From Essential obstetric and newborn care › Chapter 4: Pathologies during pregnancy and pregnancy-related disorders · Médecins Sans Frontières, Current online edition
MSF guidance on managing genital herpes, varicella, hepatitis and HIV during pregnancy, labour and delivery.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition
- Audience
- Obstetricians, midwives, general practitioners and healthcare workers providing antenatal, intrapartum and postnatal care
- Evidence
- Expert consensus based on international guidelines and evidence
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF clinical guideline section addresses the management of four key viral infections during pregnancy: genital herpes, varicella (chickenpox), hepatitis (B and E), and HIV. The guidance emphasises prevention of mother-to-child transmission through specific interventions tailored to each infection.
For genital herpes, the guideline recommends limiting vaginal examinations when visible lesions are present at delivery, treating mothers with aciclovir 400 mg three times daily for 7 days, and considering prophylactic aciclovir from 36 weeks to prevent recurrence at delivery. Varicella requires prompt antiviral treatment (aciclovir 800 mg five times daily for 7 days) to reduce risks of maternal pneumonia and severe neonatal infection. Hepatitis B transmission can be reduced from up to 90% to 5–30% through neonatal vaccination within 24 hours of birth, whilst hepatitis E poses particular danger with 20% mortality in the third trimester and requires symptomatic treatment and prevention through improved water and sanitation.
HIV management focuses on antiretroviral therapy for all HIV-infected pregnant women regardless of CD4 count or clinical stage, to be started as soon as possible and continued for life. With no intervention, mother-to-child transmission risk is 15–45%, but can be reduced to less than 2% with appropriate antiretroviral protocols. The guideline recommends avoiding prolonged labour, early membrane rupture and unnecessary invasive procedures, whilst emphasising that HIV testing should be offered to all pregnant women and repeated during the third trimester and breastfeeding period.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Genital herpes: treat with aciclovir 400 mg PO three times daily for 7 days; prophylactic aciclovir 400 mg four times daily from 36 weeks LMP until delivery can reduce recurrence at delivery
- Varicella: administer aciclovir 800 mg PO five times daily for 7 days as soon as possible after rash onset to reduce risks of severe maternal pneumonia and neonatal varicella
- Hepatitis B: neonatal vaccination within 24 hours of birth prevents 70–95% of infections (without intervention, mother-to-child transmission reaches up to 90%)
- Hepatitis E: carries 20% mortality rate in pregnant women during third trimester; treatment is symptomatic only, prevention through water, hygiene and sanitation is essential
- HIV: offer testing to all pregnant women; retest HIV-negative women during third trimester and breastfeeding period
- HIV-infected pregnant women require antiretroviral therapy regardless of CD4 count, started as soon as possible regardless of gestational age and continued for life
- HIV intrapartum care: avoid prolonged labour, prolonged or early artificial rupture of membranes, and unnecessary invasive procedures; delay cord clamping for 1–3 minutes
- HIV mother-to-child transmission can be reduced from 15–45% (with breastfeeding, no intervention) to less than 2% with appropriate antiretroviral protocols
Antiviral treatment regimens for viral infections in pregnancy
Table extracted from the guideline
| Infection | Indication | Drug & dose | Duration |
|---|---|---|---|
| Genital herpes | Active lesions | Aciclovir 400 mg PO 3 times daily | 7 days (until symptoms resolve if immunocompromised) |
| Genital herpes | Prophylaxis | Aciclovir 400 mg PO 4 times daily | From 36 weeks LMP until delivery |
| Varicella | After rash onset | Aciclovir 800 mg PO 5 times daily | 7 days |
| Hepatitis B | Neonate prevention | Hepatitis B vaccine | Within 24 hours of birth |
| HIV | All HIV-infected pregnant women | Antiretroviral therapy (see PMTCT guides) | Started ASAP, continued for life |
Source: Médecins Sans Frontières, Viral infections in pregnancy (Essential obstetric and newborn care) — MSF Essential obstetric and newborn care. Reproduced in summary form.
From the guideline
Verbatim
“HIV-infected pregnant women need antiretroviral therapy regardless of their CD4 count and clinical stage. The treatment should start as soon as possible, regardless of gestational age and should be taken for life.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute, I recognise that viral infections in pregnancy remain a critical area for Georgian obstetric practice, particularly given our successful hepatitis C elimination programme and expanding universal health coverage since 2013. The MSF recommendation I would emphasise most strongly to South Caucasus clinicians is the need for universal HIV testing at multiple points during pregnancy and the breastfeeding period, with immediate initiation of lifelong antiretroviral therapy regardless of CD4 count—a shift from older protocols that some practitioners may still follow. The realistic implementation challenge for Georgia and neighbouring countries is ensuring 24-hour availability of aciclovir in all maternity facilities, particularly for the high-dose varicella regimen (800 mg five times daily), and establishing reliable cold-chain systems to guarantee hepatitis B vaccine administration within the critical 24-hour window in rural and remote birthing centres. The hepatitis E mortality rate of 20% in the third trimester underscores the continued importance of water and sanitation infrastructure improvements, an area where the region still faces challenges despite progress in urban centres.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
This guidance is highly relevant for Georgia and the South Caucasus, where viral infections in pregnancy remain important public health challenges. Georgia’s national HIV programme and its established hepatitis C elimination initiative (since 2015) provide infrastructure for implementing MSF’s recommendations on antenatal HIV testing and antiretroviral therapy. The emphasis on hepatitis B vaccination within 24 hours aligns with Georgia’s immunisation programme. Varicella and genital herpes management require adequate aciclovir availability in maternity facilities. For the region, hepatitis E prevention is particularly relevant in settings with inadequate water and sanitation infrastructure, including rural areas and potential refugee/IDP populations. National obstetric protocols would need to ensure that all maternity facilities have access to antiretroviral prophylaxis for neonates and that HIV testing is routinely offered at multiple antenatal contacts as recommended.
Questions this guideline answers
Quick answers
Should all pregnant women with genital herpes have caesarean section?
No. Caesarean section should be discussed on a case-by-case basis only when the mother has visible herpetic lesions at the time of childbirth. The decision is individualised rather than routine.
When should aciclovir be started for pregnant women with varicella?
Aciclovir 800 mg five times daily for 7 days should be administered as soon as possible after the onset of rash to reduce the risks of severe maternal varicella pneumonia and severe neonatal varicella.
How much can hepatitis B mother-to-child transmission be reduced with neonatal vaccination?
Without intervention, mother-to-child transmission of hepatitis B virus is up to 90%. Routine hepatitis B vaccination within 24 hours after birth prevents 70–95% of infections.
When should HIV-infected pregnant women start antiretroviral therapy?
HIV-infected pregnant women need antiretroviral therapy regardless of their CD4 count and clinical stage. Treatment should start as soon as possible, regardless of gestational age, and should be taken for life.
Related on GMJ
Interconnected resources
Dictionary of Public Health
Drugs A–Z
Conditions A–Z
GMJ News coverage
- Novel Prime-and-Pull Vaccine Strategy Shows Promise Against Genital Herpes in Preclinical ModelsAug 2026
- Genital herpes cases rise in England despite overall STI declineJun 2026
- Disseminated herpes zoster with hepatic necrosis reveals late HIV diagnosis in young womanAug 2026
- How the immune system learns and remembers: innate defenses meet adaptive immunityJul 2026
Quality & accreditation
Same guideline
- Parasitic infections in pregnancy: malaria, hookworms and ascariasis — MSF Essential obstetric and newborn careChapter 4: Pathologies during pregnancy and pregnancy-related disorders
- Bacterial infections in pregnancy (MSF Essential obstetric and newborn care) — MSF Essential obstetric and newborn careChapter 4: Pathologies during pregnancy and pregnancy-related disorders
- Iron deficiency anaemia — MSF Essential obstetric and newborn careChapter 4: Pathologies during pregnancy and pregnancy-related disorders
- Diagnosis of bleeding during the second half of pregnancy (summary) — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
- Uterine rupture — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
- Abruptio placentae — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
Other guidelines on this topic
- Factors that influence adherence — MSF Tuberculosis
- Parasitic infections in pregnancy: malaria, hookworms and ascariasis — MSF Essential obstetric and newborn care
- Bacterial infections in pregnancy (MSF Essential obstetric and newborn care) — MSF Essential obstetric and newborn care
- Iron deficiency anaemia — MSF Essential obstetric and newborn care
- Diagnosis of bleeding during the second half of pregnancy (summary) — MSF Essential obstetric and newborn care
- Issuer
- Médecins Sans Frontières
- Guideline
- Essential obstetric and newborn care
- Chapter
- Chapter 4: Pathologies during pregnancy and pregnancy-related disorders
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition
- Status
- Current
- Published
- 2026-10-14
- Scope
- Section 4.4 of MSF Essential obstetric and newborn care guideline, covering viral infections during pregnancy
- Audience
- Obstetricians, midwives, general practitioners and healthcare workers providing antenatal, intrapartum and postnatal care
- Evidence
- Expert consensus based on international guidelines and evidence
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. 4.4 Viral infections. In: Essential obstetric and newborn care [Internet]. MSF; [cited 2026 Oct 14]. Available from: https://medicalguidelines.msf.org/en/viewport/EONC/english/4-4-viral-infections-31128891.htmlGMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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