psychosocial care','Discuss adherence, disclosure safety, mental health, intimate partner violence, nutrition, financial access and substance-use treatment.']], [4.1*cm,13.6*cm]), Spacer(1,8), box('Practical caution','If an invasive procedure such as amniocentesis is clinically necessary, perform it after effective ART has begun and, whenever possible, after HIV RNA becomes undetectable. This reduces risk of inoculation of maternal blood into the amniotic cavity.','FFF4E5'), P('Monitoring during pregnancy','H2x'), bullets(['Review adherence and tolerability at every visit. A rising or detectable viral load requires urgent assessment of adherence, interactions, resistance and regimen adequacy.','Measure viral load at baseline, after starting or changing ART, periodically during pregnancy, and near delivery to guide obstetric and neonatal management. Follow the frequency in the local protocol.','CD4 count guides opportunistic-infection prophylaxis and overall disease assessment, but delivery decisions are driven chiefly by viral load.','Monitor regimen-specific toxicity, including renal function with tenofovir and glucose when clinically indicated, especially with protease-inhibitor regimens.'])] story += [P('3. Antiretroviral therapy in pregnancy','H1x'), P('Core principles','H2x'), bullets(['Start <b>combination ART immediately</b> in every pregnant person diagnosed with HIV, regardless of CD4 count or gestational age. Early suppression reduces MTCT.','If a person conceives on a fully suppressive, well-tolerated regimen, continue it in most cases after specialist review. Avoid unnecessary interruption or switching.','Individualise therapy using prior ARV exposure, genotype, hepatitis B status, renal function, drug interactions and pregnancy pharmacokinetics.','Use adherence-friendly, once-daily fixed-dose combinations where suitable.']), P('Current regimen framework','H2x'), P('In the 2026 NIH guideline, preferred initial regimens for ART-naive pregnant persons without prior long-acting cabotegravir PrEP exposure include an integrase strand-transfer inhibitor (INSTI), <b>dolutegravir (DTG)</b> or <b>bictegravir (BIC)</b>, plus a tenofovir-containing two-NRTI backbone. Examples include DTG + TDF or TAF + FTC or 3TC, or BIC/TAF/FTC. Local availability and national guidelines may differ.'), table(['Drug class','Examples / role in pregnancy','Key points'],[['NRTIs','Tenofovir (TDF or TAF) + emtricitabine (FTC) or lamivudine (3TC); abacavir in selected patients','Backbone agents. Screen/monitor renal function as appropriate. TDF/FTC is also an established PrEP option.'],['INSTIs','Dolutegravir; bictegravir; raltegravir','Preferred contemporary approach. Rapid viral-load decline makes INSTIs especially useful in late presentation.'],['Protease inhibitors','Darunavir/ritonavir; atazanavir/ritonavir','Alternatives when clinically indicated. Textbook favours DRV/r or ATV/r over LPV/r where a PI is required.'],['Older agents','Zidovudine, nevirapine, efavirenz and others','May be used in particular clinical contexts, resistance patterns or protocols; do not stop effective therapy abruptly.']], [2.4*cm,7.3*cm,8.0*cm]), Spacer(1,8), box('Late presenter','Initiate ART urgently even in the third trimester. INSTI-based therapy is valuable because viral load can fall rapidly. Coordinate delivery planning with an experienced perinatal HIV team.','EAF5F5'), P('ART safety and pregnancy outcomes','H2x'), P('ART is essential, yet pregnancies affected by HIV have higher baseline risks of preterm birth, low birth weight and small-for-gestational-age birth. A 2025 systematic review/meta-analysis found higher adverse perinatal outcome risks among women with HIV receiving ART compared with women without HIV; it does not justify withholding ART. It supports careful antenatal surveillance and regimen optimisation (PMID 39760703). A second 2025 meta-analysis reported risk differences between drug classes, with protease-inhibitor based regimens showing higher pooled risks than INSTI-based regimens in the included cohorts (PMID 39407417).')] story += [P('4. Intrapartum management and mode of birth','H1x'), P('Delivery plan should be based on the most recent viral load, ART history/adherence, obstetric indications, and local expertise. Do not allow HIV status alone to dictate care when viral suppression is secure.'), table(['Viral load near delivery','Suggested management principle'],[['<1,000 copies/mL and stable suppression','Vaginal delivery is generally appropriate if there is no obstetric contraindication. Continue oral ART through labour.'],['>1,000 copies/mL or unknown','Plan cesarean birth at 38 weeks, before labour and membrane rupture, where this is consistent with national guidance. Give intrapartum IV zidovudine according to protocol.'],['Detectable / increasing viraemia late pregnancy','Urgently assess adherence/resistance, optimise ART, liaise with HIV specialist and neonatology. Risk-stratify infant as high risk if viraemia is significant close to delivery.']], [5*cm,12.7*cm]), Spacer(1,8), P('During labour','H2x'), bullets(['Continue the usual oral ART regimen.','Use intravenous zidovudine when indicated by viral load or treatment history. In the textbook, no IV zidovudine is needed for those with undetectable viral load who continue oral ART.','Avoid invasive fetal monitoring, fetal scalp blood sampling and unnecessary artificial rupture of membranes. Minimise procedures that increase fetal contact with maternal blood.','Manage rupture of membranes and labour according to obstetric need, while avoiding avoidable delay in a person with unsuppressed viral load.','Use standard infection-control precautions. Mode of delivery should also respect patient choice and obstetric safety.']), box('Exam point','Elective cesarean delivery is a preventive intervention for women with significant or unknown viraemia near delivery, not a routine requirement for every woman living with HIV.','FFF4E5')] story += [P('5. Postpartum care and infant feeding','H1x'), P('Maternal care after delivery','H2x'), bullets(['Continue lifelong ART without interruption. Postpartum loss to follow-up is common, so arrange HIV clinic review, contraception, mental-health support and medication access before discharge.','Review drug interactions with postpartum medicines and contraception. Support reproductive choice and dual prevention of HIV/STIs.','Assess adherence, viral load, depression, social safety, disclosure concerns and partner/infant testing needs.']), P('Infant feeding: patient-centred counselling','H2x'), P('Counselling should begin antenatally and be revisited after delivery. The safest option varies with setting, availability of safe replacement feeding, maternal viral suppression, preferences, and local policy.'), table(['Situation','Counselling principle'],[['Replacement feeding available and chosen','Properly prepared formula or pasteurised donor milk eliminates postnatal HIV transmission through breast milk.'],['Breastfeeding considered/chosen','Explain that sustained maternal viral load <50 copies/mL with ART and infant prophylaxis makes risk very low but not zero. Maintain close maternal viral-load and infant follow-up.'],['New maternal viraemia / acute HIV while breastfeeding','Urgently involve an HIV expert. The infant may require enhanced prophylaxis or presumptive therapy; recommendations are risk- and setting-specific.']], [5.0*cm,12.7*cm]), Spacer(1,8), box('Important distinction','This guide presents NIH 2026 guidance and OBGY principles. WHO and national programmes may recommend breastfeeding with maternal ART in settings where formula feeding is unsafe or unaffordable. Follow the applicable local guideline.','EAF5F5')] story += [P('6. Care of the HIV-exposed infant','H1x'), P('Immediate steps','H2x'), bullets(['Inform paediatrics/neonatology before delivery whenever possible.','Start neonatal ARV prophylaxis or presumptive treatment as soon as possible after birth, preferably within 6 hours.','Use <b>virologic testing</b> (HIV nucleic acid test, NAT: HIV DNA or RNA PCR) rather than antibody testing for diagnosis in infants younger than 18 months, because maternal antibody persists.','Document maternal viral load, ART exposure, adherence concerns, delivery details, feeding plan and neonatal regimen in the discharge summary.']), P('Risk-stratified neonatal ARVs: NIH 2026 framework','H2x'), table(['Risk category','Definition / example','Neonatal ARV approach'],[['Low risk','Maternal HIV RNA <50 copies/mL from 20 weeks gestation through delivery.','Zidovudine (ZDV) alone for 2 weeks.'],['High risk','Maternal HIV RNA ≥50 copies/mL in the 4 weeks before delivery, or viraemia presumed due to new diagnosis, ART discontinuation or major adherence concern.','Three-drug presumptive HIV therapy: ZDV + 3TC plus either treatment-dose NVP or DTG. Duration is 2-6 weeks; if the three-drug course is <6 weeks, continue ZDV alone to complete 6 weeks. Specialist input is needed.'],['Intermediate / unclear risk','Does not meet low- or high-risk criteria.','Individualise regimen and duration based on timing and level of viraemia, ART history and clinical circumstances.']], [3.0*cm,6.0*cm,8.7*cm]), Spacer(1,8), P('Infant diagnostic testing and follow-up','H2x'), bullets(['Obtain NAT at birth in most infants, and in all breastfeeding infants. Obtain it before or immediately after starting ARVs.','Perform subsequent NATs at protocol-defined intervals. The schedule and additional testing depend on risk, prophylaxis, and whether breastfeeding exposure continues.','If a test is positive, promptly confirm and start full paediatric ART with specialist care.','Arrange PCP prophylaxis and immunisation/follow-up according to paediatric HIV guidance and local policy when infection has not yet been excluded.'])] story += [P('7. Clinical algorithm','H1x'), box('At first antenatal contact','Offer HIV test → if positive, obtain viral load/CD4/genotype and safety labs → start or continue effective ART immediately → screen and treat co-infections → adherence and psychosocial plan.','EAF5F5'), Spacer(1,5), box('At 28-36 weeks','Check viral load and adherence → <b>suppressed:</b> plan vaginal birth unless obstetric indication → <b>>1,000 copies/mL or unknown:</b> specialist review, IV ZDV protocol and cesarean at 38 weeks.','EAF5F5'), Spacer(1,5), box('At birth','Continue maternal ART → avoid avoidable invasive procedures → neonatal team starts ARVs within 6 hours → send HIV NAT according to risk/feeding plan.','EAF5F5'), Spacer(1,5), box('After birth','Continue maternal ART and linkage to HIV care → implement feeding plan → infant ARV course + serial NATs → prompt specialist response to any maternal viraemia or positive infant test.','EAF5F5'), P('When to seek urgent expert advice','H2x'), bullets(['Acute HIV infection during pregnancy or breastfeeding.','HIV RNA remains detectable or rises despite ART.','Late presentation in labour without prior ART or unknown HIV status.','Known resistance, prior long-acting cabotegravir PrEP exposure, TB therapy or major drug interactions.','Preterm infant, breastfeeding exposure with maternal viraemia, or any positive/indeterminate infant NAT.'])] story += [P('8. 10-mark answer framework','H1x'), P('Use these headings in a written OBGY answer. Allocate detail to the prevention pathway rather than only listing drugs.'), table(['Heading','High-yield points'],[['Introduction (1 mark)','MTCT occurs antenatally, intrapartum and via breastfeeding. Untreated risk is substantial; combined prevention can reduce transmission to <1%.'],['Antenatal care (2 marks)','Universal early test; repeat in high risk; baseline viral load/CD4/genotype/co-infection screen; immediate lifelong ART; monitor adherence and viral load.'],['ART (2 marks)','Three-drug ART for all. Current preferred approach: DTG or BIC plus tenofovir-containing two-NRTI backbone, individualised to history/resistance/comorbidity.'],['Intrapartum (2 marks)','Continue ART. Avoid invasive procedures. Vaginal birth if suppressed. If >1,000 copies/mL or unknown near delivery, IV ZDV and planned cesarean at 38 weeks.'],['Postpartum and feeding (1 mark)','Continue lifelong ART; counsel on contraception and infant feeding using local guidance; replacement feeding removes breast-milk transmission.'],['Infant (2 marks)','ARVs within 6 hours, risk-based ZDV or three-drug presumptive therapy, and serial HIV NAT.']], [4.2*cm,13.5*cm]), P('One-line conclusion','H2x'), P('<b>Early diagnosis, sustained maternal viral suppression, safe delivery practices, risk-based infant prophylaxis, and virologic infant follow-up make perinatal HIV transmission largely preventable.</b>')] story += [P('9. References and source notes','H1x'), P('<b>Textbook source</b>','H2x'), P('Creasy RK, Resnik R, Iams JD, et al. <i>Creasy & Resnik’s Maternal-Fetal Medicine: Principles and Practice</i>. Sections: “HIV Mother-to-Child Transmission,” “Interventions for Prevention of HIV Mother-to-Child Transmission,” and “Management of HIV During Pregnancy,” pp. 1171-1174.'), P('<b>Current clinical guideline</b>','H2x'), P('National Institutes of Health. <i>Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States</i>. Updated 2026. Sections: Initial Use of ART During Pregnancy; Antiretroviral Management of Infants with In Utero, Intrapartum, or Breastfeeding Exposure to HIV; Introduction.'), P('<b>Recent evidence review</b>','H2x'), bullets(['Boering P, et al. Perinatal outcomes among pregnant women with HIV initiating antiretroviral therapy preconception and antenatally. <i>AIDS</i>. 2025. PMID: 39760703. Systematic review and meta-analysis.','Hey M, et al. Adverse perinatal outcomes associated with different classes of antiretroviral drugs in pregnant women with HIV. <i>AIDS</i>. 2025. PMID: 39407417. Systematic review and meta-analysis.','Abuogi LL, et al. A Systematic Review of the Use of Antiretroviral Drugs to Prevent HIV in Neonates and Infants. <i>J Pediatric Infectious Diseases Society</i>. 2026. PMID: 42391472.']), box('Clinical-use disclaimer','This educational document is not a substitute for a local ART protocol or specialist consultation. Antiretroviral drug selection, doses, neonatal regimens, testing schedules, infant-feeding decisions, and obstetric plans must be individualised.','FFF4E5')] doc.build(story,onFirstPage=footer,onLaterPages=footer) print(OUT) ''') PY python "/tmp/workspace/hiv-pregnancy-pdf/src/create_hiv_pregnancy_pdf.py" ls -lh "/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_Detailed_Study_Guide.pdf"

~/hiv-pregnancy-pdf/src/create_hiv_pregnancy_pdf.py

python "/tmp/workspace/hiv-pregnancy-pdf/src/create_hiv_pregnancy_pdf.py" && ls -lh "/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_Detailed_Study_Guide.pdf" && python - <<'PY' from pypdf import PdfReader p='/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_Detailed_Study_Guide.pdf' r=PdfReader(p) print('pages=',len(r.pages)) for i,page in enumerate(r.pages): text=page.extract_text() or '' print(i+1, len(text), text[:65].replace('\n',' | ')) PY

~/hiv-pregnancy-pdf/src/create_hiv_pregnancy_pdf.py

~/hiv-pregnancy-pdf/src/create_hiv_pregnancy_pdf.py

python "/tmp/workspace/hiv-pregnancy-pdf/src/create_hiv_pregnancy_pdf.py" && ls -lh "/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_Detailed_Study_Guide.pdf" && python - <<'PY' from pypdf import PdfReader p='/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_Detailed_Study_Guide.pdf' r=PdfReader(p) print('pages=',len(r.pages)) for i,page in enumerate(r.pages): t=(page.extract_text() or '').replace('\n',' | ') print(f'{i+1}: chars={len(t)} :: {t[:100]}') PY

~/hiv-pregnancy-pdf/src/create_hiv_pregnancy_pdf.py

python "/tmp/workspace/hiv-pregnancy-pdf/src/create_hiv_pregnancy_pdf.py" && python - <<'PY' from pypdf import PdfReader p='/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_Detailed_Study_Guide.pdf' r=PdfReader(p) print('pages=',len(r.pages)) for i,page in enumerate(r.pages): text=page.extract_text() or '' print(f'PAGE {i+1}: {len(text)} chars | '+text[:180].replace('\n',' | ')) print('TOC page:', (r.pages[1].extract_text() or '')[:700].replace('\n',' | ')) PY ls -lh "/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_Detailed_Study_Guide.pdf"

python - <<'PY' from pypdf import PdfReader from pathlib import Path p=Path('/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_Detailed_Study_Guide.pdf') assert p.exists() and p.stat().st_size > 10000 r=PdfReader(str(p)) assert len(r.pages) == 8 full='\n'.join((x.extract_text() or '') for x in r.pages) for required in ['HIV IN PREGNANCY','Antiretroviral therapy in pregnancy','Care of the HIV-exposed infant','10-mark answer framework','References and source notes']: assert required in full, required print('Verified:', p.name, 'pages=',len(r.pages), 'bytes=',p.stat().st_size) PY

HIV pregnancy antiretroviral

NIH perinatal HIV guidelines 2026 pregnancy infant antiretroviral prophylaxis

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~/hiv-pregnancy-pdf

python - <<'PY' from pathlib import Path p=Path('/tmp/workspace/hiv-pregnancy-pdf/src/create_concise_10mark_pdf.py') p.write_text('''from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.colors import HexColor from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.enums import TA_CENTER from reportlab.lib.units import cm from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable, ListFlowable, ListItem from pypdf import PdfReader out = "/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_10_Mark_Answer.pdf" NAVY=HexColor('#153D5B'); TEAL=HexColor('#087E8B'); PALE=HexColor('#EEF7F8'); INK=HexColor('#1B2730'); GREY=HexColor('#52616B') ss=getSampleStyleSheet() ss.add(ParagraphStyle(name='T', parent=ss['Title'], fontName='Helvetica-Bold', fontSize=22, leading=27, alignment=TA_CENTER, textColor=NAVY, spaceAfter=6)) ss.add(ParagraphStyle(name='Sub', parent=ss['Normal'], fontName='Helvetica', fontSize=10, leading=13, alignment=TA_CENTER, textColor=GREY, spaceAfter=11)) ss.add(ParagraphStyle(name='H', parent=ss['Heading2'], fontName='Helvetica-Bold', fontSize=11.5, leading=14, textColor=TEAL, spaceBefore=7, spaceAfter=3, keepWithNext=True)) ss.add(ParagraphStyle(name='B', parent=ss['BodyText'], fontName='Helvetica', fontSize=9.2, leading=12.6, textColor=INK, spaceAfter=4)) ss.add(ParagraphStyle(name='S', parent=ss['BodyText'], fontName='Helvetica', fontSize=7.5, leading=9.3, textColor=GREY)) def P(x, st='B'): return Paragraph(x,ss[st]) def ul(items): return ListFlowable([ListItem(P(i), leftIndent=10) for i in items], bulletType='bullet', leftIndent=16, bulletFontSize=5, spaceAfter=3) def box(text): return Table([[P(text)]], colWidths=[17.8*cm], style=TableStyle([('BACKGROUND',(0,0),(-1,-1),PALE),('BOX',(0,0),(-1,-1),.6,HexColor('#B7D8DC')),('LEFTPADDING',(0,0),(-1,-1),7),('RIGHTPADDING',(0,0),(-1,-1),7),('TOPPADDING',(0,0),(-1,-1),5),('BOTTOMPADDING',(0,0),(-1,-1),5)])) def foot(c,d): c.saveState(); w,h=A4; c.setStrokeColor(HexColor('#D2DDE2')); c.line(1.55*cm,1.18*cm,w-1.55*cm,1.18*cm); c.setFillColor(GREY); c.setFont('Helvetica',7.2); c.drawString(1.55*cm,.78*cm,'HIV in Pregnancy | Concise 10-mark answer'); c.drawRightString(w-1.55*cm,.78*cm,f'Page {d.page}'); c.restoreState() doc=SimpleDocTemplate(out,pagesize=A4,leftMargin=1.55*cm,rightMargin=1.55*cm,topMargin=1.35*cm,bottomMargin=1.5*cm,title='HIV in Pregnancy: 10 Mark Answer') story=[] story += [P('HIV IN PREGNANCY','T'),P('Antiretroviral therapy and prevention of mother-to-child transmission | Concise 10-mark answer','Sub'),HRFlowable(width='100%',thickness=1.5,color=TEAL,spaceAfter=9)] story += [P('Introduction','H'),P('HIV may be transmitted <b>in utero, during labour/delivery, or by breastfeeding</b>. Without intervention, mother-to-child transmission (MTCT) is about 25% without breastfeeding and may reach 40% with breastfeeding. With effective maternal ART and appropriate infant care, transmission can be reduced to <b>less than 1%</b>.')] story += [P('1. Antenatal management of the mother (3 marks)','H'),ul(['Offer <b>universal HIV testing</b> early in pregnancy. Repeat testing in the third trimester in high-risk women, and perform rapid testing in labour if status is unknown.','After diagnosis: assess HIV RNA viral load, CD4 count, resistance genotype, renal/liver function, hepatitis B/C, TB and other STIs.','Start <b>lifelong three-drug ART immediately</b>, irrespective of CD4 count or gestation. Do not wait for resistance results. Continue a tolerated, fully suppressive pre-pregnancy regimen after specialist review.','Preferred contemporary regimens are generally <b>dolutegravir or bictegravir plus a tenofovir-containing two-NRTI backbone</b>, individualised for resistance, comorbidity and local protocol.','Monitor adherence, toxicity and viral load. Treat co-infections and provide counselling on condoms, partner testing, nutrition and psychosocial support.'])] story += [P('2. Intrapartum management (2 marks)','H'),ul(['Continue maternal oral ART during labour.','When HIV RNA is <b>more than 1,000 copies/mL</b> near delivery, or is unknown, give IV zidovudine as per protocol and plan <b>elective cesarean at 38 weeks</b>, before labour and rupture of membranes.','If viral load is suppressed, vaginal delivery is appropriate unless there is an obstetric indication for cesarean.','Avoid fetal scalp electrodes, fetal scalp blood sampling, unnecessary artificial rupture of membranes, and other invasive procedures that may increase fetal exposure to maternal blood.'])] story += [P('3. Postpartum care and infant feeding (1 mark)','H'),ul(['Continue lifelong ART after delivery. Arrange HIV follow-up, contraception, adherence and mental-health support.','Replacement feeding with properly prepared formula or banked donor milk eliminates breast-milk transmission. If breastfeeding is chosen/necessary, follow local policy: sustained maternal viral suppression, close follow-up and infant prophylaxis are required; risk is very low but not zero.'])] story += [P('4. Management of the HIV-exposed infant (3 marks)','H'),ul(['Start neonatal ARV prophylaxis or presumptive treatment <b>as soon as possible, preferably within 6 hours</b> of birth.','<b>Low risk</b> (maternal HIV RNA <50 copies/mL from 20 weeks through delivery): zidovudine alone, usually 2 weeks in current NIH guidance.','<b>High risk</b> (maternal HIV RNA ≥50 copies/mL in the 4 weeks before delivery, new maternal diagnosis, stopped ART or major adherence concern): three-drug presumptive therapy with zidovudine + lamivudine + nevirapine or dolutegravir, with paediatric HIV specialist advice.','Use <b>HIV nucleic acid testing (DNA/RNA PCR)</b>, not antibody testing, for early diagnosis because maternal antibodies persist up to 15-18 months. Test at birth and subsequently according to the risk and feeding plan.'])] story += [P('Conclusion (1 mark)','H'),box('<b>Prevention of MTCT requires:</b> early diagnosis, immediate and sustained maternal ART with viral suppression, appropriate delivery planning, neonatal ARV prophylaxis, virologic testing of the infant, and safe infant-feeding counselling.')] story += [Spacer(1,7),P('<b>Textbook reference:</b> Creasy & Resnik’s <i>Maternal-Fetal Medicine: Principles and Practice</i>, “HIV Mother-to-Child Transmission,” “Interventions for Prevention of HIV Mother-to-Child Transmission,” and “Management of HIV During Pregnancy,” pp. 1171-1174. <b>Current update:</b> NIH Perinatal HIV Clinical Guidelines, 2026. Drug doses and local infant-feeding policy must be checked in the applicable protocol.','S')] doc.build(story,onFirstPage=foot,onLaterPages=foot) r=PdfReader(out) assert len(r.pages)<=2 text=' '.join((pg.extract_text() or '') for pg in r.pages) for phrase in ['Introduction','Antenatal management','Intrapartum management','Management of the HIV-exposed infant','Conclusion']: assert phrase in text print(out, 'pages',len(r.pages)) ''') PY python "/tmp/workspace/hiv-pregnancy-pdf/src/create_concise_10mark_pdf.py" ls -lh "/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_10_Mark_Answer.pdf"

HIV pregnancy antiretroviral

NIH perinatal HIV guideline 2026 pregnancy infant prophylaxis viral load cesarean

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python - <<'PY' from pathlib import Path p=Path('/tmp/workspace/hiv-pregnancy-pdf/src/create_flowchart_table_pdf.py') p.write_text(r'''from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.colors import HexColor from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.enums import TA_CENTER from reportlab.lib.units import cm from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, PageBreak, KeepTogether from pypdf import PdfReader OUT='/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_Flowcharts_and_Tables.pdf' NAVY=HexColor('#123B5D'); TEAL=HexColor('#087E8B'); BLUE=HexColor('#EAF5F7'); GREEN=HexColor('#EAF6EE'); ORANGE=HexColor('#FFF3E3'); PINK=HexColor('#FBECEF'); INK=HexColor('#15232D'); GREY=HexColor('#52616B'); LINE=HexColor('#B9CBD3') ss=getSampleStyleSheet() ss.add(ParagraphStyle(name='TitleX', parent=ss['Title'], fontName='Helvetica-Bold', fontSize=21, leading=25, alignment=TA_CENTER, textColor=NAVY, spaceAfter=4)) ss.add(ParagraphStyle(name='SubX', parent=ss['Normal'], fontName='Helvetica', fontSize=9.5, leading=12, alignment=TA_CENTER, textColor=GREY, spaceAfter=9)) ss.add(ParagraphStyle(name='H1X', parent=ss['Heading1'], fontName='Helvetica-Bold', fontSize=14, leading=17, textColor=NAVY, spaceBefore=5, spaceAfter=5, keepWithNext=True)) ss.add(ParagraphStyle(name='H2X', parent=ss['Heading2'], fontName='Helvetica-Bold', fontSize=10.5, leading=13, textColor=TEAL, spaceBefore=5, spaceAfter=3, keepWithNext=True)) ss.add(ParagraphStyle(name='B', parent=ss['BodyText'], fontName='Helvetica', fontSize=8.7, leading=11.2, textColor=INK, spaceAfter=3)) ss.add(ParagraphStyle(name='S', parent=ss['BodyText'], fontName='Helvetica', fontSize=7.25, leading=9.1, textColor=GREY)) ss.add(ParagraphStyle(name='Flow', parent=ss['BodyText'], fontName='Helvetica', fontSize=8.4, leading=10.5, textColor=INK, alignment=TA_CENTER)) def P(x,st='B'): return Paragraph(x,ss[st]) def arrow(): return P('<font color="#087E8B" size="15">▼</font>','Flow') def flowbox(text, color=BLUE, w=17.8*cm): return Table([[P(text,'Flow')]],colWidths=[w],style=TableStyle([('BACKGROUND',(0,0),(-1,-1),color),('BOX',(0,0),(-1,-1),.7,LINE),('LEFTPADDING',(0,0),(-1,-1),7),('RIGHTPADDING',(0,0),(-1,-1),7),('TOPPADDING',(0,0),(-1,-1),5),('BOTTOMPADDING',(0,0),(-1,-1),5),('VALIGN',(0,0),(-1,-1),'MIDDLE')])) def tbl(headers,rows,widths): d=[[P('<b>'+x+'</b>','S') for x in headers]]+[[P(c,'S') for c in row] for row in rows] return Table(d,colWidths=widths,repeatRows=1,style=TableStyle([('BACKGROUND',(0,0),(-1,0),NAVY),('TEXTCOLOR',(0,0),(-1,0),colors.white),('GRID',(0,0),(-1,-1),.35,LINE),('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,HexColor('#F5F8FA')]),('VALIGN',(0,0),(-1,-1),'TOP'),('LEFTPADDING',(0,0),(-1,-1),5),('RIGHTPADDING',(0,0),(-1,-1),5),('TOPPADDING',(0,0),(-1,-1),4),('BOTTOMPADDING',(0,0),(-1,-1),4)])) def footer(c,d): c.saveState(); w,h=A4; c.setStrokeColor(LINE); c.line(1.5*cm,1.1*cm,w-1.5*cm,1.1*cm); c.setFillColor(GREY); c.setFont('Helvetica',7); c.drawString(1.5*cm,.73*cm,'HIV in Pregnancy | Flowcharts and tables | Concise 10-mark revision'); c.drawRightString(w-1.5*cm,.73*cm,'Page %d' % d.page); c.restoreState() doc=SimpleDocTemplate(OUT,pagesize=A4,leftMargin=1.5*cm,rightMargin=1.5*cm,topMargin=1.25*cm,bottomMargin=1.42*cm,title='HIV in Pregnancy Flowcharts and Tables') st=[] st += [P('HIV IN PREGNANCY','TitleX'),P('10-mark answer in flowcharts and tables | ART, delivery, mother and child','SubX')] st += [P('A. Core prevention pathway','H1X'), flowbox('<b>EARLY ANTENATAL HIV TEST</b><br/>Universal testing at booking; repeat in third trimester if high risk / ongoing exposure.',BLUE),arrow(),flowbox('<b>HIV POSITIVE</b><br/>Viral load + CD4 + resistance testing + screen for TB, hepatitis B/C and STIs.<br/><b>Do not delay ART while awaiting results.</b>',GREEN),arrow(),flowbox('<b>START / CONTINUE LIFELONG COMBINATION ART</b><br/>Aim: sustained undetectable maternal HIV RNA. Check adherence, interactions and toxicity at each visit.',BLUE),arrow(),flowbox('<b>VIRAL LOAD NEAR DELIVERY</b><br/>Guides route of birth, intrapartum zidovudine need and newborn ARV regimen.',ORANGE)] st += [P('B. Antenatal management table','H1X'),tbl(['Step','What to do','Why it matters'],[ ['Screen','Test early in every pregnancy. Repeat if high risk, acute-HIV symptoms or STI. Rapid test in labour if status unknown.','Early ART lowers maternal disease progression and MTCT.'], ['Assess','HIV RNA, CD4, resistance genotype, FBC, renal/liver function; screen for TB, hepatitis B/C and STIs.','Defines treatment choice and identifies co-infections.'], ['Treat','Give three-drug ART to every pregnant woman with HIV, irrespective of CD4 count. A fully suppressive pre-pregnancy regimen is usually continued after review.','Maternal ART is treatment for the mother and prevention for the child.'], ['Monitor','Check adherence and HIV RNA regularly, especially near delivery. Address stigma, nutrition, mental health and partner testing.','Viral load is the key modifiable predictor of transmission.'], ['Avoid exposure','Avoid invasive prenatal procedures where possible. If essential, perform after effective ART and preferably with undetectable HIV RNA.','Limits fetal exposure to maternal blood.']], [2.2*cm,8.0*cm,7.6*cm])] st += [P('C. ART: exam-ready summary','H1X'),tbl(['Situation','Answer to write'],[ ['All women with HIV','Start ART as soon as diagnosed and continue lifelong, even if diagnosed late in pregnancy.'], ['Preferred current approach','INSTI-based regimen: dolutegravir or bictegravir + a tenofovir-containing two-NRTI backbone, individualised to resistance, renal function, hepatitis B and local protocol.'], ['If already on ART','Do not interrupt an effective, tolerated, suppressive regimen without specialist reason.'], ['Main goal','Undetectable HIV RNA before delivery and throughout postpartum period.']], [4.0*cm,13.8*cm])] st += [PageBreak()] st += [P('D. Delivery decision flowchart','H1X'),flowbox('<b>CHECK HIV RNA CLOSE TO DELIVERY</b>',BLUE),arrow(), Table([[flowbox('<b>HIV RNA &lt;1,000 copies/mL<br/>and adherent on ART</b><br/>Vaginal birth appropriate unless obstetric indication for cesarean.<br/>Continue oral ART.',GREEN,8.55*cm),flowbox('<b>HIV RNA &gt;1,000 copies/mL<br/>or viral load unknown</b><br/>IV zidovudine as per protocol + planned cesarean at 38 weeks, before labour and membrane rupture.',PINK,8.55*cm)]],colWidths=[8.9*cm,8.9*cm],style=TableStyle([('VALIGN',(0,0),(-1,-1),'TOP'),('LEFTPADDING',(0,0),(-1,-1),0),('RIGHTPADDING',(0,0),(-1,-1),0)])),Spacer(1,5), flowbox('<b>IN ALL LABOURS</b><br/>Continue ART. Avoid fetal scalp electrode, fetal scalp blood sampling, unnecessary artificial rupture of membranes and other invasive procedures.',ORANGE)] st += [P('E. Intrapartum and postpartum table','H1X'),tbl(['Time','Key actions'],[ ['In labour','Continue maternal ART. IV zidovudine when indicated by viraemia or treatment history. Use standard precautions and minimise invasive fetal procedures.'], ['After delivery - mother','Continue lifelong ART. Arrange HIV follow-up, contraception, adherence support, mental-health review and partner services.'], ['Infant feeding','Formula or banked donor milk removes breast-milk HIV transmission. If breastfeeding is chosen/necessary, follow local policy with sustained maternal suppression, close viral-load monitoring and infant prophylaxis. Risk is low but not zero.']], [4.0*cm,13.8*cm])] st += [P('F. Management of HIV-exposed newborn','H1X'),flowbox('<b>BIRTH</b><br/>Notify paediatrics. Start neonatal ARVs as soon as possible, preferably within 6 hours. Obtain HIV NAT as indicated.',BLUE),arrow(), Table([[flowbox('<b>LOW RISK</b><br/>Maternal HIV RNA &lt;50 copies/mL from 20 weeks through delivery.<br/><b>Zidovudine alone</b>, generally 2 weeks in current NIH guidance.',GREEN,8.55*cm),flowbox('<b>HIGH RISK</b><br/>HIV RNA ≥50 copies/mL within 4 weeks of delivery, new diagnosis, no/poor ART adherence.<br/><b>Three-drug presumptive therapy</b>: ZDV + 3TC + NVP or DTG; specialist advice.',PINK,8.55*cm)]],colWidths=[8.9*cm,8.9*cm],style=TableStyle([('VALIGN',(0,0),(-1,-1),'TOP'),('LEFTPADDING',(0,0),(-1,-1),0),('RIGHTPADDING',(0,0),(-1,-1),0)])),arrow(),flowbox('<b>FOLLOW-UP</b><br/>Use HIV nucleic acid testing (HIV DNA/RNA PCR), not antibody testing, in infants under 18 months. Serial testing depends on risk and ongoing breastfeeding exposure.',ORANGE)] st += [P('G. Marks distribution for a 10-mark answer','H1X'),tbl(['Section','Marks'],[['Introduction: routes and prevention of MTCT','1'],['Antenatal assessment and ART','3'],['Intrapartum delivery plan','2'],['Postpartum care and feeding counselling','1'],['Neonatal ARVs and HIV testing','3']], [14.7*cm,3.1*cm]),Spacer(1,6),P('<b>References:</b> Creasy & Resnik’s <i>Maternal-Fetal Medicine</i>, pp. 1171-1174. NIH Perinatal HIV Clinical Guidelines, updated 2026. Check local protocols for exact ARV drug doses, newborn schedules and infant-feeding policy.','S')] doc.build(st,onFirstPage=footer,onLaterPages=footer) r=PdfReader(OUT); text=' '.join((x.extract_text() or '') for x in r.pages) assert len(r.pages)==2 for s in ['Core prevention pathway','Delivery decision flowchart','Management of HIV-exposed newborn','Marks distribution']: assert s in text print(OUT, 'pages',len(r.pages)) ''') PY python "/tmp/workspace/hiv-pregnancy-pdf/src/create_flowchart_table_pdf.py" ls -lh "/tmp/workspace/hiv-pregnancy-pdf/output/HIV_in_Pregnancy_Flowcharts_and_Tables.pdf"