HIV Awareness 6: Pregnancy and HIV

The Good News
Due to advances in HIV care and treatment, many women living with HIV (HIV+) are living longer, healthier lives. As HIV+ women think about their futures, some are deciding to have the babies they always wanted.

The good news is that advances in HIV treatment have also greatly lowered the chances that a mother will pass HIV on to her baby (known as the rate of mother-to-child HIV transmission). If the mother takes appropriate medical precautions, the chances of transmission can go down from about 1 in 4 (when not taking any HIV drugs) to less than 1 in 50 (when taking proper HIV drugs). In addition, studies have shown that being pregnant will not make HIV progress faster in the mother.

Before You Get Pregnant
It is important to plan carefully before getting pregnant:
Discuss your plans with your HIV health care provider to make sure you are on the right treatment plan for your own health and to reduce the risk of transmitting HIV to your baby (more about this in the next sections)
Find an obstetrician (OB) or midwife who is familiar with HIV care. He or she can explain your options for getting pregnant with as little risk to your partner as possible.
Ask your HIV health care provider and your OB or midwife to talk with each other and coordinate to make sure you receive appropriate care before and during your pregnancy
Get screened for sexually transmitted diseases (STDs) and hepatitis B or C
Give up smoking, drinking, and drugs. All of these can be bad for your health and the health of your baby.
Start taking pregnancy vitamins ("prenatal" vitamins) that contain folic acid and calcium while you are trying to become pregnant. This can reduce the rates of some birth defects.
If friends and family do not support your decision to have a child, put together a support network of people who are caring, non-judgmental, and well educated about HIV and pregnancy. Your network can include of medical providers, counselors, and other HIV+ women who are considering pregnancy or have had children.

The Pregnancy Guidelines
A group of experts on pregnancy in HIV+ women has developed guidelines that provide information about appropriate care and treatment for HIV+ women who are, or may become, pregnant.
As a first step, the pregnancy guidelines recommend a thorough check up, including a number of blood tests, to find out about your health and the status of your HIV infection. A resistance test (see TWP sheet on resistance for info about this test) should be included if you:
Are starting HIV drugs
Are taking HIV drugs and have a detectable viral load (500 – 1,000 copies or more)
The results of a resistance test can help you and your health care provider choose the best drugs to take.

HIV drugs can reduce the risk of transmitting HIV from mother to baby. For this reason, HIV drugs are recommended for all pregnant women regardless of CD4 count and viral load. Even if the mother does not need HIV treatment for her own health, it is important for her to take HIV drugs to lower the risk of mother-to-child transmission. The drugs need to be taken just as they are prescribed to have the best chance of working. (See TWP sheet on adherence for more info.)

There are certain HIV drugs that should be avoided or used with caution because of possible side effects in the mother or the developing baby. Some examples are Sustiva (efavirenz), Atripla (which contains Sustiva), Viread (tenofovir), and the combinations of Videx (didanosine, ddI) and Zerit (stavudine, d4T) or Zerit and Retrovir (zidovudine or AZT). Viramune (nevirapine) should not be started in HIV+ women with CD4 cell counts over 250.

Discuss the risks and benefits of the HIV drugs with your health care provider so that you can decide which treatments are best for you and your baby. Your health care provider can call the National Perinatal HIV Hotline at 1-888-448-8765 for free, expert advice on all aspects of caring for HIV+ pregnant women.

HIV Drugs and Pregnancy
Deciding when to start treatment depends on your own health and when you find out you are pregnant. The pregnancy guidelines make the following recommendations:

For HIV+ Women Not Taking HIV Drugs
When HIV treatment is needed for the health of the woman: she should receive a combination of HIV drugs based on treatment guidelines for non-pregnant adults. Retrovir should be used as one of the drugs in the combination if possible. HIV treatment should start as soon as possible, including in the first trimester (three months) of pregnancy.
When HIV treatment is not needed for the health of the woman: she should also receive HIV treatment to prevent mother-to-child transmission. Retrovir should be used and, in most cases, combined with other HIV drugs. Women in the first trimester may consider waiting to start the HIV drugs until after the first 10–12 weeks of pregnancy. After the birth of the baby, the mother should be evaluated to see if she needs to continue HIV treatment for her own health.
In both of the above cases, HIV drug treatment should continue during labor and delivery. At that time, the Retrovir should be switched to intravenous (IV) administration. After delivery, the baby should receive liquid Retrovir for six weeks.

For HIV+ Women Already Taking HIV Drugs
Continue current HIV drugs if they are working well to control the virus and have not been show to harm the pregnant mother or developing baby (see list above) . If the drugs are not working, switch to a more effective combination. Retrovir should be used as one of the drugs in the combination if possible. The drugs should be continued during labor and delivery, during which time IV Retrovir should be given to the mother. After delivery, the baby should receive liquid Retrovir for six weeks.

For HIV+ Pregnant Women in Labor Who Have Not Taken HIV Drugs
A woman in labor who has not taken HIV drugs can still reduce the risk of infecting her baby by using HIV drugs during labor and delivery and to treat the baby for a short time after birth. The guidelines recommend the following options:
IV Retrovir for the mother during labor and liquid Retrovir: for the baby for six weeks after birth.
Single-dose Viramune for the mother at the beginning of labor and IV Retrovir during labor. Consideration should be given to adding Epivir (lamivudine or 3TC) during labor and continuing Retrovir and Epivir for three to seven days after delivery. This may reduce the possibility of the mother’s virus becoming resistant to Viramune. The baby receives single-dose Viramune plus liquid Retrovir for six weeks.
IV Retrovir given to the mother during labor and liquid Retrovir plus additional drugs for the baby after delivery. However, it is unclear if this strategy further reduces the risk of transmission.
After the baby is born, it is recommended that the mother be evaluated to determine whether HIV treatment is recommended for her.

For Babies Born to HIV+ Women Who Have Not Taken HIV Drugs Before or During Labor
The baby can still receive treatment to reduce the risk of transmission. The guidelines recommend the following options:
Liquid Retrovir given to the baby for six weeks, started as soon as possible after birth.
Liquid Retrovir, plus additional drugs, given to the baby. However, it is unclear if this strategy further reduces the risk of transmission.
After the baby is born, it is recommended that the mother be evaluated to determine whether HIV treatment is recommended for her.

Invasive Tests, Procedures and Delivery
There are a number of invasive prenatal tests, such as amniocentesis, chorionic villus sampling (CVS), and percutaneous umbilical blood sampling, that may increase the risk of HIV transmission to the baby. Talk to your health care provider if you need these tests. Certain procedures during delivery, such as invasive monitoring and forceps- or vacuum-assisted delivery, should be avoided if possible.

There are 2 types of delivery: cesarean (C-section) and vaginal delivery:

C-section
Elective or planned C-sections are done before labor begins and before the mother’s "water" (membranes that surround the baby) breaks. This reduces the baby’s contact with the mother’s blood and may reduce the risk of transmission in certain cases. Since C-sections require surgery, they carry some risks. Women who have C-sections are more likely to get infections than those who give birth vaginally. C-sections are recommended for HIV+ pregnant women who:
Have an unknown viral load
Have a viral load greater than 1,000 copies at 36 weeks of pregnancy
Vaginal delivery
For a woman on combination HIV treatment with a low viral load (less than 1,000), a C-section is not likely to further reduce her already low risk of transmitting HIV.

The decision of which type of delivery is most appropriate should be discussed with your health care provider early in your pregnancy.

After the Baby is Born
During the first six weeks, the baby will need to take Retrovir (zidovudine) (and possibly other HIV drugs). A blood test called a complete blood count (CBC) should be performed on the baby before he or she starts the medication. The baby will also need to take medication to prevent pneumonia after finishing Retrovir, unless there is adequate information to confirm that the infant does not have HIV. Taking these medications doesn’t mean the baby is sick; it is just a precaution to decrease the chances of getting HIV and other illnesses.

The baby will receive several HIV tests to determine if he or she is infected. An HIV DNA PCR or and HIV RNA PCR virologic assay should be used. Virologic assays test for the HIV virus, rather than HIV antibodies. HIV antibody tests, which are commonly used to determine HIV infection in adults, should not be used in newborns since babies carry their mother’s antibodies for 12 to 18 months.

HIV virologic testing should be done at 14 to 21 days, one to two months, and four to six months. A positive HIV virologic test should be confirmed with a second test. Two positive HIV virologic tests establish a diagnosis of HIV infection. HIV may be ruled out with two or more negative tests with one at one month and another at four months or later, when the mother is not breast-feeding. Many experts confirm HIV-negative status with an HIV antibody test when the baby is 12 to 18 months old.

Since a baby can be infected with HIV through breast milk, it is important not to breast feed if you have other options. You can still have a strong bond with your child even if you bottle feed.


In Conclusion
Deciding to have a baby is a big step for any woman, but for an HIV+ woman, it is even more complicated. Talk to your HIV health care provider and OB or midwife before you start trying to get pregnant. If you plan ahead, there are many things you can do to protect your health and the health of your new baby.



Information provided on this blog is for educational purposes only. It is designed to support, not replace, personal medical care and should never be used as a substitute for personal medical attention, diagnosis, or hands-on treatment. I recommend all medical decisions be made in consultation with your personal health care provider.